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Serious Incidents in Dermatology

Serious Incidents in Dermatology

Every month, NHS England (NHSE) publishes the statistics of serious incidents reported across the country on a provisional basis before it is then published in full after necessary investigations have taken place. The provisional and full reports can be found here. Also known as ‘Never Events’, these incidents can be surgical or non-surgical in nature. Only serious incidents in England are currently reported on, but the data may be held with relevant authorities in Scotland, Wales and Northern Ireland. Dermatologists should be aware of the ‘wrong site’ surgical incidents that are reported, typically involving the excision of skin lesions. NHS England have published the policy and framework, as well as the most up to date list of what constitutes a Never Event. These are updated frequently.

The following resources are vital to ensuring that the correct procedures are followed during surgery, to minimise the chance of incident:

  • WHO Surgical Checklist: The essential steps before surgery, internationally recognised and supported. The checklist can be found here. This can be easily adapted for each Trust, and there are many useful examples to be found, such as this example from County Durham Foundation Trust.
  • Five Steps to Safer Surgery: Find the guide to download here, as published by the Association for Perioperative Practice.


The Never Events relating to Dermatology are typically wrong site surgeries. Under this category, incorrect skin lesion removals or biopsies are the third most common incident subtype, behind incorrect site blocks and teeth removals. The table below shows some recent statistics:


Total wrong site surgeries

No. of incorrect skin lesion surgeries (removals or biopsies)

April 2018- March 2019*



April 2019- March 2020



April 2020- January 2021*



*Provisional data.


In 2018, Imperial College London conducted a review of serious incidents reported across England, in conjunction with NHSE, and produced a report analysing these cases. The report can be found here and gives a useful overview of the issues that have arisen in the past and how they can be mitigated in the future.


National and Local Safety Standards

In the wider picture, national and local standards have been produced an implemented with the intention of providing a safety structure for the prevention of these serious incidents. The BAD has also produced a National Safety Standard for Invasive Dermatology Skin Procedures (NatSSIP) guidance for ensuring safety procedures in skin cancer. This coincides with the local guidance (LocSSIPs) produced by healthcare trusts to ensure standards of care. LocSSIPs may be used in conjunction with the WHO checklist, rather than instead of it. A good example of a LocSSIP used in practice is the protocol used by Luton and Dunstable University Hospital, which is listed by NHS Improvement.


Common Problems

Through reviewing wrong site surgery reports both recent and historical, there are a number of commonalities between different Never Event incidents. Some of them are listed below:

  • Failure to follow the WHO checklist correctly
  • Failure to double check with the patient the site of surgery in situations where the use of mirrors would be beneficial.
  • A fault in communications between doctors, nurses and other healthcare professionals. Junior members of staff need to be able to flag up issues and challenge senior clinicians (in particular, locums) about adherence to surgical procedures and risk to the patient.
  • Misplacement or insufficient management of paperwork relating to the procedure.

All staff involved in surgical operations should be involved and/or represented in clinical governance meetings.


The BAD provides service reviews to help Trusts experiencing serious incidents and Never Events. For more information, or to request a review, please contact

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