Surgical Blunders Rise Sharply In The NHS

Crisis in the Operating Theatre: Hundreds Harmed by Preventable NHS Surgical Mistakes

Startling disclosures about a woman's case involving the mistaken removal of part of her spine reveal she is just one of many hundreds of individuals impacted by errors during surgery in the National Health Service in the year just gone. This case highlights a deeply concerning trend within the health service. Recent data illustrates that medical professionals performed over four hundred grave surgical mistakes on people during the preceding twelve months.

These serious events, which are termed 'never events', should be entirely preventable. They encompass excising an incorrect organ, procedures on an improper part of the body, and medical tools being forgotten inside a person. In some situations, entire surgical procedures were conducted on an unintended person. The persistence of these errors raises serious questions about patient safety protocols across the NHS.

A System Under Scrutiny

A stark warning has come from the Royal College of Surgeons. The organisation stated that the National Health Service must gain a deeper comprehension of the factors contributing to the escalation in these events to stop a recurrence of such mistakes. This call to action underscores the urgency of addressing what many see as systemic failings.

A spokesperson for the college emphasised that surgical teams take patient safety very seriously. They acknowledged the distressing impact these errors have on the individuals affected and the medical personnel involved. Hospitals must carefully analyse these figures and take decisive action to understand the root causes. Open and honest learning, including everyone in the surgical team, is crucial to prevent these errors from being repeated.

The Human Cost of Surgical Mistakes

Among those affected is a woman named Gill. She received a recommendation for a procedure involving her right cervical rib to alleviate agonising pain. However, the performing surgeon carried out an improper operation. This resulted in the removal of sections of her vertebral column, causing irreversible damage to the spinal cord. Her story provides a harrowing insight into the devastating consequences of such blunders.

She described her experience with the terrifying realisation upon waking. She recalled having no sensation in her arms and legs and feeling immense alarm. Doctors advised her about the possibility of permanent loss of mobility. The incident left her unable to perform her job effectively and forced her to abandon her previously dynamic lifestyle, which had involved dancing. Her physical movements are now constrained.

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Life-Altering Consequences

The aftermath of the botched surgery has been profound for Gill. She faces ongoing challenges with using her right hand, a constant reminder of the error. The emotional toll has been immense. She conveyed that being informed you may lose the ability to walk is an incredibly daunting and dreadful prospect. Her experience demonstrates the deep psychological scars left by medical negligence.

Through the legal support of Bond Turner, a law firm specialising in such cases, Gill managed to obtain a financial settlement. This compensation addressed the suffering and distress she endured, a diminished quality of life, and lost income, both already incurred and anticipated. It also covered expenses for future home modifications and household needs, as well as costs for therapy, equipment, and ongoing care needs.

A National Tally of Errors

Provisional NHS information paints a grim picture. In the period from April 2024 through March 2025, a total of 403 comparable situations categorised as 'never events' were recorded. These are defined by the NHS as major incidents that are mostly avoidable and should not happen if existing national guidance is followed. The figures show a worrying pattern over recent years, with a gradual increase in such incidents.

In the preceding year, 2023 to 2024, 370 such cases were noted. The year 2022 to 2023 saw 384 cases recorded. The numbers were 407 in 2021-22 and 364 in 2020-21. This means that across the recent half-decade, the total number of reported cases surpassed 1,900. These statistics highlight a persistent and deeply rooted problem within the healthcare system.

Wrong Site Surgery Dominates Blunders

The most prevalent category of surgical mistake is termed ‘wrong site surgery’. This classification accounts for a significant portion of all documented 'never events' and includes operations performed on an incorrect individual or at an improper location. Examples include operating on the incorrect limb, eye, or knee. Such mistakes can lead to catastrophic outcomes, including unnecessary amputation or loss of function.

Preliminary figures showed that among 185 ‘wrong site surgery’ events in one year, surgeons conducted operations on the incorrect body section in 46 instances. In 36 other situations, an incorrect skin lesion was taken off. More alarmingly, in nine situations, individuals were subjected to a surgery meant for another person entirely. These errors point to fundamental breakdowns in patient identification and pre-operative verification processes.

A Catalogue of Preventable Errors

In a little more than one-fourth of the reported incidents, a medical implement, sponge, or needle fragment was forgotten inside the individual. These retained foreign objects can lead to severe pain, infection, and the need for further invasive procedures to remove them. Such events are considered particularly egregious as they indicate a failure of basic surgical counting and checking protocols.

Approximately 50 patients were given an incorrect implant or prosthetic device. This included individuals being fitted with an incorrect prosthetic for a knee or hip, a mistake that can lead to significant mobility issues and require complex revision surgery. Additional mishaps included the transfusion of an incompatible blood type, incorrect administration of medicine, and excessive doses of insulin being administered.

Hospital Hotspots Identified

While these 'never events' typically happen infrequently, perhaps one or two times each year at most medical centres, NHS figures show a worrying concentration in certain trusts. The hospitals with the poorest records can experience these events more than ten times per year. In the last 12-month period, some of the highest numbers were recorded at specific NHS Foundation Trusts.

For instance, 13 such incidents were recorded by University Hospitals Birmingham NHS Foundation Trust, while Royal Free London NHS Foundation Trust reported 10, and University Hospital Southampton documented 11. These figures have placed these trusts under intense scrutiny. It is important to note, however, that some argue these numbers may reflect larger patient volumes and a more transparent reporting culture rather than inherently less safe care.

The Trust Response

A response was sought from all these trusts. At University Hospital Southampton, chief medical officer Paul Grundy addressed the findings. He stated, “We view any events of this kind with extreme seriousness and regret that they took place." He clarified that no individuals sustained grave injury in any of the situations at the trust.

Grundy stressed the institution's devotion to providing the highest quality of care and its consistency in being transparent when reporting mistakes. He added that the trust promotes staff to document events if they happen. On the rare occasions an error is made, a comprehensive inquiry is launched. This process ensures that learnings are disseminated to improve clinical care quality and safety.

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Focus on University Hospitals Birmingham

University Hospitals Birmingham NHS Foundation Trust has faced particular scrutiny, having the highest number of claims for surgical never events over a decade. A review in 2023 identified concerns around leadership and culture. Additionally, an inquiry by the Royal College of Physicians into the trust's transfusion service described 14 never events as the "tip of an iceberg," uncovering over 150 additional adverse events in just three months.

The review pointed to inaction at senior management level in addressing known problems. It concluded there was a lack of understanding among senior leaders about the significance of the risks. The investigations into these never events were often deemed "too superficial," and the severity of harm was frequently minimised in reports. This highlights a potential cultural issue that could impede genuine learning and improvement.

Challenges Facing the Royal Free London

Challenges have also been faced by the Royal Free London NHS Foundation Trust. A surprise inspection was carried out by the Care Quality Commission (CQC) following an increase in major events. Inspectors found that while incidents were reported and investigated, the lessons learned were not always effectively shared with frontline staff. A subsequent internal investigation into the trust's pharmacy found a "poor safety culture" where incidents were not always reported and staff did not feel able to speak up.

In response, a spokeswoman for the Royal Free stated that they acted promptly to address all concerns raised. This included implementing more robust processes, improving training and record-keeping, and making staff aware of the avenues available for raising concerns. The trust has reiterated its commitment to promoting an open and honest culture at all levels.

The Financial Burden of Failure

The cost of these surgical mistakes extends beyond human suffering. It places a significant financial strain on an already stretched NHS. Between 2014 and 2024, successful claims for surgical never events resulted in payouts totalling £37.6 million. The average compensation per claim was approximately £65,000. This money could otherwise be spent on patient care and service improvement.

Over a recent five-year period, NHS Resolution recorded 11,700 claims related to surgery errors. The total cost of medicolegal claims against general surgery departments alone exceeded £850 million over a decade. Experts note that this expenditure represents a serious and worsening concern for the health service, with costs increasing by over 50% in ten years.

Exploring the Root Causes

Experts suggest that poor communication is a major contributor to many of these mistakes. Misinterpreting written notes or verbal instructions can lead directly to wrong site surgery or retained objects. Ambiguity in communication, especially during safety-critical moments in the operating theatre, is a significant risk factor that needs to be addressed through clearer protocols.

Staffing pressures, fatigue, and burnout within the NHS are also acknowledged as contributing factors. A culture of blame, rather than one of learning, can deter staff from reporting near misses and errors, preventing valuable lessons from being learned. Furthermore, administrative mistakes, such as incorrect scheduling or clinic listing errors, can create the conditions for a never event to occur before the patient even reaches the operating theatre.

The Role of Safety Checklists

To combat these very issues, the Surgical Safety Checklist from the World Health Organisation (WHO) was introduced. Mandated for use across the NHS in 2009, this simple tool is designed to improve teamwork and ensure critical checks are performed before, during, and after surgery. Studies have shown the checklist can reduce deaths and surgical complications significantly, on certain occasions by as much as one-third.

The checklist functions as a critical instrument for improving communication, teamwork, and the overall safety culture in the operating room. It prompts the surgical team to pause at key moments to confirm the patient's identity, the surgical site, and the procedure, and to account for all instruments and swabs.

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Challenges in Implementation

Despite its proven benefits, the effectiveness of the WHO checklist depends entirely on how it is used. Studies have revealed inconsistent compliance. While some parts of the checklist, like the 'Time Out' before incision, have high completion rates, other parts, such as the 'Sign Out' at the end, are often overlooked. This suggests that on some occasions there is a tick-box mentality, rather than genuine engagement.

Surveys of operating theatre staff have shown that while they agree a checklist is used, many do not feel it is always effective or that the entire team gives it their full attention. To counter this, some trusts have moved from paper checklists to large, wall-mounted versions to increase visibility and team engagement, with dramatic improvements in compliance.

NHS England’s Broader Strategy

In response to these ongoing safety challenges, NHS England has launched a comprehensive patient safety strategy. The strategy aims to build a safer culture and implement safer systems across the entire health service. A key component is moving away from a culture of blame towards one that focuses on learning and improvement.

The strategy involves a new Patient Safety Incident Response Framework (PSIRF), which centres on maximising learning from errors. It also introduces the 'Learn from Patient Safety Events' (LFPSE) service, a national system for recording and analysing the more than three million safety events reported each year. This data-driven approach seeks to identify systemic issues and prevent recurrence.

Involving Patients and Supporting Staff

A central pillar of the new approach is the greater involvement of patients and their families in safety processes. NHS England is introducing Patient Safety Partners into trusts to ensure the patient voice is heard. This aligns with evidence showing that when patients are treated as partners in their care, there are significant gains in safety and satisfaction.

For staff, the strategy focuses on building capability through training. A national patient safety syllabus has been launched, with over 1.4 million staff completions of essential safety training recorded. The goal is to embed systems thinking and a just culture, where staff are encouraged and supported to document events without fear of reprisal.

A Change in Reporting

It is also important to understand the historical context of the data. The method for measuring 'never events' has been altered by the NHS within the last ten years. Before 2014, the figures exclusively counted situations in which an individual suffered direct injury. The system was subsequently changed to also include incidents that had the capacity to result in injury.

This change in methodology naturally resulted in an increase in the quantity of recorded cases. It reflects a more proactive approach to safety, aiming to identify and rectify risks before they result in patient injury. In 2017-18, further minor adjustments were made to the sub-classifications for categorising various kinds of situations, refining the data collection process.

The Path Forward

An NHS representative commented that personnel make extraordinary efforts to maintain patient safety, and events of this nature are very infrequent in the context of millions of procedures performed annually. They reiterated that when such events happen, NHS trusts have a duty to conduct a thorough inquiry and implement meaningful measures for learning and improvement.

The continued occurrence of hundreds of 'never events' each year, however, shows there is still a long way to go. Eliminating these preventable errors requires a relentless focus on robust systems, a culture of safety that permeates every level of the organisation, and a commitment to learning from every single mistake, no matter how small.