Never Events
Never Events are serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety recommendations. The Never Events policy and framework – revised January 2018 suggests that Never Events may highlight potential weaknesses in how an organisation manages fundamental safety processes. Never Events are different from other patient safety incidents as the overriding principle of having the Never Events list is that even a single Never Event acts as a red flag that an organisation’s systems for implementing existing safety advice/alerts may not be robust.
The concept of Never Events is not about apportioning blame to organisations when these incidents occur but rather to learn from what happened. This is why, following consultation, in the revised Never Events policy and framework – published January 2018 we removed the option for commissioners to impose financial sanctions when Never Events were reported. The foreword to the framework states: “…allowing commissioners to impose financial sanctions following Never Events reinforced the perception of a ‘blame culture’. Our removal of financial sanctions should not be interpreted as a weakening of effort to prevent Never Events. It is about emphasising the importance of learning from their occurrence, not blaming”. Identifying and addressing the reasons behind this can potentially improve safety in ways that extend far beyond the department where the Never Event occurred, or the type of procedure involved.
The definitions and designated list of Never Events were revised from February 2018 so the direct comparison of the number of Never Events with earlier periods is not appropriate. You can find about more about these changes on the revised Never Events policy and framework webpage.
The revised 2018 Never Events policy and framework requires commissioners and providers to agree and report Never Events via the Strategic Executive Information System (StEIS). Where a patient safety incident is logged as a Never Event but does not appear to fit any definition on the Never Events list 2018 (published 28 February 2018) commissioners are asked to discuss this with the provider organisation and either add extra detail to StEIS to confirm it is a Never Event or remove its Never Event designation from the StEIS system.
Supporting healthcare providers to prevent Never Events
The Care Quality Commission has undertaken a thematic review in collaboration with NHS Improvement (now part of NHS England) to get a better understanding of what can be done to prevent the occurrence of Never Events, with the resulting report ‘Opening the door to change’ published in December 2018.
The report includes a recommendation that “NHS Improvement (now part of NHS England) should review the Never Events framework and work with professional regulators and royal colleges to take account of the difference in the strength of different kinds of barrier to errors (such as distinguishing between those that should be prevented by human interactions and behaviours such as using checklists, counts and sign-in processes; and those that could be designed out entirely such as through the removal of equipment or fitting/using physical barriers to risks). As mentioned above, we are in the process of conducting this review, and details of any resulting changes to the Never Events list can be found on the revised Never Events policy and framework webpage.
The report also suggested that organisations did not always have strong systems for implementing alerts. Key problems included:
- organisations circulating alerts to raise awareness rather than taking the required actions to address an issue
- responsibility taken at a junior level for recording an organisation’s completion of the actions
- instead of central coordination across an organisation, individual teams being asked to implement the required actions locally, leading to duplication and the most effective systemic actions left incomplete
To help address these issues, a new National Patient Safety Alerting Committee (NaPSAC) has been established, whose role includes the development and governance of the new national patient safety alerts. These alerts require healthcare providers to introduce new systems for planning and coordinating the required actions, including executive oversight.
In September 2015, the first set of national safety standards for invasive procedures (NatSSIPs) were published by NHS England to help prevent Never Events, with all relevant NHS organisations in England instructed to develop and implement their own local standards based on the national principles. The standards set out broad principles of safe practice and advise healthcare professionals on how they can implement best practice. The Centre for Perioperative Care published revised national safety standards for invasive procedures (NatSSIPs 2) in January 2023.
The National Patient Safety team and our partners also continue to work to further prevent individual types of Never Events. Examples include:
- our 2016 Alert ‘Nasogastric tube misplacement: continuing risk of death and severe harm’ and resource set
- the May 2020 aide-memoire produced by professional bodies for nutrition, anaesthetics and intensive care to help prevent nasogastric tube Never Events, including special considerations for COVID-19 patients
- the 2021 national patient safety alert – eliminating the risk of inadvertent connection to medical air via a flowmeter
Investigating and learning from Never Events NHS providers are encouraged to learn from mistakes and any organisation that reports a Never Event is expected to conduct a patient safety incident investigation (PSII) so it can learn and take action on the underlying causes.
The fact that more and more NHS staff take the time to report incidents helps to ensure that this learning is happening locally. We continue to encourage NHS staff to report Never Events to StEIS; PSIIs per this guidance; and all patient safety events to LFPSE, to help us identify any risks so that necessary action can be taken.
This report is drawn from the StEIS system and includes all patient safety incidents with a reported incident date between April 2018 and March 2019, and which on 8 May 2025 were designated by their reporters as Never Events. It is important to note that the list of Never Events can be subject to changes year on year so this report relates to the Never Events list for that year. The recording organisations also change over time so the organisations in this report were correct at the time of reporting and some may no longer exist, for example, clinical commissioning groups (CCGs).
Data on Never Events from previous years can be found on the NHS England website.
Summary
When data for this report was extracted on 8 May 2025, 554 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had a reported incident date between April 2018 and March 2019, of these 554 incidents:
- 538 patient safety incidents appeared to meet the definition of a Never Event in the Never Events list 2018 (published 28 February 2018)
- 11 patient safety incidents did not appear to meet the definition of a Never Event
More detail is provided in the tables on the following pages.
Table 1: Never Events April 2018 to March 2019 by month of incident
Note: As described above, a further 11 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly. Numbers are subject to change as local investigations are completed.
|
Month in which Never Event occurred |
Number of Never Events |
|
April |
37 |
|
May |
54 |
|
June |
61 |
|
July |
35 |
|
August |
57 |
|
September |
32 |
|
October |
48 |
|
November |
42 |
|
December |
39 |
|
January |
42 |
|
February |
41 |
|
March |
50 |
|
Total |
538 |
Source: Reported NHS Never Events from StEIS
Table 2: Never Events April 2018 to March 2019 by type of incident with additional detail
Note: As described above, a further 11 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly. Numbers are subject to change as local investigations are completed.
|
Description of Never Event |
Count |
|
Wrong site surgery |
233 |
|
Incision to wrong side/site |
6 |
|
Injection to wrong side/site |
28 |
|
Procedure intended for another patient |
12 |
|
Procedure not part of the surgical plan |
3 |
|
Procedure not required |
1 |
|
Removal of organ/structure when surgical plan was to conserve it |
7 |
|
Wrong procedure |
6 |
|
Wrong side/site procedure |
109 |
|
Wrong site block |
35 |
|
Wrong skin lesion removed/biopsy |
26 |
|
Retained foreign object post procedure |
109 |
|
Cotton wool ball |
1 |
|
Disposable item of equipment/part of disposable item of equipment |
9 |
|
Guide wire/part of guide wire |
25 |
|
K wire |
1 |
|
Ribbon gauze |
1 |
|
Surgical instrument/part of surgical instrument |
12 |
|
Surgical needle |
2 |
|
Surgical swab |
14 |
|
Throat pack |
2 |
|
Vaginal swab |
40 |
|
Vascular catheter/part of catheter |
2 |
|
Wrong implant/prosthesis |
71 |
|
Bone cement |
1 |
|
Breast implant |
1 |
|
Corneal graft |
1 |
|
Ear implant |
1 |
|
Fracture fixation prosthesis |
8 |
|
Gastrostomy tube |
1 |
|
Hip |
26 |
|
Intra uterine device |
6 |
|
K wire |
1 |
|
Knee |
13 |
|
Lens |
8 |
|
Neuro stimulator |
2 |
|
Stent |
1 |
|
Vascular graft |
1 |
|
Unintentional connection of a patient requiring oxygen to an air flowmeter |
51 |
|
Patient connected to air rather than oxygen |
51 |
|
Misplaced naso- or oro-gastric tubes |
26 |
|
Apparently misleading pH test result |
9 |
|
Placement checks not described or not clearly described |
8 |
|
X-ray misinterpretation; no indication ‘four criteria’ used |
9 |
|
Overdose of insulin due to abbreviations or incorrect device |
14 |
|
Abbreviations |
1 |
|
Insulin withdrawn from a pen device |
2 |
|
Wrong syringe used |
11 |
|
Administration of medication by the wrong route |
10 |
|
Oral medication given intravenously |
7 |
|
Oral medication given subcutaneously |
1 |
|
Oral medication given via endotracheal tube |
1 |
|
Subcutaneous medication given intravenously |
1 |
|
Mis-selection of high strength midazolam during conscious sedation |
8 |
|
High strength midazolam administered |
8 |
|
Failure to install functional collapsible shower or curtain rails |
7 |
|
Curtain rail failed to collapse |
7 |
|
Transfusion or transplantation of ABO incompatible blood components or organs |
4 |
|
Blood intended for another patient |
1 |
|
Wrong blood |
3 |
|
Overdose of methotrexate for non cancer treatment |
3 |
|
Methotrexate prescribed and administered more than the intended weekly dose |
3 |
|
Falls from poorly restricted windows |
2 |
|
Window restrictor not fitted or failed |
2 |
|
Total |
538 |
Source: Reported NHS Never Events from StEIS
Table 3: Never Events April 2018 to March 2019 by healthcare provider
Note: As described above, a further 11 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly. Numbers are subject to change as local investigations are completed.
|
Organisation Name |
Number of Never Events |
|
Abbeyfields Medical Centre reported by North East Essex Clinical Commissioning Group |
1 |
|
Airedale NHS Foundation Trust |
3 |
|
Alder Hey Children’s NHS Foundation Trust |
3 |
|
Ashford and St Peter’s Hospitals NHS Foundation Trust |
1 |
|
BMI The Park Hospital reported by NHS Nottingham City Clinical Commissioning Group |
1 |
|
BPAS, Oxford, reported by NHS Oxfordshire Clinical Commissioning Group |
1 |
|
Barking, Havering and Redbridge University Hospitals NHS Trust |
2 |
|
Barnet, Enfield and Haringey Mental Health NHS Trust |
1 |
|
Barnsley Hospital NHS Foundation Trust |
3 |
|
Barts Health NHS Trust |
13 |
|
Basildon and Thurrock University Hospitals NHS Foundation Trust |
5 |
|
Bedford Hospital NHS Trust |
5 |
|
Bedfordshire Hospitals NHS Foundation Trust |
1 |
|
Birmingham Community Healthcare NHS Foundation Trust |
2 |
|
Birmingham Women’s and Children’s NHS Foundation Trust |
4 |
|
Blackpool Teaching Hospitals NHS Foundation Trust |
1 |
|
Bolton NHS Foundation Trust |
3 |
|
Bradford Teaching Hospitals NHS Foundation Trust |
3 |
|
Bridgewater Community Healthcare NHS Trust |
2 |
|
Brighton and Sussex University Hospitals NHS Trust |
2 |
|
Broomfield Hospital reported by North East Essex Clinical Commissioning Group |
2 |
|
Buckinghamshire Healthcare NHS Trust |
4 |
|
Calderdale and Huddersfield NHS Foundation Trust |
4 |
|
Cambridge University Hospitals NHS Foundation Trust |
2 |
|
Cambridgeshire Community Services NHS Trust |
1 |
|
Cambridgeshire Community Services reported by NHS Luton Clinical Commissioning Group |
2 |
|
Care UK – Devizes NHS Treatment Centre |
1 |
|
Care UK – Southampton reported by NHS Southampton Clinical Commissioning Group |
1 |
|
Care UK, HMP Wakefield reported by Yorkshire and Humber Clinical Commissioning Group |
1 |
|
Chelsea and Westminster Hospital NHS Foundation Trust |
4 |
|
Chesterfield Royal Hospital NHS Foundation Trust |
3 |
|
City Healthcare Partnership, Hull reported by NHS Hull Clinical Commissioning Group |
2 |
|
City Hospitals Sunderland NHS Foundation Trust |
3 |
|
Countess of Chester Hospital NHS Foundation Trust |
3 |
|
County Durham and Darlington NHS Foundation Trust |
4 |
|
Dartford and Gravesham NHS Trust |
2 |
|
Derbyshire Community Health Services NHS Foundation Trust |
1 |
|
Doncaster And Bassetlaw Teaching Hospitals NHS Foundation Trust |
3 |
|
East and North Hertfordshire NHS Trust |
5 |
|
East Cheshire NHS Trust |
6 |
|
East Kent Hospitals University NHS Foundation Trust |
8 |
|
East Lancashire Hospitals NHS Trust |
2 |
|
East Suffolk and North Essex NHS Foundation Trust |
5 |
|
East Sussex Healthcare NHS Trust |
1 |
|
Epsom and St Helier University Hospitals NHS Trust |
2 |
|
Euxton Hall Hospital, Chorley reported by NHS Greater Preston Clinical Commissioning Group |
1 |
|
Frimley Health NHS Foundation Trust |
3 |
|
Gateshead Health NHS Foundation Trust |
2 |
|
Genix healthcare reported by NHS Hull Clinical Commissioning Group |
1 |
|
Gentle Dental Care reported by Croydon Clinical Commissioning Group |
1 |
|
George Eliot Hospital NHS Trust |
1 |
|
Gibraltar House Clinic – Dental Surgery, Chatham, Kent reported by a South East Provider |
1 |
|
Gloucestershire Hospitals NHS Foundation Trust |
3 |
|
Great Western Hospitals NHS Foundation Trust |
5 |
|
Guy’s and St Thomas’ NHS Foundation Trust |
9 |
|
Hampshire Hospitals NHS Foundation Trust |
1 |
|
Heart of England NHS Foundation Trust |
6 |
|
Highlands Health Centre Dental Service reported by NHS Hull Clinical Commissioning Group |
2 |
|
Homerton Healthcare NHS Foundation Trust |
3 |
|
Imperial College Healthcare NHS Trust |
6 |
|
Ipswich Hospital NHS Trust |
2 |
|
James Paget University Hospitals NHS Foundation Trust |
1 |
|
Kettering General Hospital NHS Foundation Trust |
1 |
|
King’s College Hospital NHS Foundation Trust |
12 |
|
Kingston and Richmond NHS Foundation Trust |
1 |
|
Lancashire and South Cumbria NHS Foundation Trust |
1 |
|
Lancashire Teaching Hospitals NHS Foundation Trust |
8 |
|
Leeds Teaching Hospitals NHS Trust |
9 |
|
Leicestershire Partnership NHS Trust |
1 |
|
Liverpool Heart and Chest Hospital NHS Foundation Trust |
1 |
|
Liverpool University Hospitals NHS Foundation Trust |
1 |
|
Liverpool Women’s NHS Foundation Trust |
2 |
|
Locala, Huddersfield reported by NHS Greater Huddersfield Clinical Commissioning Group |
2 |
|
London North West University Healthcare NHS Trust |
7 |
|
Maidstone and Tunbridge Wells NHS Trust |
2 |
|
Manchester University NHS Foundation Trust |
5 |
|
Medway Community Healthcare |
1 |
|
Medway NHS Foundation Trust |
3 |
|
Mersey and West Lancashire Teaching Hospitals NHS Trust |
1 |
|
Mersey Care NHS Foundation Trust |
1 |
|
Mid and South Essex NHS Foundation Trust |
2 |
|
Mid Cheshire Hospitals NHS Foundation Trust |
1 |
|
Mid Essex Hospital Services NHS Trust |
4 |
|
Mid Yorkshire Teaching NHS Trust |
3 |
|
Milton Keynes University Hospital NHS Foundation Trust |
3 |
|
Moorfields Eye Hospital NHS Foundation Trust |
2 |
|
My Dentist Leigh reported by NHS Wigan Borough Clinical Commissioning Group |
1 |
|
MyDentist, Bognor Regis reported by a South East Provider |
1 |
|
Unknown reported by NHS England (East of England) |
1 |
|
Norfolk and Norwich University Hospitals NHS Foundation Trust |
5 |
|
North Bristol NHS Trust |
5 |
|
North Cumbria Integrated Care NHS Foundation Trust |
2 |
|
North Middlesex University Hospital NHS Trust |
5 |
|
North Tees and Hartlepool NHS Foundation Trust |
1 |
|
North West Anglia NHS Foundation Trust |
1 |
|
Northampton General Hospital NHS Trust |
1 |
|
Northamptonshire Healthcare NHS Foundation Trust |
1 |
|
Northern Care Alliance NHS Foundation Trust |
1 |
|
Northern Devon Healthcare NHS Trust |
2 |
|
Northern Lincolnshire and Goole NHS Foundation Trust |
3 |
|
Northumbria Healthcare NHS Foundation Trust |
6 |
|
Nottingham University Hospitals NHS Trust |
1 |
|
Nuffield Hospital, North Staffs reported by Stoke on Trent Clinical Commissioning Group |
1 |
|
Nuffield Hospital, North Staffordshire reported by North Staffordshire Clinical Commissioning Group |
1 |
|
Oaklands Hospital reported by NHS Salford Clinical Commissioning Group |
1 |
|
Oxford Health NHS Foundation Trust |
2 |
|
Oxford University Hospitals NHS Foundation Trust |
10 |
|
Oxford University NHS Foundation Trust |
1 |
|
Parkside Hospital reported by NHS Wandsworth Clinical Commissioning Group |
1 |
|
Pennine Acute Hospitals NHS Trust |
3 |
|
Peter Bruff Unit reported by North East Essex Clinical Commissioning Group |
1 |
|
Pinehill Hospital reported by NHS East and North Hertfordshire Clinical Commissioning Group |
1 |
|
Poole Hospital NHS Foundation Trust |
3 |
|
Portsmouth Hospitals University NHS Trust |
5 |
|
Priory Hospital Southampton reported by NHS England |
1 |
|
Queen Victoria Hospital NHS Foundation Trust |
1 |
|
Ramsay Healthcare reported by NHS Bedfordshire Clinical Commissioning Group |
1 |
|
Ramsay Rivers Hospital reported by NHS West Essex Clinical Commissioning Group |
1 |
|
Rowley Hall Hospital reported by Stafford and Surrounds Clinical Commissioning Group |
1 |
|
Royal Berkshire NHS Foundation Trust |
7 |
|
Royal Brompton and Harefield NHS Foundation Trust |
1 |
|
Royal Cornwall Hospitals NHS Trust |
3 |
|
Royal Devon University Healthcare NHS Foundation Trust |
5 |
|
Royal Free London NHS Foundation Trust |
9 |
|
Royal Liverpool and Broadgreen University Hospitals NHS Trust |
3 |
|
Royal Papworth Hospital NHS Foundation Trust |
1 |
|
Royal Surrey County Hospital NHS Foundation Trust |
2 |
|
Royal United Hospitals Bath NHS Foundation Trust |
3 |
|
Salisbury NHS Foundation Trust |
3 |
|
Sandwell and West Birmingham Hospitals NHS Trust |
3 |
|
Sheffield Children’s NHS Foundation Trust |
3 |
|
Sheffield Teaching Hospitals NHS Foundation Trust |
4 |
|
Sherwood Forest Hospitals NHS Foundation Trust |
1 |
|
Smile Together, West Country Dental Care reported by NHS England |
1 |
|
Somerset NHS Foundation Trust |
4 |
|
South Tees Hospitals NHS Foundation Trust |
5 |
|
South Warwickshire University NHS Foundation Trust |
2 |
|
Southport and Ormskirk Hospital NHS Trust |
2 |
|
Spire Healthcare, Southampton General Hosptial reported by NHS Southampton Clinical Commissioning Group |
1 |
|
Spire Little Aston Hospital reported by Birmingham and Solihull Clinical Commissioning Group |
1 |
|
Spire Manchester Hospital reported by NHS Manchester Clinical Commissioning Group |
1 |
|
Spire Methley Park Hospital reported by NHS Leeds Clinical Commissioning Group |
1 |
|
Spire Regency Hospital reported by NHS Eastern Cheshire Clinical Commissioning Group |
1 |
|
St Catharines Hospital reported by NHS Wirral Clinical Commissioning Group |
1 |
|
St George’s University Hospitals NHS Foundation Trust |
4 |
|
St Hugh’s Hospital reported by NHS Lincolnshire East Clinical Commissioning Group |
1 |
|
Stockport NHS Foundation Trust |
3 |
|
Surrey and Sussex Healthcare NHS Trust |
2 |
|
Sussex Community NHS Foundation Trust |
1 |
|
The Dudley Group NHS Foundation Trust |
1 |
|
The Hillingdon Hospitals NHS Foundation Trust |
3 |
|
The Newcastle Upon Tyne Hospitals NHS Foundation Trust |
6 |
|
The Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust |
1 |
|
The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust |
1 |
|
The Rotherham NHS Foundation Trust |
4 |
|
The Royal Bournemouth and Christchurch Hospitals NHS Foundation Trust |
3 |
|
The Royal Wolverhampton NHS Trust |
4 |
|
The Shrewsbury and Telford Hospital NHS Trust |
4 |
|
The Walton Centre NHS Foundation Trust |
1 |
|
Torbay and South Devon NHS Foundation Trust |
2 |
|
United Lincolnshire Teaching Hospitals NHS Trust |
7 |
|
University College London Hospitals NHS Foundation Trust |
11 |
|
University Hospital Southampton NHS Foundation Trust |
3 |
|
University Hospitals Birmingham NHS Foundation Trust |
3 |
|
University Hospitals Bristol and Weston NHS Foundation Trust |
5 |
|
University Hospitals of Derby and Burton NHS Foundation Trust |
8 |
|
University Hospitals of Leicester NHS Trust |
7 |
|
University Hospitals of Morecambe Bay NHS Foundation Trust |
3 |
|
University Hospitals of North Midlands NHS Trust |
7 |
|
University Hospitals Plymouth NHS Trust |
7 |
|
University Hospitals Sussex NHS Foundation Trust |
3 |
|
Wallace House Surgery reported by NHS Bristol North Somerset and South Gloucestershire Clinical Commissioning Group |
1 |
|
Walsall Healthcare NHS Trust |
14 |
|
Warrington and Halton Teaching Hospitals NHS Foundation Trust |
1 |
|
West Hertfordshire Teaching Hospitals NHS Trust |
2 |
|
West Suffolk NHS Foundation Trust |
2 |
|
Weston Area Health NHS Trust |
1 |
|
Whitehouse Dental Surgery reported by NHS England |
1 |
|
Whittington Health NHS Trust |
3 |
|
William Harvey Hospital reported by NHS Medway Clinical Commissioning Group |
1 |
|
Woodland Hospital reported by NHS Nene Clinical Commissioning Group |
1 |
|
Worcestershire Acute Hospitals NHS Trust |
1 |
|
Wrightington, Wigan and Leigh NHS Foundation Trust |
5 |
|
Wye Valley NHS Trust |
3 |
|
York and Scarborough Teaching Hospitals NHS Foundation Trust |
5 |
|
iCash Ipswich, Cambridgeshire Community Services NHS Trust |
1 |
|
Total |
538 |
Source: Reported NHS Never Events from StEIS