‘Never Event’ as Patient Receives Wrong Sized Prosthetic During Surgery at Orthopaedic Hospital in Gobowen

In a case reported by BBC News and other organisations, a patient was accidentally implanted with the wrong prosthetic implant in a ‘Never Event’ at a Shropshire hospital.

The event was reported to the Shropshire, Telford and Wrekin Clinical Commissioning Group (CCG) governing body in September 2021. Surgeons mistakenly implanted a small prosthesis into a patient instead of a medium-sized one. The surgery took place May 2021 at the Robert Jones and Agnes Hunt (RJAH) hospital, a specialist orthopaedic hospital in Gobowen, near Oswestry. The hospital has not yet confirmed the specific prosthetic implant involved in the error or the type of surgical procedure.

What is a ‘Never Event’?

A ‘Never Event’ is defined as a “serious, largely preventable patient safety incident that should not occur if healthcare providers have implemented existing national guidance or safety recommendations.” Never Events typically act as red flags, requiring serious incident investigations and improvements by NHS bodies.

Never Events may occur in a number of situations classified into different categories by NHS England. The surgical error in May 2021 was the third ‘Never Event’ reported at the Gobowen’s Robert Jones and Agnes Hunt (RJAH) hospital in the past two years.

The other two Never Events at the trust occurred in April and included an incident where healthcare providers administered an anaesthetic block (i.e., a local anaesthetic that’s injected close to a nerve) on the wrong side of the patient’s body. The other event “related to a patient given an injection in the wrong hand.”

Minutes from a meeting by the hospital directors reported that both patients were “fine.” The hospital was put under investigation in July 2021 following these errors. The Shropshire, Telford and Wrekin Clinical Commissioning Group (CCG) told the Local Democracy Reporting Service that “immediate remedial actions” were taken.

According to NHS England, the organisation “is one of the only healthcare systems in the world that is this open and transparent about patient safety incident reporting, particularly around Never Events. We are clear that we need to openly tackle these issues, not ignore them.”

Investigation Launched into the Never Event

The Robert Jones and Agnes Hunt Orthopaedic Hospital Trust (RJAH) has since launched an investigation into the Never Event at the Gobowen hospital. But following a review of the surgery, the trust has gone on to say that “Due to the timing of this Never Event and the subsequent actions taken from the previous, following review, no further immediate actions were required.”

Chief Medical Officer at RJAH, Ruth Longfellow, commented “Incidents of this nature are extremely rare. When they do occur, we carry out a full investigation and that is what is happening right now.

“In this case, the patient underwent surgery in May. We became aware of the issue with the size of the implant during follow-up care in September, and immediately made them aware and apologised.

“We take the matter extremely seriously and will use the ongoing investigation to identify learning that will help us to further reduce the likelihood of a repeat in future.”

Whilst it is not always possible to prevent patient safety incidents, healthcare providers can and should take preventative actions—especially with regards to Never Events. Each Never Event carries the risk of serious injury or even death.

In a March 2021 article appearing in the BMJ Opinion, Michael Devlin, the Head of Professional Standards & Liaison at the Medical Defence Union (MDU), argued that “the never events policy has had a limited effect on patient safety.” He suggested a reassessment, claiming that “the persistent use of the word ‘never’ reinforces the unhelpful concepts of blame and liability and is a distraction from what really matters.”

Rather, we should focus on creating an open and learning culture that supports those involved (patients, families and staff) along with finding out what went wrong and learning lessons so that similar events can be prevented in future.”

Was Your Prosthetic or Joint Implant Inserted Incorrectly?

If the wrong prosthetic or implant was used in your orthopaedic surgery, or the prosthetic or implant was inserted incorrectly, you could claim compensation. Although no amount of compensation can change what happened, it goes a long way in easing financial pressures and helping you or your loved one move forward with life.

Our experts have supported clients all over England and Wales by securing compensation for orthopaedic negligence. Whether the negligence was associated with missed fracturesnegligent surgery or treatment such as negligent joint replacements, we work hard to make sure that you receive the compensation you need to live as full a life as possible.

Contact Devonshires Claims today to start your free no-obligation case evaluation.  We provide a ‘No Win – No Fee’ claims service so you will not incur any costs if your claim is unsuccessful*.  To start your free no-obligation case evaluation contact us today on 0333 900 8787, email admin@devonshiresclaims.co.uk or complete our online form.

Get in touch

Devonshires Claims
Ground Floor
30 Finsbury Circus
Finsbury, London
EC2M 7DT