Never Events 2011/12 - Severe Scalding of Patients

Severe scalding of patients has been added to the Department of Health's list of Never Events.

Defined as ‘serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented by healthcare providers’, Never Event incidents have clear potential for causing harm or death but can be avoided by properly implementing the relevant guidance.

Following consultation, Severe Scalding of Patients is now included on the expanded list.  Such incidents can be avoided by adhering to the relevant guidance documents

• Health Technical Memorandum 04-01 - The control of Legionella, hygiene, “safe” hot water, cold water and drinking water systems, 2006 (current version 2016)
• Health Technical Memorandum HTM 64 (Sanitary assemblies), 2006 (superceded by HBN 00-10)
• NHS Model Engineering Specification D08 (Thermostatic Mixing Valves – healthcare premises), 1999 (now supplemental to HTM 04-01)
• Scalding risks from hot water in health and social care LAC: 79/5, 2007 (superceded)

which promote the installation of Thermostatic Mixing Valves as the preferred means for controlling water temperatures to meet the relevant safety requirements.

To access the full Department of Health document, 'The NHS “never events” list, revised in 2018, please click the adjacent link. (external link)

• Author: Hannah Berry
• Date: 14 July 2011