THE ongoing catalogue of so-called 'never events' under Great Western Hospitals NHS Foundation Trust is a disgrace.

A total of four have now taken place in the past 12 months.

It is worth remembering that, as we explain in our story, a never event is officially defined by the NHS as the most serious incident of its kind, having the potential to cause serious harm or death.

The NHS also says such events are entirely preventable where proper safety measures have been implemented.

A single never event, according to the guidance, can be taken by trust bosses as a sign that immediate steps to improve patient safety must be taken, while a repetition can indicate a failure of leaders to take patient safety seriously.

Great Western Hospitals NHS Foundation Trust is among the most dangerous to patients in this respect, and its response to the horrific situation does little to alleviate public fear.

A spokesman pointed out that most of the 1.5 million patients treated per year have positive experiences.

Assuming this to be true, it is not merely irrelevant but insultingly irrelevant.

The majority of patients having positive experiences is no mitigation whatever for certain patients being exposed without cause to the risk of death or serious injury.

Giving patients a positive experience is the job for which NHS trusts are paid.

Putting patients in danger of being killed or grievously harmed is not.

If this pattern of failure continues, it is only a matter of time before some innocent person dies — and we shall all know who to blame.

The trust’s leadership must either prove that it is addressing this awful situation or else give way to people who can keep patients safe.