1. Never Events framework consultation 2024

In February 2024, NHS England launched a consultation seeking views on whether the existing Never Events Framework remains an effective mechanism to support patient safety improvement.

The outcome of the consultation was published on the 16 September 2025 NHS England » Never Events framework: 2024 consultation findings. This signals the start of a discovery phase to explore the preferred option of a new approach to the Never Events framework, by exploring and testing alternatives in collaboration with stakeholders, including patients and NHS staff.

2. Important notes on the provisional nature of this data

To support learning from Never Events we are committed to publishing this data as early as possible. However, because reports of apparent Never Events are submitted by healthcare providers as soon as possible, often before local investigation is complete, all data is provisional and subject to change.

Due to the complex combination of incidents identified as Never Events when first reported, patient safety incidents designated as Never Events at a later date, and incidents initially reported as Never Events that on investigation are found not to meet the criteria, our monthly provisional Never Event reports provide cumulative totals for the current financial year. This is to ensure the information provided is as consistent and as accurate as possible.

This provisional report is drawn from the Strategic Executive Information System (StEIS) system and Learn from Patient Safety Events (LFPSE) and includes all patient safety incidents with an incident occurring date during April 2026 and which on the 19 May 2026 were designated by their reporters as Never Events.

Data on Never Events for 2025/26 and previous years can be found on the NHS England website. Once sufficient time has elapsed after the end of the 2025/26 reporting year for local incident investigation and national analysis of data, we will produce a final whole-year report of Never Events, which will replace this provisional data.

3. Data quality

Since the introduction of version 6 of LFPSE, organisations can now report Never Events to LFPSE directly.  We have reviewed and included those incident reports on LFPSE that are reported as a Never Event and state the type of Never Event, for example, Wrong Site Surgery. As with previous reporting, some of these incidents did not appear to meet the definition of a Never Event and so have not been included in the final numbers. We will continue to review the data quality of those events that are reported as a Never Event with no type to ensure that we are not excluding genuine incidents that are believed to be Never Events.

4. Record summary

4.1 StEIS

When data for this report was extracted on 19 May 2026, 14 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had an incident occurring date during April 2026., of these 14 incidents:

• 14 patient safety incidents appeared to meet the definition of a Never Event outlined in the Never Events list 2018 (published 28 February 2018). This number is subject to change as local investigations are completed.
• 0 patient safety incidents did not appear to meet the definition of a Never Event.

4.2 LFPSE

When data for this report was extracted on 19 May 2026, 17 patient safety incidents on the LFPSE system were designated by their reporters as Never Events, of these incidents:

• 13 patient safety incidents appeared to meet the definition of a Never Event, this number is subject to change as local investigations are completed.
• 4 patient safety incidents did not appear to meet the definition of a Never Event.

4.3 Duplicates

There are occurrences where the same Never Event has been recorded on both the LFPSE and StEIS databases. As part of the process for creating this publication, the data has gone through de-duplication. Never Events of the same type reported by the same organisation as occurring on the same date (or within 1 day) are considered duplicates. In this publication:

• 3 Never Events were identified as recorded on both databases and were subsequently removed from StEIS to avoid double counting.

The remaining incidents from both databases were then combined together to create the aggregate counts in the following tables in this report.

5. Reporting by month

Table 1: Count of Never Events by month

Based on never events reported to have occurred during April 2026.

Source: Reported NHS Never Events from LFPSE and StEIS

6. Recording by type

Table 2: Count of Never Events by type category

Based on Never Events reported to have occurred during April 2026.

Source: Reported NHS Never Events from LFPSE and StEIS

7. Recording by organisation

Table 3: Count of Never Events by reporting organisation

Based on never events reported to have occurred during April 2026.

Source: Reported NHS Never Events from LFPSE and StEIS