Never Events data

The NHS in England is one of the only healthcare systems in the world that is this open and transparent about patient safety incident reporting, particularly around Never Events. We are clear that we need to openly tackle these issues, not ignore them.

We publish provisional Never Events data every month as an update of the cumulative total for the current financial year. The data is published in the following formats:

  • the overall provisional number of Never Events reported in the current financial year to date – these are displayed by month
  • the provisional number of each type of Never Event reported, with a more detailed breakdown of sub categories of Never Event
  • the provisional number of each type of Never Event reported by an organisation
Due to the initiation on 1 February 2018 of a revised Never Events list, which included changes to some of the definitions of Never Events and the addition of new types of Never Event, reports covering periods since 1 February 2018 are not comparable with earlier reports.

Never Events framework consultation 2024

We are currently consulting on the future of the Never Events framework.

The consultation is being held following the findings of reports from the CQC and HSIB, and further focus groups held by the National Patient Safety Team throughout 2021/22, that highlighted for several types and sub-types of Never Events the barriers are not strong enough to make an incident wholly preventable.

Visit our dedicated Never Events Framework Consultation webpage for more information and to share your views. The webpage includes an easy read version of the consultation document.

The consultation will run until 5 May 2024.

Following the consultation closure, we will review the responses and engage further with stakeholders, including patient representatives, on the next steps.

Provisional 2024/25 data: 1 April 2024 – 31 May 2024

Provisional 2023/24 data: 1 April 2023 – 31 March 2024

Provisional 2022/23 data: 1 April 2022 and 31 March 2023

Provisional 2021/22 data: 1 April 2021 – 31 March 2022

Provisional 2020/21 data: 1 April 2020 – 31 March 2021

Provisional 2018/19 data: 1 April 2018 to 31 March 2019

Final data from 2019/20

Each year, once sufficient time has elapsed for local incident investigation and national analysis of data to take place, we publish a final whole-year report which supersedes our monthly provisional reports.

Final data from 2017/18

Final data from 2016/17

Final data from 2015/16

Final data from 2014/15 and earlier

Comparing the 2016/17 and 2015/16 data with previous years

It is not possible to compare the number of Never Events reported in the 2016/17 and 2015/16 final updates with reports covering previous years. This is because the Never Events Policy and Framework and the Never Events list was revised in March 2015.

The NHS has become better at incident reporting which is also expected to have led to an increase in the numbers of reported Never Events. In addition, the numbers of Never Events reported by independent providers is also increasing as they report more incidents to our national systems to support learning.

Other considerations

The following points should be considered regarding the increase in the numbers of Never Events reported in 2015/16:
In April 2013 a much more robust process was also introduced to ensure all Never Events were designated as such on the STEIS incident reporting system, and we also clarified the definition of Retained Foreign Objects Post Procedure type of Never Events to ensure providers and commissioners understood more clearly which incidents should be declared as Never Events.

  • the definition of what constitutes a Never Event was amended as it now requires the potential to cause serious harm/death rather than actual harm to have occurred
  • many of the definitions of Never Events on the Never Events list have been refined e.g. Wrong Site Surgery now includes wrong site blocks (42 reported 2015/16), a clarification was made that wrong tooth extraction is a Never Event (33 reported 2015/16) and the list now includes wrong level spinal surgery (11 reported 2015/16)
  • wrong site surgery was clarified to include surgical interventions done outside the operating department environment and includes line insertions e.g. Hickman, central lines etc
  • wrong implant/prosthesis was amended to remove the requirement for further surgery to replace the incorrect implant/prosthesis and the occurrence of complications