A patient was given the wrong blood during one of four Never Event ‘blunders’ at Warrington and Halton Teaching Hospitals NHS Foundation Trust.
Fortunately none of the “blunders,” which also included a patient receiving a surgical procedure on the wrong part of their body, caused any harm to the patients involved.
Medical negligence solicitors, Blackwater Law have obtained data via a Freedom of Information request detailing the types of ‘Never Events’ that occurred at Warrington and Halton Teaching Hospitals between 01 April 2023 – 30 December 2023.
The NHS defines a ‘Never Event’ as ‘serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.’ Never events have the potential to cause serious injury or even death.
Warrington and Halton Teaching Hospitals were shown to have recorded four ‘Never Events’ within this time. The following details were revealed about the incidents.
In one shocking incident, a patient was given the wrong blood type for a blood transfusion. According to the National Institute for Health (NIH), a blood transfusion using an incompatible blood type can often cause acute kidney injury and can potentially be life threatening.
The trust also registered two separate incidents of what is known as a ‘wrong site procedure,’ where a surgical procedure is carried out on the incorrect part of the body. In one of the incidents, a patient was given an injection into the wrong side of their body. In another incident, a patient was given an injection to the wrong limb entirely. The details unfortunately are unclear as to which limb.
The fourth incident involved a retained surgical swab, left inside of a patient following a surgical procedure. Swabs are pieces of gauze which are used to absorb bodily fluids like blood. A retained swab event is when a swab is unintentionally left inside a patient’s body after an invasive procedure. This can lead to serious infections, and often will usually lead to further surgery to retrieve the swab.
Commenting on the emerging details, Jason Brady, Partner & Head of Blackwater Law said: “It is concerning to see the details of these ‘Never Events.’ At Blackwater Law we see the impact that these incidents have, not just on the person affected, but also on their families.
“It is important to remember that behind each one of these ‘Never Events’ is an individual. They are the ones who must deal with the lasting impact of these incidents which the NHS themselves say should not be happening.”
In February 2024, NHS England published the number of never events at each trust in the country occurring between 01 April 2023 – 31 December 2023. In this period, there were 268 ‘Never Events’ recorded across the NHS.
NHS England no longer readily publishes the types of never events that occurred at a trust, only the number of them. The Freedom of Information Request by Blackwater Law reveals the types of never events that occurred at Warrington and Halton Teaching Hospitals.
A spokesperson for Warrington and Halton Teaching Hospitals NHS Foundation Trust said: “At Warrington and Halton Teaching Hospitals patient safety incidents and ‘Never Events’ are extremely rare and ensuring patients are safe in our care is of the greatest importance to us.
“Should a patient safety incident occur, we follow national policy to record it, undertake a full investigation to understand and learn from what happened, and are committed to being open and transparent with patients and their families about what has gone wrong.
“Our investigations into the four incidents found there was no harm caused to any of the patients involved.”
