NHS England » Never Events reported as occurring between April 2020 and March 2021

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 2020 and March 2021, and which on the 15 July 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 15 July 2025, 416 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had a reported incident date between April 2020 and March 2021, of these 416 incidents:

383 patient safety incidents appeared to meet the definition of a Never Event in the Never Events list 2018 (published 28 February 2018). This number is subject to change as local investigations are completed
33 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 2020 to March 2021 by month of incident

Note: As described above, a further 33 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	20
May	18
June	28
July	28
August	27
September	40
October	49
November	37
December	33
January	26
February	26
March	51
Total	383

Source: Reported NHS Never Events from StEIS

Table 2: Never Events April 2020 to March 2021 by type of incident with additional detail

Description of Never Event	Count
Wrong site surgery	150
Incision to wrong side/site	1
Injection to wrong side/site	13
Procedure intended for another patient	19
Procedure not part of the surgical plan	1
Procedure not required	1
Removal of organ/structure when surgical plan was to conserve it	1
Wrong procedure	10
Wrong side/site procedure	40
Wrong site block	31
Wrong skin lesion removed/biopsy	33
Retained foreign object post procedure	89
Disposable item of equipment/part of disposable item of equipment	5
Guide wire/part of guide wire	27
Not known	1
Surgical instrument/part of surgical instrument	10
Surgical needle/part of surgical needle	3
Surgical swab	15
Tonsil swab	1
Unknown	2
Vaginal swab	25
Misplaced naso or oro gastric tubes and feed administered	32
Apparantly misleading pH test result	5
Placement checks not described or not clearly described	11
X-ray misinterpretation; no indication ‘four criteria’ used	16
Unintentional connection of a patient requiring oxygen to an air flowmeter	30
Patient connected to air flowmeter rather than oxygen flowmeter	30
Wrong implant/ prosthesis	29
Brain stimulation lead	1
Fracture fixation plate/screw	4
Hip	2
Intra uterine contraceptive device	3
Intra medullary nail	1
Knee	2
Lens	10
Stent	4
Vascular graft	1
Vein graft	1
Administration of medication by the wrong route	24
Medication intended for a flush administered intravenously	1
Not known	1
Oral medication given intravenously	16
Oral medication given subcutaneously	5
Topical analgesia medication given intravenously	1
Overdose of insulin due to abbreviations or incorrect device	8
Insulin removed from insulin pen device	1
Wrong syringe	7
Transfusion or transplantation of ABO incompatible blood components of organs	8
Wrong blood transfused	8
Failure to install functional collapsible shower or curtain rails	4
Curtain rail failed to collapse	4
Mis selection of a strong potassium solution	2
Potassium administered in error	2
Scalding of patients	2
Patient scalded in the bath	1
Patient scalded in the shower	1
Wrong implant/prosthesis	2
Hip	1
Nail	1
Chest or neck entrapment in bed rails	1
Patient trapped between mattress and bedrail	1
Chest or neck entrapment in bedrails	1
Patient trapped between mattress and bedrail	1
Mis selection of high strength midazolam during concious sedation	1
Wrong strength midazolam administered	1
Total	383

Source: Reported NHS Never Events from StEIS

Table 3: Never Events April 2020 to March 2021 by healthcare provider

Organisation Name	Number of Never Events
Alder Hey Children’s NHS Foundation Trust	1
Ashford and St Peter’s Hospitals NHS Foundation Trust	1
Barking, Havering and Redbridge University Hospitals NHS Trust	4
Barnsley Hospital NHS Foundation Trust	2
Barts Health NHS Trust	11
Basildon and Thurrock University Hospitals NHS Foundation Trust	5
Bedford Hospital NHS Trust	1
Bedfordshire Hospitals NHS Foundation Trust	2
Birmingham Community Healthcare NHS Foundation Trust	1
Birmingham Women’s and Children’s NHS Foundation Trust	2
Brighton and Sussex University Hospitals NHS Trust	6
Buckinghamshire Healthcare NHS Trust	2
Calderdale and Huddersfield NHS Foundation Trust	3
Cambridge University Hospitals NHS Foundation Trust	3
Cambridgeshire and Peterborough NHS Foundation Trust	1
Cambridgeshire Community Services NHS Trust	1
Central and North West London NHS Foundation Trust	1
Chelsea and Westminster Hospital NHS Foundation Trust	2
Chesterfield Royal Hospital NHS Foundation Trust	2
County Durham and Darlington NHS Foundation Trust	2
Croydon Health Services NHS Trust	1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust	1
Dartford and Gravesham NHS Trust	1
Dewsbury Road Dental Practice reported by NHS Leeds Clinical Commissioning Group	1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust	4
East and North Hertfordshire NHS Trust	3
East Kent Hospitals University NHS Foundation Trust	4
East Lancashire Hospitals NHS Trust	3
East Suffolk and North Essex NHS Foundation Trust	6
East Sussex Healthcare NHS Trust	4
Epsom and St Helier University Hospitals NHS Trust	3
Euxton Hall Hospital reported by NHS Chorley and South Ribble Clinical Commissioning Group	1
First Community Health and Care Cic	1
Frimley Health NHS Foundation Trust	6
Gateshead Health NHS Foundation Trust	1
Gloucestershire Hospitals NHS Foundation Trust	9
Great Ormond Street Hospital For Children NHS Foundation Trust	1
Great Western Hospitals NHS Foundation Trust	3
Guy’s and St Thomas’ NHS Foundation Trust	4
Hampshire Hospitals NHS Foundation Trust	3
Harrogate and District NHS Foundation Trust	1
Homerton Healthcare NHS Foundation Trust	3
Hull University Teaching Hospitals NHS Trust	1
Imperial College Healthcare NHS Trust	6
Isle of Wight NHS Trust	1
James Paget University Hospitals NHS Foundation Trust	2
KIMS Hospital reported by NHS Kent and Medway Clinical Commissioning Group	1
Kettering General Hospital NHS Foundation Trust	2
King’s College Hospital NHS Foundation Trust	5
Kingston and Richmond NHS Foundation Trust	2
Lancashire and South Cumbria NHS Foundation Trust	1
Lancashire Teaching Hospitals NHS Foundation Trust	5
Leeds Community Healthcare NHS Trust	1
Leeds Teaching Hospitals NHS Trust	8
Lewisham and Greenwich NHS Trust	2
Lincolnshire Partnership NHS Foundation Trust	1
Liverpool University Hospitals NHS Foundation Trust	6
Liverpool Women’s NHS Foundation Trust	1
London North West University Healthcare NHS Trust	1
Lyons Court Care Home, Carelines Lifestyle reported by NHS Durham Dales, Easington and Sedgefield Clinical Commissioning Group	1
Macclesfield Health Hub reported by NHS Cheshire Clinical Commissioning Group	1
Maidstone and Tunbridge Wells NHS Trust	1
Manchester University NHS Foundation Trust	2
Medway NHS Foundation Trust	2
Mersey and West Lancashire Teaching Hospitals NHS Trust	3
Mersey Care NHS Foundation Trust	1
Mid and South Essex NHS Foundation Trust	2
Mid Cheshire Hospitals NHS Foundation Trust	2
Mid Essex Hospital Services NHS Trust	1
Mid Yorkshire Teaching NHS Trust	5
Milton Keynes University Hospital NHS Foundation Trust	1
Moorfields Eye Hospital NHS Foundation Trust	3
Mydentist Co Durham reported by NHS County Durham Clinical Commissioning Group	1
NHS England North East And Yorkshire (Cumbria And North East)	1
Norfolk and Norwich University Hospitals NHS Foundation Trust	3
North Bristol NHS Trust	1
North Cumbria Integrated Care NHS Foundation Trust	3
North East London NHS Foundation Trust	1
North Tees and Hartlepool NHS Foundation Trust	1
North West Anglia NHS Foundation Trust	3
Northampton General Hospital NHS Trust	5
Northamptonshire Healthcare NHS Foundation Trust	1
Northern Care Alliance NHS Foundation Trust	3
Northern Lincolnshire And Goole NHS Foundation Trust	2
Northumbria Healthcare NHS Foundation Trust	2
Nottingham University Hospitals NHS Trust	3
Nuffield Health Tees Hopital reported by NHS South Tees Clinical Commissioning Group	1
Oakland’s Hospital reported by NHS Salford Clinical Commissioning Group	1
Oxford University Hospitals NHS Foundation Trust	2
Pennine Acute Hospitals NHS Trust	2
Portsmouth Hospitals University NHS Trust	3
Queen Victoria Hospital NHS Foundation Trust	1
Ramsey Health, New Hall Hospital reported by NHS Dorset Clinical Commissioning Group	1
Ramsey Healthcare – Beacon Park Hospital reported by Stafford and Surrounds Clinical Commissioning Group	1
Royal Berkshire NHS Foundation Trust	6
Royal Cornwall Hospitals NHS Trust	9
Royal Free London NHS Foundation Trust	5
Sandwell and West Birmingham Hospitals NHS Trust	4
Sheffield Children’s NHS Foundation Trust	1
Sheffield Teaching Hospitals NHS Foundation Trust	3
Sherwood Forest Hospitals NHS Foundation Trust	4
Solent NHS Trust	1
Somerset NHS Foundation Trust	1
South Tees Hospitals NHS Foundation Trust	8
South Tyneside and Sunderland NHS Foundation Trust	3
South Warwickshire University NHS Foundation Trust	2
SpaMedica, Skelmersdale reported by NHS Fylde and Wyre Clinical Commissioning Group	1
Spire Hospital Washington reported by NHS County Durham Clinical Commissioning Group	1
Spire Montefiore Hospital reported by NHS Brighton and Hove Clinical Commissioning Group	1
Spire Washington Hospital reported by NHS County Durham Clinical Commissioning Group	1
St George’s University Hospitals NHS Foundation Trust	2
Stockport NHS Foundation Trust	2
Surrey and Sussex Healthcare NHS Trust	1
Sussex Community NHS Foundation Trust	1
The Dudley Group NHS Foundation Trust	3
The Hillingdon Hospitals NHS Foundation Trust	1
The London Clinic reported by North West London Clinical Commissioning Group	1
The Newcastle Upon Tyne Hospitals NHS Foundation Trust	4
The Princess Alexandra Hospital NHS Trust	1
The Queen Elizabeth Hospital, King’s Lynn, NHS Foundation Trust	1
The Rotherham NHS Foundation Trust	3
The Royal Bournemouth And Christchurch Hospitals NHS Foundation Trust	5
The Royal Wolverhampton NHS Trust	2
The Shrewsbury and Telford Hospital NHS Trust	3
The Walton Centre NHS Foundation Trust	1
Torbay and South Devon NHS Foundation Trust	5
United Lincolnshire Teaching Hospitals NHS Trust	1
University College London Hospitals NHS Foundation Trust	8
University Hospital Southampton NHS Foundation Trust	1
University Hospitals Birmingham NHS Foundation Trust	13
University Hospitals Bristol And Weston NHS Foundation Trust	5
University Hospitals Coventry and Warwickshire NHS Trust	2
University Hospitals of Derby and Burton NHS Foundation Trust	1
University Hospitals of Leicester NHS Trust	7
University Hospitals of Morecambe Bay NHS Foundation Trust	4
University Hospitals of North Midlands NHS Trust	1
University Hospitals Plymouth NHS Trust	3
University Hospitals Sussex NHS Foundation Trust	3
Warrington and Halton Teaching Hospitals NHS Foundation Trust	2
Wells Road Dental Practice, Bristol reportd by South West – Provider	1
West Hertfordshire Teaching Hospitals NHS Trust	4
West Suffolk NHS Foundation Trust	2
Wirral University Teaching Hospital NHS Foundation Trust	2
Wotton Dental and Implant Clinic reported by South West – Provider	1
Wrightington, Wigan and Leigh NHS Foundation Trust	1
Wye Valley NHS Trust	1
York And Scarborough Teaching Hospitals NHS Foundation Trust	2
NA	1
Total	383

Source: Reported NHS Never Events from StEIS

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Never Events

Supporting healthcare providers to prevent Never Events

Summary

Table 1: Never Events April 2020 to March 2021 by month of incident

Table 2: Never Events April 2020 to March 2021 by type of incident with additional detail

Table 3: Never Events April 2020 to March 2021 by healthcare provider