Surgeon made 'incorrect incision' on patient in Sheffield hospital theatre in extremely rare 'never event'

The incident was one of three ‘never events’ recorded by the NHS Trust in 2023. NHS England defines never events as “patient safety incidents that are wholly preventable”.

Making an incorrect incision means a surgeon in the operating theatre in one of Sheffield Teaching Hospitals NHS Foundation Trust’s (STH) numerous sites created an opening in a patients body in the wrong place.

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Kirsten Major, Chief Executive, Sheffield Teaching Hospitals NHS Foundation Trust said: “We care for over two million patients each year and carry out circa 50,000 procedures. We take patient safety extremely seriously and strive to not have any ‘never events’.

“Regrettably in 2023 we did have three never events and we are very sorry they happened.  In each instance there was either no or low harm to the patients involved.”

One of the two other never events included a foreign object being retained in a patient after a surgical or invasive procedure.

These objects can include swabs, needles, guidewires or other instruments used in theatre. The FOI response does not specifiy what the retained objects were, but did say the incident caused “no harm to the patient”.

The third never event was categorised as an “expired implant” and again caused no harm to the patient.

The incorrect incision incident was the only never event in 2023 specified to have caused “low harm to the patient”.

All three never events at STH last year occured in theatres.

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Never events can cover come under a range of categories including:

• Surgical - e.g. wrong site surgery, retained objects
• Medication - e.g. administration of medication by the wrong route
• Mental Health - e.g. failure to install functional collapsible shower or curtain rails
• General - Scalding of patients, falls from poorly restricted windows

These incidents are incredibly rare. The three never events recorded by STH come within roughly 50,000 procedures - or 0.006 per cent.

Ms Major added: “Whenever there is an incident caused by an error, and regardless of the extent they impact on the patient, it is thoroughly reviewed and learning shared, or processes/training changed to ensure the chances of it happening again are minimised.

“We also share the learning with the patient involved. One example in theatres of where we try to prevent never events is that there is a safety checklist completed before procedures take place to check critical information relevant to the operation and patient.”