Never Events – Retention of Instruments After Surgery

‘Never Events’ are patient safety incidents that are wholly preventable and should never occur.

What are some examples of Never Events?

Never Events are defined and listed by the NHS. They include such incidents as a foreign body/medical instrument being left in a patient, wrong implant/prosthesis, and administration of medication by the wrong route, plus many more. The important thing about Never Events are that they are preventable.

Each Never Event type has the potential to cause serious patient harm or death. However, serious harm or death does not need to have happened as a result of a specific incident for that incident to be categorised as a Never Event. Each year approximately 500 Never Events take place that could have, and should have been prevented.

Retention of a foreign object – a case study

From 1st April 2015 to 31st March 2020, there have been approximately 800 claims for incidents of retained foreign object post procedure. In terms of clinical specialty where these 800 Never Events occurred, they most commonly were attributed to general surgery (22%), with obstetrics following (13%), and then orthopaedic surgery and gynaecology (10% each).

Retained foreign object post procedure is listed within the Never Event list, and is defined as, “retention of a foreign object in a patient after a surgical/invasive procedure”.

A surgical/invasive procedure may include interventional radiology, cardiology, interventions related to vaginal birth and interventions performed outside the surgical environment. A foreign object may include any item that is subject to a formal counting or checking procedure both at the start of the procedure and upon completion (such as for swabs, needles, instruments and guidewires).

I recently settled a case involving the retention of forceps during a medical procedure. My client underwent an open aortic aneurysm repair. Four days after surgery, a CT scan revealed a metal surgical instrument (a pair of forceps) had been left in situ. My client underwent an avoidable second procedure to remove the forceps and he spent extra time in hospital to recover.

Ultimately, my client’s case was that there was a failure in leaving a metal surgical instrument in the client, a failure to record a final swab/instrument count following the operation and a failure to detect the object until 4 days later. This Never Event was preventable and should not have happened.

In view of the facts of the case and the clear Never Event that had occurred, it was not necessary or cost-effective to obtain liability expert evidence, therefore an early Letter of Notification was served on the Defendant. Whilst awaiting a response, I obtained medical expert evidence in order to assess causation and the extent of my client’s injury. The Defendant admitted breach of duty and causation and after quantifying the claim, I was able to settle my client’s case in the sum of £12,000.00.