Concerns raised after three 'never events' recorded by NHS hospital trust in just two months

Royal Free London NHS Foundation Trust chief nurse admits the serious medical mistakes at unnamed hospitals were “wholly preventable”, reports Joe Ives, Local Democracy Reporter

A patient undergoing resuscitation had a line accidentally placed into their artery in one of three ‘never events’ recorded by a North London NHS hospitals trust in the past two months.

These serious mistakes were discussed by Julie Hamilton, board trustee and group chief nurse at Royal Free London NHS Foundation Trust, during the board’s meeting on Wednesday (3rd).

NHS guidelines define ‘never events’ as “serious incidents that are wholly preventable” if national guidance and safety recommendations are followed. These provide “strong systemic protective barriers” and should be “implemented by all healthcare providers”.

“It is disappointing that these keep happening,” Hamilton admitted at Wednesday’s Royal Free London board meeting.

The trust member argued that they should be preventable “with the right systems in place”, adding: “They’re called never events because they should never happen.”

Royal Free London runs Barnet Hospital, Chase Farm Hospital, North Middlesex University Hospital and Royal Free Hospital.

The three ‘never event’ incidents happened in April and May. None were reported by the trust during the entirety of the previous twelve-month period, Hamilton said.

One of the incidents saw a patient receiving “a wrong injection during a procedure”. The other two were categorised in what the NHS calls “wrong site” incidents. These involve the insertion of a line into the wrong part of a patient’s body.

The most serious of these involved a line being mistakenly placed into the artery of an “acutely unwell” patient who was in a “resuscitation situation”. The line should have gone into a vein. Hamilton did not disclose where this accident happened.

The trust board member argued Royal Free London normally has a “low threshold” for reporting such serious mistakes and said two of the three incidents “had no harm”.

However, she also emphasised that the trust was “taking the opportunity to do a bit of a relook” at actions taken following a “previous little spell of never events” in previous years.

North Middlesex University Hospital NHS Trust was merged into Royal Free London in January 2025.

This move came after both trusts had been experiencing ongoing issues, highlighted by poor waiting times and critical reports from Care Quality Commission (CQC) inspectors.

The merger, designed to improve services and offer “better joined-up community services”, made Royal Free London one of the largest NHS organisations in the country.

It now runs four major hospitals, including three accident and emergency (A&E) departments, across the North London boroughs of Enfield, Barnet and Camden, with North Mid also serving large parts of Haringey.

Between 1st April 2022 and 31st March 2023, Royal Free London recorded eight ‘never events’, while the former trust running North Mid recorded four.

In the 2023/24 financial year, the last complete financial period before the merger, Royal Free London recorded two while the North Mid recorded none.

Speaking at Wednesday’s meeting, Royal Free London chair Mark Lam said ‘never events’ needed “continued monitoring” to ensure a pattern of mistakes does not start to develop.

When Royal Free London carries out its audits on the checklists designed to prevent such incidents, the trust’s compliance is usually “pretty good,” Hamilton said.

The board member said these checklists are important, but admitted that addressing the “wider dynamic” in some of the locations where these mistakes are happening was also a key factor.

She said “human factor elements” are usually at play during such incidents. These, Hamilton said, include specific details of how staff work together and the “culture in those situations”.

Hamilton said the trust will be making sure “there’s a real clear dynamic” between specific teams. Focusing on improving this, Hamilton said, is what the board “hope will make the difference”.

Dr Gillian Smith, chief medical officer of Royal Free London NHS Foundation Trust, agreed that “human factors training is really important”.

She added: “It’s how we maintain that because we know that however often you remind people about checklists and do this work, it’s that constant training and iteration as teams that we need to maintain, and I guess that’s the culture shift we need.

“It’s not just a one-off training intervention, it’s something we need to shift ourselves towards and do it on a continuous basis.”

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