NHS Never Events : What are they and why do they happen?

The NHS is respected throughout the rest of the world, for the fact that it provides free access to its multitude of services. We’ve all heard the horror stories from other countries, the US in particular, where patients have undergone life-saving emergency treatment, only to find that they are presented with a monumental bill for the medical services that they have received and for which they become personally liable because they don’t have adequate healthcare insurance or indeed any at all. That doesn’t happen in the UK. Treatment under the NHS is free to all irrespective of their financial circumstances. The quality of that treatment is, on the whole, first class.

Mistakes can and do happen in any walk of life. The NHS is not immune to that. When mistakes happen and the patient involved suffers as a result of the error by NHS healthcare professionals, then the victim of the mistake may decide to make a claim for medical negligence.

However, there are some mistakes that should never happen. The NHS acknowledges that.

What are NHS Never Events?

The definition of Never Events is given as:

'serious incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic barriers are available at a national level and should have been implemented by all healthcare providers'.

The NHS provides a list of the incidents, updated from time to time, that are considered to be never events i.e. potential serious occurrences that should never happen.

The 2018 revised list of Never Events is as follows:


  1. Wrong Site Surgery (e.g. operating on the wrong area of the body or even the wrong person)
  2. Wrong Implant/Prothesis (e.g. using the wrong artificial body parts during joint replacement surgery)
  3. Retained Foreign Object (e.g. leaving a scalpel or other surgical injury in the body after an operation


  1. Mis-selection of a strong potassium solution
  2. Administration of medication by the wrong route
  3. Overdose of insulin due to abbreviations or incorrect device
  4. Overdose of methotrexate for non-cancer treatment
  5. Mis-selection of high strength midazolam during conscious sedation

Mental Health

  1. Failure to install a functional collapsible shower or curtain rails


  1. Falls from poorly restricted windows
  2. Chest or neck entrapment in bed rails
  3. Transfusion or transplantation of ABO-incompatible blood components or organs
  4. Misplaced naso- or ora- gastric tubes
  5. Scalding of patients
  6. Unintentional connection of a patient requiring oxygen to an airflow meter
  7. Undetected oesophageal intubation (incorrect placement of a tube into the oesophagus) -temporarily suspended as a Never Event

This list covers what are considered to be the most basic of errors including mistakes such as

  • operating on the wrong patient or on the wrong area of a patient
  • leaving surgical instruments inside the patient after surgery
  • giving someone incorrect drugs or dosage of drugs.

Do Never Events still happen?

Given that the NHS has published a list of events that it considers would be the most obvious forms of medical negligence, you would be forgiven for thinking that such mistakes should never happen. Unfortunately, they do, and although such basic errors are exceptionally rare, statistics released by the NHS for the period 1 April 2018 and 31 January 2019, indicate that 430 incidents were reported as Never Events.

These reports included incidents of: -

  • Wrong Site Surgery (165 incidents) Retained instruments following surgical procedures (91 incidents Wrong implant/prosthesis (58 incidents) Unintentional connection of a patient requiring oxygen to an airflow meter (43 incidents)-
    • Misplaced naso- or ora- gastric tubes (26 incidents)
    • Overdoes of insulin due to abbreviations or incorrect device (12 incidents)
  • Wrong route administration of medication (10 incidents)
    • Failure to install a functional collapsible shower or curtain rails (7 incidents)
    • Transfusion or transplantation of ABO-incompatible blood components or organs (4 incidents)
    • Mis-selection of high strength midazolam during conscious sedation (3incidents)
    • Overdose of methotrexate for non-cancer treatment (3 incidents)
    • Falls from poorly restricted windows (1 incident)

The NHS publish this data and indeed, specifically classify what mistakes (or, in other words, incidents of clinical negligence) are considered to be Never Events, in order to highlight potential weaknesses in safety processes and therefore to identify areas where improvement is required and further preventative measures can be made. Nevertheless, the fact that between 8 and 9 NHS Never Events happen on average each week is a cause for concern, because they are largely preventable.

Spencers Solicitors - a case study of a medical negligence claim arising out of a Never Event

Our client underwent keyhole surgery to remove her appendix. Following the surgery, the client suffered from back pain. A month later he had a scan which failed to show any injury to her back. The client continued to complain of back pain but it was over two years until she eventually underwent an MRI scan which revealed that there was a piece of metal in her abdomen.

The client underwent further surgery to remove a metal medical instrument which had been left inside the client’s abdomen during the appendix operation over two and a half years earlier, following which her back pain stopped.

Spencers Solicitors were successful in pursuing a medical negligence claim against the NHS because of the medical instrument having been left inside the client’s body, following surgery and also for the delay in dealing with the issue, which had caused the client to suffer physical pain, anxiety and loss of earnings.

NHS Never Events are 'devastating for patients and their surgeons

Andrew Miles, a Consultant Colorectal Surgeon and Director of Professional Affairs at the Royal College of Surgeons described such incidents as “devastating for patients and their surgeons, (even if no harm has been done)”.

The medical negligence solicitors team here at Spencers, have extensive experience of acting on behalf of clients as a result of the consequences of Never Events taking place. Our specialist medical negligence lawyers have represented patients making claims against the NHS in a variety of cases including:

  • instances of excessive amounts of anaesthesia being administered during surgery
  • swabs and instruments being left in the patient following surgery (retained instruments following surgical procedures)
  • treatment being administered to the wrong limb (wrong-site surgery)

In our experience, one of the most fundamental things a client seeks to establish is why the error occurred and this can often be the most difficult thing to establish, even with the current "duty of candour" which requires treatment providers to be open and transparent with patients in respect of their care and treatment.

In addition to ensuring that our clients are fully compensated by making medical negligence claim on their behalf, to recover compensation for pain, suffering and loss of amenity, we, as a team, are committed to assisting clients in getting answers and providing support at what is often the most difficult and stressful time of their lives, with the aim of putting things right.

If you have been the victim of an NHS Never Event and have suffered as a result, contact Spencers Solicitors medical negligence specialists on 08000 93 00 94, now for a free, confidential chat to see if we can help you.

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