Surgery: Negligence

“Never Events”, including wrong-site surgery, are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.

Providers are urged to foster a positive safety culture among their staff, and ensure an appropriate local focus on incident recognition, recording, and response.

The NHS Never Event policy and framework, explains what a Never Event is and how staff providing and commissioning National Health Service-funded services should identify, investigate, and manage the response to a Never Event. The Care Quality Commission assess the occurrence of Never Events as an indicator to review a healthcare providers safety culture, leadership, and fundamental safety processes, using its inspection framework to undertake a systemic safety assessment when a Never Event occurs.

The National Safety Standards for Invasive Procedures were published by NHS England in September 2015 to improve the safety of invasive procedures and to reduce surgical Never Events. In 2023, the Centre for Perioperative Care updated the standards to cover a wider range of interventional specialties and place greater emphasis on organisational culture, teamwork, and human factors.