Posted on 12 Sep 2013
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Never Events Cause another Death

In a recent news update, Michelmores' Clinical Negligence team commented on the NHS list of 'never events' - errors so egregious that they should be unheard of. One of these, 'maladministration of insulin', has recently cost the life of Claire Harry, 36, at the Royal Cornwall Hospital Truro.

Having presented at the hospital with a chest infection, Harry, a diabetic, was being monitored every 6 hours, rather than the stipulated 2-hourly intervals. She fell into a diabetic coma and suffered irreversible brain damage, remaining alive but unresponsive for a further two weeks before dying of bronchial pneumonia.

An avoidable fate

Occurrence of never events is, according to the Department of Health, 'also an indicator of how safe the organisation is, and the patient safety culture within that setting.' Following the coroner's inquest into Harry's death, which found that the patient's hypoglycaemia was not noticed and treated in time, the hospital introduced a tranche of changes including more thorough staff training.

Michelmores' Oliver Thorne, an expert in claims against negligent NHS trusts, is disappointed by the news of Harry's death. 'I've got a lot of love for the NHS,' he says, 'and in many cases I can sympathise with the conditions the staff have to work in, the constraints. But for something like this, something totally avoidable; you can't tolerate it.'

According to the hospital statistics website Dr Foster, Royal Cornwall's 'death in low risk conditions' figures are 'within the expected range', although the hospital also played host to another avoidable death, when a new-born child died after the ambulance he was in was turned away by a senior nurse.

Clearly, Oliver feels, there is room for improvement, and accountability should have a role to play. 'In a scenario like this, the compensation aspect of making a negligence claim is only one side of it. There is also a constructive side to pursuing legal action against the NHS, causing management staff to rethink, to improve.

'The fact that the hospital wrought some fundamental changes after the death is encouraging, and I hope the new measures are effective. It's just gutting that somebody had to die for it to happen.' Two women have lost their lives, and at Mid Staffs an entire Foundation Trust is facing criminal proceedings; and all this over events that should never have happened at all.

You can read the recent Michelmores Update on never events here.