NHS England » Never Events reported as occurring between April 2022 and March 2023

Never Events

Now that sufficient time has elapsed to allow for local incident investigation and national analysis of data following the end of the 2022-23 reporting year, this report provides a final update of Never Events reported as occurring between April 2022 and March 2023. It replaces and supersedes the previously published provisional data report for 2022-23.

This report is drawn from the Strategic Executive Information System (StEIS) and includes all patient safety incidents with a reported incident date between April 2022 and March 2023, and which on the 26 September 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 26 September 2025, 426 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had a reported incident date between April 2022 and March 2023, of these 426 incidents:

401 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.
25 patient safety incidents did not appear to meet the definition of a Never Event.

More details are provided in the tables below.

Table 1: Never Events April 2022 to March 2023 by month of incident

Note: As described above, a further 25 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly.

Month in which Never Event occurred	Number of Never Events
April	37
May	43
June	29
July	34
August	39
September	31
October	35
November	24
December	35
January	38
February	32
March	24
Total	401

Source: Reported NHS Never Events from StEIS

Table 2: Never Events April 2022 to March 2023 by type of incident with additional detail

Note: As described above, a further 25 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly.

Description of Never Event	Count
Wrong site surgery	178
Incision to wrong side/site	5
Injection to wrong side/site	27
Procedure intended for another patient	18
Procedure not required	4
Removal of organ/structure when surgical plan was to conserve it	4
Wrong procedure	4
Wrong side/site procedure	38
Wrong site block	41
Wrong skin lesion removed/biopsy	37
Retained foreign object post procedure	100
Cochlear implant spacer	1
Dental block	2
Disposable item of equipment/part of disposable item of equipment	4
Guide wire/part of guide wire	25
Surgical instrument/part of surgical instrument	15
Surgical ribbon gauze	1
Surgical swab	19
Throat pack	1
Vaginal swab	32
Wrong implant/prosthesis	43
Aortic graft	1
Fracture fixation prosthesis	2
Gastrojejunal tube	1
Hip	6
Intrauterine contraceptive device	5
Knee	10
Lens	13
Sacral nerve stimulation device	1
Shunt	1
Stent	1
Toe	2
Misplaced naso or oro gastric tubes and feed administered	32
Apparently misleading pH test result	7
Placement checks not described or not clearly described	7
X-ray misinterpretation: no indication ‘four criteria’ used	18
Administration of medication by the wrong route	17
Medication given via suprapubic catheter rathere than jejunsostomy	1
Nasal medication given intravenously	1
Nebuliser medication given intravenously	1
Oral medication given intravenously	11
Oral medication given subcutaneously	3
Unintentional connection of a patient requiring oxygen to an air flowmeter	8
Patient connected to air instead of oxygen	8
Overdose of insulin due to abbreviations or incorrect device	7
Wrong syringe	7
Transfusion or transplantation of ABO incompatible blood components or organs	7
Unintentional ABO mismatched solid organ transplant	2
Wrong blood	5
Falls from poorly restricted windows	3
Window restrictor not fitted/failed	3
Chest or neck entrapment in bedrails	1
Patient trapped between bedrail and mattress	1
Failure to install functional collapsible shower or curtain rails	1
Rail failed to collapse	1
Mis selection of a strong potassium solution	1
Potassium administered instead of fentanyl	1
Overdose of methotrexate for non-cancer treatment	2
Methotrexate prescribed and administered more than the intended weekly dose	2
Scalding of patients	1
Bath water too hot	1
Total	401

Source: Reported NHS Never Events from StEIS

Table 3: Never Events April 2022 to March 2023 by healthcare provider

Note: As described above, a further 25 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly.

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	5
BMI Winterborne reported by NHS Dorset Clinical Commissioning Group	1
BPAS Birmingham South reported by Birmingham and Solihull Clinical Commissioning Group Contracted Services	1
Barking, Havering and Redbridge University Hospitals NHS Trust	7
Barlborough Hospital reported by NHS Sheffield Clinical Commissioning Group	1
Barts Health NHS Trust	4
Basildon and Thurrock University Hospitals NHS Foundation Trust	1
Bedfordshire Hospitals NHS Foundation Trust	3
Berkshire Healthcare NHS Foundation Trust	1
Birmingham Community Healthcare NHS Foundation Trust	1
Birmingham Women’s and Children’s NHS Foundation Trust	7
Bolton NHS Foundation Trust	1
Boston West Hospital reported by NHS Lincolnshire Clinical Commissioning Group	1
Bradford Teaching Hospitals NHS Foundation Trust	1
Brighton and Sussex University Hospitals NHS Trust	1
Buckinghamshire Healthcare NHS Trust	1
Calderdale and Huddersfield NHS Foundation Trust	4
Cambridge University Hospitals NHS Foundation Trust	2
Chelsea and Westminster Hospital NHS Foundation Trust	1
Countess of Chester Hospital NHS Foundation Trust	4
Dannsa House Care Home reported by NHS Nottingham and Nottinghamshire Integrated Care Board	1
Dartford and Gravesham NHS Trust	2
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust	2
Dorset County Hospital NHS Foundation Trust	1
East and North Hertfordshire Teaching NHS Trust	2
East Cheshire NHS Trust	1
East Kent Hospitals University NHS Foundation Trust	6
East Lancashire Hospitals NHS Trust	1
East Suffolk and North Essex NHS Foundation Trust	3
East Sussex Healthcare NHS Trust	1
Epsom and St Helier University Hospitals NHS Trust	3
Epsomedical, Epsom Day Surgery reported by Surrey Heartlands Integrated Care Board	3
Frimley Health NHS Foundation Trust	4
George Eliot Hospital NHS Trust	2
Gloucestershire Hospitals NHS Foundation Trust	2
Great Ormond Street Hospital for Children NHS Foundation Trust	2
Great Western Hospitals NHS Foundation Trust	2
Guy’s and St Thomas’ NHS Foundation Trust	5
HMT St Hughs reported by NHS North East Lincolnshire Clinical Commissioning Group	1
Hampshire Hospitals NHS Foundation Trust	3
Harrogate and District NHS Foundation Trust	2
Herefordshire and Worcestershire Health and Care NHS Trust	1
Homerton Healthcare NHS Foundation Trust	3
Hull University Teaching Hospitals NHS Trust	6
Imperial College Healthcare NHS Trust	2
Independent Health Group, Millstream Medical Centre Salisbury reported by NHS Banes, Swindon and Wiltshire Clinical Commissioning Group	1
James Paget University Hospitals NHS Foundation Trust	2
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	4
Lewisham and Greenwich NHS Trust	5
Liverpool University Hospitals NHS Foundation Trust	3
Liverpool Women’s NHS Foundation Trust	1
London North West University Healthcare NHS Trust	2
Maidstone and Tunbridge Wells NHS Trust	3
Manchester University NHS Foundation Trust	11
Medway NHS Foundation Trust	4
Mersey and West Lancashire Teaching Hospitals NHS Trust	2
Mid Cheshire Hospitals NHS Foundation Trust	1
Mid Essex Hospital Services NHS Trust	1
Mid Yorkshire Teaching NHS Trust	1
Milton Keynes University Hospital NHS Foundation Trust	1
Moorfields Eye Hospital NHS Foundation Trust	4
Newcastle Upon Tyne Hospitals NHS Foundation Trust	7
Newmedica Eye Clinic, Worcester reported by NHS Herefordshire and Worcestershire Clinical Commissioning Group	1
Norfolk And Norwich University Hospitals NHS Foundation Trust	5
North Bristol NHS Trust	5
North Middlesex University Hospital NHS Trust	4
North Tees and Hartlepool NHS Foundation Trust	4
North West Anglia NHS Foundation Trust	5
Northampton General Hospital NHS Trust	3
Northern Care Alliance NHS Foundation Trust	4
Northern Devon Healthcare NHS Trust	4
Northumbria Healthcare NHS Foundation Trust	4
Nottingham University Hospitals NHS Trust	6
Oxford University Hospitals NHS Foundation Trust	7
Pioneer Healthcare, Claremont Hospital reported by NHS Halton Clinical Commissioning Group	1
Poole Hospital NHS Foundation Trust	4
Portsmouth Hospitals University NHS Trust	4
Practice Plus Group Hospital, Southampton reported by NHS Southampton Clinical Commissioning Group	1
Queen Victoria Hospital NHS Foundation Trust	1
Ramsay Healthcare, Ashstead Hospital reported by NHS Surrey Heartlands Clinical Commissioning Group	1
Ramsay Healthcare, Euxton Hall Hospital reported by NHS Greater Preston Clinical Commissioning Group	1
Robert Jones Agnes Hunt Orthopaedic Hospital NHS Foundation Trust	3
Royal Berkshire NHS Foundation Trust	3
Royal Cornwall Hospitals NHS Trust	1
Royal Devon University Healthcare NHS Foundation Trust	6
Royal Free London NHS Foundation Trust	8
Royal National Orthopaedic Hospital NHS Trust	1
Royal Surrey NHS Foundation Trust	3
Royal United Hospitals Bath NHS Foundation Trust	3
Sandwell and West Birmingham Hospitals NHS Trust	4
Sheffield Children’s NHS Foundation Trust	2
Sheffield Teaching Hospitals NHS Foundation Trust	5
Sherwood Forest Hospitals NHS Foundation Trust	1
Shropshire and Telford Hospitals NHS Trust	3
Somerset NHS Foundation Trust	5
South Tees Hospitals NHS Foundation Trust	7
South Tyneside and Sunderland NHS Foundation Trust	2
South Warwickshire University NHS Foundation Trust	2
Southport and Ormskirk Hospital NHS Trust	3
Spire Nottingham Hospital reported by NHS Nottingham and Nottinghamshire Clinical Commissioning Group	1
St George’s University Hospitals NHS Foundation Trust	4
Surrey and Sussex Healthcare NHS Trust	1
Tameside and Glossop Integrated Care NHS Foundation Trust	1
The Dudley Group NHS Foundation Trust	1
The Princess Alexandra Hospital NHS Trust	3
The Royal Marsden NHS Foundation Trust	2
The Westbourne Centre reportd by NHS Birmingham and Solihull Clinical Commissioning Group	1
Thornbury Hospital reported by NHS South Yorkshire Integrated Care Board	1
Torbay and South Devon NHS Foundation Trust	3
United Lincolnshire Teaching Hospitals NHS Trust	6
University College London Hospitals NHS Foundation Trust	3
University Hospital Southampton NHS Foundation Trust	5
University Hospitals Birmingham NHS Foundation Trust	11
University Hospitals Bristol and Weston NHS Foundation Trust	4
University Hospitals Coventry and Warwickshire NHS Trust	5
University Hospitals of Derby and Burton NHS Foundation Trust	3
University Hospitals of Leicester NHS Trust	8
University Hospitals of Morecambe Bay NHS Foundation Trust	2
University Hospitals of North Midlands NHS Trust	3
University Hospitals Plymouth NHS Trust	4
Walsall Healthcare NHS Trust	2
Warrington and Halton Teaching Hospitals NHS Foundation Trust	3
West Hertfordshire Teaching Hospitals NHS Trust	3
West Suffolk NHS Foundation Trust	2
Whittington Health NHS Trust	1
Wirral University Teaching Hospital NHS Foundation Trust	2
Worcestershire Acute Hospitals NHS Trust	4
Wrightington, Wigan and Leigh NHS Foundation Trust	3
Wye Valley NHS Trust	1
Yeovil District Hospital NHS Foundation Trust	1
York and Scarborough Teaching Hospitals NHS Foundation Trust	5
NA	2
Total	401

Source: Reported NHS Never Events from StEIS

Cookies on the NHS England website

Never Events

Summary

Table 1: Never Events April 2022 to March 2023 by month of incident

Table 2: Never Events April 2022 to March 2023 by type of incident with additional detail

Table 3: Never Events April 2022 to March 2023 by healthcare provider