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.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.
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.
Because of 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) and includes all patient safety incidents with a reported incident date between April 2025 and November 2025, and which on the 5 January 2026 were designated by their reporters as Never Events.
Data on Never Events for 2023/24 and previous years can be found on the NHS England website. Once sufficient time has elapsed after the end of the 2024/25 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.
Summary
When data for this report was extracted on 5 January 2026, 282 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had a reported incident date between April 2025 and November 2025, of these 282 incidents:
- 274 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
- 8 patient safety incidents did not appear to meet the definition of a Never Event
More detail is provided in the tables below.
Table 1: Never Events April 2025 to November 2025 by month of incident
Note: As described above, a further 8 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 |
27 |
|
May |
35 |
|
June |
40 |
|
July |
48 |
|
August |
35 |
|
September |
28 |
|
October |
31 |
|
November |
30 |
|
Total |
274 |
Source: Reported NHS Never Events from StEIS
Table 2: Never Events April 2025 to November 2025 by type of incident with additional detail
Note: As described above, a further 8 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 |
116 |
|
Incision to wrong side/site |
4 |
|
Injection to wrong side/site |
22 |
|
Procedure intended for another patient |
10 |
|
Procedure not part of the surgical plan |
4 |
|
Removal of organ/structure when surgical plan was to conserve it |
1 |
|
Wrong procedure |
4 |
|
Wrong side/site procedure |
28 |
|
Wrong site block |
29 |
|
Wrong skin lesion removed/biopsy |
14 |
|
Retained foreign object post procedure |
73 |
|
Cotton wool ball |
1 |
|
Disposable item of equipment/part of disposable item of equipment |
6 |
|
Guide wire/part of guide wire |
16 |
|
Surgical instrument/part of surgical instrument |
13 |
|
Surgical needle/part of surgical needle |
3 |
|
Surgical swab |
14 |
|
Throat pack |
1 |
|
Vaginal swab |
19 |
|
Wrong implant/prosthesis |
35 |
|
Aortic valve |
1 |
|
Fracture fixation prosthesis |
1 |
|
Heart valve |
1 |
|
Hip |
4 |
|
Intrauterine contraceptive device |
3 |
|
Knee |
11 |
|
Lens |
8 |
|
Not known |
1 |
|
Shoulder |
1 |
|
Spinal cord simulator |
1 |
|
Stent |
3 |
|
Administration of medication by the wrong route |
14 |
|
Oral medication given intravenously |
12 |
|
Oral medication given subcutaneously |
1 |
|
Procedure intended for another patient |
1 |
|
Overdose of insulin due to abbreviations or incorrect device |
13 |
|
Use of abbreviations |
1 |
|
Wrong syringe |
12 |
|
Misplaced naso- or oro-gastric tubes |
9 |
|
Apparantly misleading pH result |
1 |
|
Placement checks not described or not clearly described |
3 |
|
X-ray misinterpretation; no indication ‘four criteria’ used |
5 |
|
Transfusion or transplantation of ABO-incompatible blood components or organs |
6 |
|
Wrong blood |
6 |
|
Falls from poorly restricted windows |
2 |
|
Window restrictor not fitted or failed |
2 |
|
Mis-selection of high strength midazolam during conscious sedation |
2 |
|
High strength midazolam adminisitered |
2 |
|
Chest or neck entrapment in bed rails |
1 |
|
Patient trapped between bedrail and mattress |
1 |
|
Overdose of methotrexate for non-cancer treatment |
1 |
|
Methotrexate prescribed and administered more than the intended weekly dose |
1 |
|
Scalding of patients |
1 |
|
Burns from shower temperature |
1 |
|
Unintentional connection of a patient requiring oxygen to an air flowmeter |
1 |
|
Patient connected to air rather than oxygen |
1 |
|
Total |
274 |
Source: Reported NHS Never Events from StEIS
Table 3: Never Events April 2025 to November 2025 by healthcare provider
Note: As described above, a further 8 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 |
2 |
|
Barking, Havering and Redbridge University Hospitals NHS Trust |
2 |
|
Barnsley Hospital NHS Foundation Trust |
1 |
|
Barts Health NHS Trust |
6 |
|
Basildon and Thurrock University Hospitals NHS Foundation Trust |
2 |
|
Bedfordshire Hospitals NHS Foundation Trust |
2 |
|
Bolton NHS Foundation Trust |
1 |
|
Bradford Teaching Hospitals NHS Foundation Trust |
1 |
|
Brighton and Sussex University Hospitals NHS Trust |
2 |
|
Buckinghamshire Healthcare NHS Trust |
5 |
|
Calderdale and Huddersfield NHS Foundation Trust |
4 |
|
Cambridge University Hospitals NHS Foundation Trust |
4 |
|
Cambridgeshire and Peterborough NHS Foundation Trust |
1 |
|
Cheshire and Wirral Partnership NHS Foundation Trust |
1 |
|
Chesterfield Royal Hospital NHS Foundation Trust |
1 |
|
Circle Healthcare, Harbour Hospital reported by NHS Dorset Integrated Care Board |
1 |
|
Clementine Churchill Hospital reported by NHS North West London Integrated Care Board |
2 |
|
Countess of Chester Hospital NHS Foundation Trust |
1 |
|
County Durham and Darlington NHS Foundation Trust |
1 |
|
Croydon Health Services NHS Trust |
2 |
|
Dartford and Gravesham NHS Trust |
1 |
|
Derbyshire Community Health Services NHS Foundation Trust |
1 |
|
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust |
2 |
|
Dorset County Hospital NHS Foundation Trust |
1 |
|
Dudley Group NHS Foundation Trust |
2 |
|
East Kent Hospitals University NHS Foundation Trust |
2 |
|
East Lancashire Hospitals NHS Trust |
2 |
|
East Suffolk and North Essex NHS Foundation Trust |
4 |
|
East Sussex Healthcare NHS Trust |
2 |
|
Epsom and St Helier University Hospitals NHS Trust |
2 |
|
Epsomedical, Cobham Hospital reported by NHS Surrey Heartlands Integrated Care Board |
1 |
|
Fitzwilliam hospital – Ramsay Health Care reported by NHS Cambridgeshire and Peterborough Integrated Care Board |
1 |
|
Frimley Health NHS Foundation Trust |
3 |
|
Gloucestershire Hospitals NHS Foundation Trust |
2 |
|
Great Western Hospitals NHS Foundation Trust |
2 |
|
Guy’s and St Thomas’ NHS Foundation Trust |
7 |
|
Hampshire and Isle of Wight Healthcare NHS Foundation Trust |
1 |
|
Hampshire Hospitals NHS Foundation Trust |
2 |
|
Harrogate and District NHS Foundation Trust |
1 |
|
Homerton Healthcare NHS Foundation Trust |
1 |
|
Hull University Teaching Hospitals NHS Trust |
6 |
|
Imperial College Healthcare NHS Trust |
3 |
|
Isle of Wight NHS Trust |
3 |
|
James Paget University Hospitals NHS Foundation Trust |
1 |
|
Kent Community Health NHS Foundation Trust |
1 |
|
Kettering General Hospital NHS Foundation Trust |
2 |
|
Lancashire Teaching Hospitals NHS Foundation Trust |
1 |
|
Leeds Teaching Hospitals NHS Trust |
1 |
|
Lewisham and Greenwich NHS Trust |
2 |
|
Liverpool University Hospitals NHS Foundation Trust |
1 |
|
London North West University Healthcare NHS Trust |
2 |
|
MSI Reproductive Choices UK, Maidstone Regional Treatment Centre reported by NHS Kent and Medway Integrated Care Board |
1 |
|
Maidstone and Tunbridge Wells NHS Trust |
3 |
|
Manchester University NHS Foundation Trust |
9 |
|
Mid and South Essex NHS Foundation Trust |
2 |
|
Mid Cheshire Hospitals NHS Foundation Trust |
2 |
|
Mid Essex Hospital Services NHS Trust |
3 |
|
Mid Yorkshire Teaching NHS Trust |
1 |
|
Milton Keynes University Hospital NHS Foundation Trust |
1 |
|
Moorfields Eye Hospital NHS Foundation Trust |
1 |
|
Newcastle Upon Tyne Hospitals NHS Foundation Trust |
6 |
|
Norfolk and Norwich University Hospitals NHS Foundation Trust |
1 |
|
North Bristol NHS Trust |
2 |
|
North Cumbria Integrated Care NHS Foundation Trust |
1 |
|
North Tees and Hartlepool NHS Foundation Trust |
1 |
|
North West Anglia NHS Foundation Trust |
5 |
|
Northern Care Alliance NHS Foundation Trust |
6 |
|
Northern Lincolnshire and Goole NHS Foundation Trust |
5 |
|
Northumbria Healthcare NHS Foundation Trust |
3 |
|
Oxford University Hospitals NHS Foundation Trust |
6 |
|
Poole Hospital NHS Foundation Trust |
3 |
|
Portsmouth Hospitals University NHS Trust |
7 |
|
Practice Plus Group – Plymouth reported by NHS Devon Integrated Care Board |
1 |
|
Princess Alexandra Hospital NHS Trust |
1 |
|
Queen Victoria Hospital NHS Foundation Trust |
2 |
|
Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust |
2 |
|
Royal Berkshire NHS Foundation Trust |
4 |
|
Royal Cornwall Hospitals NHS Trust |
2 |
|
Royal Devon University Healthcare NHS Foundation Trust |
4 |
|
Royal Free London NHS Foundation Trust |
1 |
|
Royal Orthopaedic Hospital NHS Foundation Trust |
2 |
|
Royal United Hospitals Bath NHS Foundation Trust |
2 |
|
Salisbury NHS Foundation Trust |
2 |
|
Sandwell and West Birmingham Hospitals NHS Trust |
2 |
|
Sheffield Children’s NHS Foundation Trust |
3 |
|
Sheffield Teaching Hospitals NHS Foundation Trust |
3 |
|
Sherwood Forest Hospitals NHS Foundation Trust |
1 |
|
Shrewsbury and Telford Hospital NHS Trust |
3 |
|
Somerset NHS Foundation Trust |
3 |
|
South Tees Hospitals NHS Foundation Trust |
2 |
|
South Tyneside and Sunderland NHS Foundation Trust |
1 |
|
South Warwickshire University NHS Foundation Trust |
1 |
|
Southport and Ormskirk Hospital NHS Trust |
2 |
|
Spa Medica – Chelmsford reported by NHS Mid Essex Integrated Care Board |
1 |
|
Spire Southampton reported by NHS Hampshire, Southampton and Isle of Wight Integrated Care Board |
1 |
|
Spire Wellesley reported by NHS Mid Essex Integrated Care Board |
1 |
|
St George’s University Hospitals NHS Foundation Trust |
5 |
|
Stockport NHS Foundation Trust |
1 |
|
Swallows Residential Care Home reported by NHS Lewisham Integrated Care Board |
1 |
|
Torbay and South Devon NHS Foundation Trust |
1 |
|
Tyneside Surgical Services reported by NHS Newcastle Gateshead Integrated Care Board |
1 |
|
University College London Hospitals NHS Foundation Trust |
3 |
|
University Hospital Southampton NHS Foundation Trust |
4 |
|
University Hospitals Birmingham NHS Foundation Trust |
7 |
|
University Hospitals Bristol and Weston NHS Foundation Trust |
1 |
|
University Hospitals Coventry and Warwickshire NHS Trust |
2 |
|
University Hospitals of Derby and Burton NHS Foundation Trust |
4 |
|
University Hospitals of Leicester NHS Trust |
1 |
|
University Hospitals of Morecambe Bay NHS Foundation Trust |
1 |
|
University Hospitals of North Midlands NHS Trust |
4 |
|
University Hospitals Plymouth NHS Trust |
2 |
|
University Hospitals Sussex NHS Foundation Trust |
2 |
|
Warrington and Halton Teaching Hospitals NHS Foundation Trust |
2 |
|
West Hertfordshire Teaching Hospitals NHS Trust |
2 |
|
Whittington Health NHS Trust |
1 |
|
Wirral University Teaching Hospital NHS Foundation Trust |
4 |
|
Worcestershire Acute Hospitals NHS Trust |
1 |
|
Wye Valley NHS Trust |
2 |
|
Total |
274 |
Source: Reported NHS Never Events from StEIS