Never Events
Now that sufficient time has elapsed to allow for local incident investigation and national analysis of data following the end of the 2021-22 reporting year, this report provides a final update of Never Events reported as occurring between April 2021 and March 2022. It replaces and supersedes the previously published provisional data report for 2021-22.
This report is drawn from the StEIS system and includes all patient safety incidents with a reported incident date between April 2021 and March 2022, 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, 454 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had a reported incident date between April 2021 and March 2022, of these 454 incidents:
- 426 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.
- 28 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 2021 – March 2022 by month of incident
Note: As described above, a further 28 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 |
|---|---|
| Apr | 37 |
| May | 32 |
| Jun | 30 |
| Jul | 47 |
| Aug | 30 |
| Sep | 33 |
| Oct | 52 |
| Nov | 39 |
| Dec | 31 |
| Jan | 39 |
| Feb | 29 |
| Mar | 27 |
| Total | 426 |
Source: Reported NHS Never Events from StEIS
Table 2: Never Events April 2021 – March 2022 by type of incident with additional detail
Note: As described above, a further 28 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 | 179 |
| Incision to wrong side/site | 11 |
| Injection to wrong side/site | 27 |
| Not known | 3 |
| Procedure intended for another patient | 14 |
| Procedure not part of the surgical plan | 1 |
| Procedure not required | 3 |
| Removal of organ/structure when surgical plan was to conserve it | 1 |
| Wrong procedure | 6 |
| Wrong side/site procedure | 43 |
| Wrong site block | 47 |
| Wrong skin lesion removed/biopsy | 23 |
| Retained foreign object post procedure | 106 |
| Disposable item of equipment/part of disposable item of equipment | 12 |
| Guide wire/part of guide wire | 19 |
| Ophathalmic port | 1 |
| Ophthalmic trocar | 1 |
| Ribbon gauze | 1 |
| Surgical instrument/ part of surgical instrument | 12 |
| Surgical swab | 21 |
| Throat pack | 1 |
| Trial shoulder prosthesis | 1 |
| Unknown | 1 |
| Vaginal swab | 35 |
| Valve from breast prosthesis | 1 |
| Wrong implant/ prosthesis | 47 |
| Aortic valve | 1 |
| Breast | 1 |
| Fracture fixation prosthesis | 6 |
| Hip | 12 |
| Intra uterine contraceptive device | 4 |
| Knee | 11 |
| Lens | 9 |
| Shoulder | 1 |
| Stent | 1 |
| Vascular access device | 2 |
| Misplaced naso or oro gastric tubes and feed administered | 31 |
| Apparently misleading pH test result | 7 |
| Placement checks not described or not clearly described | 11 |
| X-ray misinterpretation; no indication ‘four criteria’ used | 14 |
| Administration of medication by the wrong route | 23 |
| Oral medication given intravenously | 18 |
| Oral medication given subcutaneously | 5 |
| Unintentional connection of a patient requiring oxygen to an air flowmeter | 13 |
| Patient connected to air instead of oxygen | 13 |
| Overdose of insulin due to abbreviations or incorrect device | 11 |
| Insulin withdrawn from an insulin pen | 2 |
| Wrong syringe | 9 |
| Transfusion or transplantation of ABO incompatible blood components or organs | 6 |
| Wrong blood | 6 |
| Falls from poorly restricted windows | 3 |
| Window restrictor not fitted/failed | 3 |
| Mis selection of high strength midazolam during concious sedation | 2 |
| High strength midazolam administered | 2 |
| Overdose of methotrexate for non cancer treatment | 2 |
| Methotrexate prescribed and administered more than the intended weekly dose | 2 |
| Mis selection of a strong potassium solution | 1 |
| Potassium selected by mistake | 1 |
| Total | 426 |
Source: Reported NHS Never Events from StEIS
Table 3: Never Events April 2021 – March 2022 by healthcare provider
Note: As described above, a further 28 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 |
|---|---|
| Airedale NHS Foundation Trust | 1 |
| Alder Hey Children’s NHS Foundation Trust | 1 |
| Ashford And St Peter’s Hospitals NHS Foundation Trust | 1 |
| BMI Hospital (Huddersfield) reported by Greater Huddersfield CCG | 1 |
| BMI Ridgeway Hospital reported by NHS BaNES, Swindon and Wiltshire CCG | 1 |
| BMI West Midlands Hospital reported by NHS Coventry & Rugby CCG | 1 |
| Barking, Havering And Redbridge University Hospitals NHS Trust | 3 |
| Barts Health NHS Trust | 4 |
| Basildon And Thurrock University Hospitals NHS Foundation Trust | 1 |
| Bedfordshire Hospitals NHS Foundation Trust | 1 |
| Birmingham Women’s And Children’s NHS Foundation Trust | 4 |
| Blackpool Teaching Hospitals NHS Foundation Trust | 5 |
| Bolton NHS Foundation Trust | 3 |
| Bradford Teaching Hospitals NHS Foundation Trust | 3 |
| Brighton And Sussex University Hospitals NHS Trust | 2 |
| Buckinghamshire Healthcare NHS Trust | 3 |
| Calderdale And Huddersfield NHS Foundation Trust | 1 |
| Cambridge University Hospitals NHS Foundation Trust | 5 |
| Central And North West London NHS Foundation Trust | 1 |
| Chelsea And Westminster Hospital NHS Foundation Trust | 2 |
| Circle Health Group, Bishops Wood Hospital reported by NHS Herts Valleys CCG | 1 |
| Circle Hospital, Reading reported by NHS Berkshire West CCG – Provider | 2 |
| Countess Of Chester Hospital NHS Foundation Trust | 3 |
| County Durham And Darlington NHS Foundation Trust | 2 |
| Croydon Health Services NHS Trust | 2 |
| Dartford And Gravesham NHS Trust | 2 |
| Derbyshire Community Health Services NHS Foundation Trust | 1 |
| Doncaster And Bassetlaw Teaching Hospitals NHS Foundation Trust | 1 |
| Dorset County Hospital NHS Foundation Trust | 1 |
| East And North Hertfordshire Teaching NHS Trust | 4 |
| East Kent Hospitals University NHS Foundation Trust | 2 |
| East Lancashire Hospitals NHS Trust | 2 |
| East Suffolk And North Essex NHS Foundation Trust | 7 |
| East Sussex Healthcare NHS Trust | 3 |
| Epsom And St Helier University Hospitals NHS Trust | 1 |
| Epsomedical reported by NHS Surrey Heartlands CCG – Provider | 2 |
| Essex Treatment Centre reported by North West London Collaboration of CCG’s | 1 |
| Frimley Health NHS Foundation Trust | 3 |
| Gloucestershire Health And Care NHS Foundation Trust | 1 |
| Gloucestershire Hospitals NHS Foundation Trust | 10 |
| Great Ormond Street Hospital For Children NHS Foundation Trust | 2 |
| Great Western Hospitals NHS Foundation Trust | 3 |
| Guy’s And St Thomas’ NHS Foundation Trust | 8 |
| Hampshire Hospitals NHS Foundation Trust | 2 |
| Harrogate And District NHS Foundation Trust | 4 |
| Heatherbrook Surgery reported by NHS East Leicestershire and Rutland CCG | 1 |
| Homerton Healthcare NHS Foundation Trust | 1 |
| Hull University Teaching Hospitals NHS Trust | 6 |
| Humber Teaching NHS Foundation Trust | 1 |
| Imperial College Healthcare NHS Trust | 4 |
| KIMS Hospital reported by NHS Kent and Medway CCG – Provider | 1 |
| Kettering General Hospital NHS Foundation Trust | 3 |
| King’s College Hospital NHS Foundation Trust | 4 |
| Kingston And Richmond NHS Foundation Trust | 3 |
| Lancashire Teaching Hospitals NHS Foundation Trust | 2 |
| Leeds Teaching Hospitals NHS Trust | 6 |
| Lewisham And Greenwich NHS Trust | 4 |
| Liverpool Heart and Chest NHS Foundation Trust | 1 |
| Liverpool University Hospitals NHS Foundation Trust | 8 |
| Liverpool Women’s NHS Foundation Trust | 1 |
| Locala, Huddersfield reported by Greater Huddersfield CCG | 1 |
| London North West University Healthcare NHS Trust | 4 |
| Maidstone And Tunbridge Wells NHS Trust | 4 |
| Manchester University NHS Foundation Trust | 11 |
| Martlets Hospice reported by NHS Brighton and Hove CCG | 1 |
| Medway NHS Foundation Trust | 1 |
| Mersey And West Lancashire Teaching Hospitals NHS Trust | 1 |
| Mid Cheshire Hospitals NHS Foundation Trust | 3 |
| Mid Essex Hospital Services NHS Trust | 4 |
| Mid Yorkshire Teaching NHS Trust | 3 |
| Milton Keynes University Hospital NHS Foundation Trust | 2 |
| Moorfields Eye Hospital NHS Foundation Trust | 1 |
| Norfolk And Norwich University Hospitals NHS Foundation Trust | 2 |
| Norfolk and Norwich Surgical Limited, St Stephens Gate MedicL Practice reported by NHS Arden & GEM CSU (Anglia) – Provider | 1 |
| North Bristol NHS Trust | 3 |
| North Cumbria Integrated Care NHS Foundation Trust | 1 |
| North Middlesex University Hospital NHS Trust | 4 |
| North Tees And Hartlepool NHS Foundation Trust | 2 |
| North West Anglia NHS Foundation Trust | 5 |
| Northampton General Hospital NHS Trust | 3 |
| Northern Care Alliance NHS Foundation Trust | 2 |
| Northern Devon Healthcare NHS Trust | 1 |
| Northern Lincolnshire And Goole NHS Foundation Trust | 5 |
| Northumbria Healthcare NHS Foundation Trust | 4 |
| Norwich Practices Ltd reported by NHS Arden & GEM CSU (Anglia) | 1 |
| Nottingham University Hospitals NHS Trust | 9 |
| Nuffield Hospital, York reported by NHS Vale of York CCG – Provider | 1 |
| Oxford University Hospitals NHS Foundation Trust | 4 |
| Pennine Acute Hospitals NHS Trust | 2 |
| Pioneer Healthcare,Kinvara Private Hospital, Rotherham reported by Kirklees CCG | 1 |
| Portsmouth Hospitals University NHS Trust | 5 |
| Practice Plus Group Hospital, Shepton Mallet reported by NHS Somerset CCG – Provider | 1 |
| Ramsay Health Care UK, Clifton Park Hosptil reported by NHS Vale of York CCG – Provider | 1 |
| Ramsay Health Care UK, Horton Treatment Centre reported by NHS Oxfordshire CCG | 1 |
| Royal Berkshire NHS Foundation Trust | 4 |
| Royal Cornwall Hospitals NHS Trust | 1 |
| Royal Devon University Healthcare NHS Foundation Trust | 6 |
| Royal Free London NHS Foundation Trust | 1 |
| Royal National Orthopaedic Hospital NHS Trust | 1 |
| Royal Papworth Hospital NHS Foundation Trust | 1 |
| Royal Surrey NHS Foundation Trust | 1 |
| Royal United Hospitals Bath NHS Foundation Trust | 1 |
| Salisbury NHS Foundation Trust | 3 |
| Sandwell And West Birmingham Hospitals NHS Trust | 10 |
| Sheffield Teaching Hospitals NHS Foundation Trust | 5 |
| Sherwood Forest Hospitals NHS Foundation Trust | 5 |
| Solent NHS Trust | 2 |
| South Tees Hospitals NHS Foundation Trust | 4 |
| South Tyneside And Sunderland NHS Foundation Trust | 4 |
| South Warwickshire University NHS Foundation Trust | 2 |
| SpaMedica, Manchester reported by NHS Manchester CCG | 1 |
| Spire Liverpool reported by NHS Liverpool CCG | 2 |
| Spire Montefiore Hospital reported by NHS Brighton and Hove CCG | 1 |
| St George’s University Hospitals NHS Foundation Trust | 5 |
| Stockport NHS Foundation Trust | 1 |
| Sulis Hospital, Bath reported by NHS BaNES, Swindon and Wiltshire CCG | 1 |
| The Berkshire Independent Hospital reported by NHS Berkshire West CCG – Provider | 1 |
| The Dudley Group NHS Foundation Trust | 1 |
| The Hillingdon Hospitals NHS Foundation Trust | 1 |
| The Newcastle Upon Tyne Hospitals NHS Foundation Trust | 4 |
| The Princess Alexandra Hospital NHS Trust | 2 |
| The Robert Jones And Agnes Hunt Orthopaedic Hospital NHS Foundation Trust | 3 |
| The Rotherham NHS Foundation Trust | 3 |
| The Royal Orthopaedic Hospital NHS Foundation Trust | 2 |
| The Royal Wolverhampton NHS Trust | 1 |
| The Shrewsbury And Telford Hospital NHS Trust | 1 |
| The Walton Centre NHS Foundation Trust | 2 |
| Torbay And South Devon NHS Foundation Trust | 1 |
| United Lincolnshire Teaching Hospitals NHS Trust | 2 |
| University College London Hospitals NHS Foundation Trust | 3 |
| University Hospital Southampton NHS Foundation Trust | 5 |
| University Hospitals Birmingham NHS Foundation Trust | 6 |
| University Hospitals Bristol And Weston NHS Foundation Trust | 3 |
| University Hospitals Coventry And Warwickshire NHS Trust | 6 |
| University Hospitals Of Derby And Burton NHS Foundation Trust | 7 |
| University Hospitals Of Leicester NHS Trust | 9 |
| University Hospitals Of Morecambe Bay NHS Foundation Trust | 2 |
| University Hospitals Of North Midlands NHS Trust | 6 |
| University Hospitals Plymouth NHS Trust | 4 |
| University Hospitals Sussex NHS Foundation Trust | 1 |
| Walsall Healthcare NHS Trust | 3 |
| Warrington And Halton Teaching Hospitals NHS Foundation Trust | 1 |
| West Hertfordshire Teaching Hospitals NHS Trust | 1 |
| West Suffolk NHS Foundation Trust | 2 |
| Whittington Health NHS Trust | 2 |
| Wirral University Teaching Hospital NHS Foundation Trust | 4 |
| Woodthorpe Hospital, Nottinghsm reported by NHS Nottingham and Nottinghamshire CCG – Provider | 1 |
| Worcestershire Acute Hospitals NHS Trust | 9 |
| Wrightington, Wigan And Leigh NHS Foundation Trust | 3 |
| Wye Valley NHS Trust | 1 |
| Yeovil District Hospital NHS Foundation Trust | 2 |
| York And Scarborough Teaching Hospitals NHS Foundation Trust | 2 |
| NA | 2 |
| Total | 426 |
Source: Reported NHS Never Events from StEIS