The latest provisional data published by NHS England has revealed that 142 patient safety incidents were recorded as Never Events between April and July 2025. Of these, 139 incidents met the formal definition set out in the 2018 Never Events framework, with three cases currently under review.
What is a Never Event?
Never Events are serious, preventable patient safety incidents that should not occur if healthcare providers follow established national guidance and safety recommendations.
Under the revised 2018 framework, a single Never Event is treated as a red flag, indicating potential weaknesses in an organisation’s fundamental safety systems.
The policy emphasises learning rather than blame. Financial sanctions were removed in 2018 to discourage a “blame culture”. However, the absence of sanctions does not reduce the seriousness of these incidents, particularly for those harmed.
Preventing Never Events
The 2018 report by the Care Quality Commission, Opening the Door to Change, identified significant issues in how organisations manage and act on safety alerts:
- Alerts were often circulated mainly to raise awareness, without ensuring that the required corrective actions were fully implemented.
- Responsibility for confirming completion of actions was frequently delegated to junior staff, with limited senior oversight.
- A lack of central coordination meant individual teams were expected to implement actions locally, leading to duplication, inconsistency, and incomplete implementation of the most effective system-wide improvements.
To strengthen patient safety, NHS England has established the National Patient Safety Alerting Committee (NaPSAC) to oversee and coordinate the implementation of safety alerts, and NHS providers are expected to conduct Patient Safety Incident Investigations (PSIIs) after every Never Event, focusing on identifying root causes and improving systems.
The most common types of Never Events
Between April and July 2025, the most frequently reported Never Events were:
- Wrong site surgery (58 incidents) – Operations carried out on the wrong side, body part, lesion, or even the wrong patient.
- Retained foreign objects (35 incidents) – Surgical items such as guide wires, instruments, swabs, or needles left inside patients after procedures.
- Wrong implant or prosthesis (14 incidents) – Patients receiving incorrect hip, knee, shoulder, spinal, or lens implants.
- Medication errors (17 incidents) – Including insulin overdoses, medication administered by the wrong route, and use of high-strength midazolam.
These categories highlight recurring system failures in areas where national safety guidance is already in place.
Healthcare providers reporting Never Events
The provisional data from NHS England shows that the 139 qualifying Never Events were reported across a wide range of NHS trusts and independent providers in England.
While the majority of organisations reported one or two incidents, several providers recorded higher numbers during the April–July 2025 period. These included:
- 6 incidents – Manchester University NHS Foundation Trust
- 5 incidents – The Newcastle Upon Tyne Hospitals NHS Foundation Trust
- 4 incidents each – Buckinghamshire Healthcare NHS Trust, St George’s University Hospitals NHS Foundation Trust and Wirral University Teaching Hospital NHS Foundation Trust
The 2024 Never Events framework consultation
In February 2024, NHS England launched a consultation to review whether the current Never Events framework remains effective. This followed concerns from the Health Services Safety Investigations Body that some of the safeguards designed to prevent certain Never Events may not be strong or reliable enough.
The consultation highlighted the need to update the framework to ensure the list of Never Events accurately reflects the issues that matter most to patients and the NHS. A discovery phase will explore and test potential alternatives, with the goal of creating a more robust and representative system for preventing serious, avoidable patient safety incidents.
How Tees can help
Behind the 139 recorded Never Events are patients and families who may face life-changing and devastating consequences including:
- further surgery
- extended hospital stays
- long-term injury
- psychological trauma
- financial loss
- In the most serious cases, loss of life.
Our specialist medical negligence team has extensive experience handling a wide range of claims. We work with independent medical experts to establish what happened, assess whether care fell below expected standards, and identify what support or compensation may be available to help you recover and manage ongoing care.
If you are considering a potential medical negligence claim, we offer a confidential, no-obligation consultation to discuss your options and provide guidance and support throughout the process. Contact us today.
