Never Events are serious, largely preventable patient safety incidents that should not occur if proper safeguards are followed. When they do happen, they represent a profound failure in care and can have life-changing consequences for patients and their families. As such, they are classified as nationally reportable incidents under NHS England’s Never Events policy framework.
Every year, hundreds of these incidents are reported across NHS hospitals in England. While the vast majority of treatment is delivered safely, even a single avoidable catastrophic error raises urgent questions about systems, accountability, and patient safety. Providers also owe a statutory duty of candour to notify affected patients, offer a sincere apology, explain what is known, and keep them updated as investigations progress.
This article explains what Never Events are, how they arise, real examples of what can go wrong, and what legal options exist for those affected, focusing on the position in England and Wales.
What Is a Never Event?
The term “Never Event” is used by the NHS to describe serious, largely preventable incidents that should not happen if established safety procedures are correctly implemented. NHS England maintains a published Never Events List (which is updated periodically), which defines the event types and the national safety requirements intended to prevent them
The concept is rooted in patient safety policy. Under frameworks such as the former Serious Incident Framework and the current Patient Safety Incident Response Framework, hospitals must investigate these events thoroughly, identify root causes, and implement learning to prevent recurrence. Under PSIRF, investigations are systems‑based and should involve patients and families where appropriate, with demonstrable learning and action plans to prevent recurrence.
Importantly, a Never Event is not simply a poor outcome. It arises where:
- Clear national safety guidance existed.
- The incident was entirely avoidable.
- Serious harm occurred, or the risk of serious harm was present.
They are, in effect, system failures. They are not the same as inherent treatment risks or recognised complications.
Common categories include wrong site surgery, retained foreign objects post‑procedure, wrong implant or prosthesis, misplaced nasogastric or orogastric tubes resulting in feed into the respiratory tract, and administration of medication via the wrong route.
How Common Are Never Events?
Although Never Events are described as “wholly preventable”, they continue to occur across NHS providers in England.
According to the provisional NHS England publication covering 1 April 2024 to 31 March 2025, a total of 421 incidents were initially recorded as Never Events. Of these, 403 incidents appeared to meet the 2018 Never Events definition at the time of reporting. A further 18 were under review and may not ultimately meet the criteria. As investigations continue, figures remain subject to change.
The most common category was wrong site surgery, accounting for 185 cases. This includes:
- 46 wrong side or wrong site procedures.
- 41 wrong site nerve blocks.
- 36 wrong skin lesions removed or biopsied.
- 9 procedures carried out on the wrong patient.
- 4 procedures that were not required at all.
The second most frequent category was retained foreign objects post-procedure, with 106 cases. These involved items such as:
- 32 vaginal swabs or packs.
- 23 guide wires.
- 19 surgical swabs.
- 17 surgical instruments or parts of instruments.
- 10 disposable equipment items.
These figures are drawn from the Strategic Executive Information System (StEIS) and reflect reports made before the completion of local investigations. National reporting is transitioning from StEIS to the Learning from Patient Safety Events (LFPSE) service, and figures are also subject to national validation.
A Real-life Example
In one case, a man attended hospital expecting nothing more than a consultation – a routine discussion with his consultant. Instead, he underwent a cystoscopy.
A cystoscopy is an invasive internal bladder examination involving the insertion of a camera into the urethra. It is not a minor administrative mix-up. It is a physical procedure requiring preparation and consent. Proceeding without valid, procedure‑specific consent may itself amount to a breach of duty under the ‘Montgomery v Lanarkshire Health Board’ principles.
The mistake only came to light when another patient, who shared the same name, later queried at reception when his own cystoscopy would take place. Staff then realised the wrong individual had undergone the procedure.
Other cases in the same reporting period included:
- A woman who consented to a hysterectomy but woke from anaesthetic to discover her right ovary had been removed unnecessarily.
- Laser surgery performed on the wrong patient while the intended patient waited for their appointment.
- A glaucoma sufferer receiving laser treatment to the wrong eye.
- Surgeons removing the wrong adrenal gland.
- A patient discharged home before discovering in his paperwork that surgery for a kidney stone had been carried out on the wrong side of his body, requiring further corrective operations.
- A sciatica patient noticing that local anaesthetic had been injected into her “good” leg before surgery, prompting staff to halt and reassess.
Each scenario reveals breakdowns in verification processes. Contributory factors often include interruptions and time pressure, incomplete “time‑out” checks, inadequate swab/instrument counts, poor handover and record‑keeping, and gaps in staffing, supervision or escalation.
Transparency and Reporting
Never Events are logged and published to encourage openness and learning. Freedom of Information disclosures have played a role in bringing some incidents into public awareness.
Public reporting is intended to drive improvement, promote standardisation of safety practices, and demonstrate accountability. Providers must also comply with the statutory duty of candour: to notify the patient (or family), offer a sincere apology, explain what is known, and provide updates as inquiries progress.
Professional bodies have consistently emphasised the importance of access to justice for injured patients. Representatives from the Association of Personal Injury Lawyers have described Never Events as appalling failings in patient care that should never have happened.
Public reporting serves two functions:
- Supporting improvement.
- Reassuring patients that transparency is valued.
However, some critics argue that the UK definition of Never Events remains narrower than comparable reporting systems in countries such as the United States, where additional categories – including serious medication reactions, preventable inpatient suicides, and patient abduction – are explicitly listed.
N.B. An apology given under the duty of candour is not, in law, an admission of liability (Compensation Act 2006, s.2).
Legal Rights After a Never Event
Not every medical mistake constitutes negligence in law. A Never Event, however, often provides strong evidence that established safety protocols were not followed.
To pursue a clinical negligence claim in England and Wales, it must generally be shown that:
- A duty of care existed.
- That duty was breached.
- The breach caused injury.
- The claim is brought within the relevant limitation period – usually three years from the date of knowledge for adults.
Compensation may include:
- General damages (pain, suffering and loss of amenity).
- Past and future financial losses (earnings, care and case management, treatment and therapies, aids and equipment, travel).
- Housing and adaptation costs.
- Provisional damages or periodical payments.
Claims against NHS bodies are typically handled by NHS Resolution. Time limits vary in certain circumstances:
- For children, time runs from their 18th birthday.
- For protected parties lacking capacity, time does not run while capacity is absent.
- For fatal claims, the period is generally three years from death or the personal representative’s date of knowledge.
The court has a discretion to disapply limitation under section 33 of the Limitation Act 1980.
An apology or disciplinary outcome, however, cannot be guaranteed through civil proceedings. The legal process focuses on compensation and accountability through financial redress.
Complaints to the Trust, escalation to the Parliamentary and Health Service Ombudsman, and referrals to professional regulators (e.g., GMC/NMC) or the Care Quality Commission can proceed in parallel but do not provide compensation.
The Claim Process
If you have suffered harm because of a Never Event, the legal process follows a clear and structured pathway. While every case is different, most claims progress through the following stages:
1. Free Initial Consultation
Your claim begins with a confidential, no-obligation discussion. You explain what happened and how it has affected you. A specialist solicitor will assess whether the incident is likely to meet the legal test for negligence and advise you on funding options, including No Win, No Fee.
2. Gathering Medical Records and Evidence
If you decide to proceed, your solicitor obtains your full medical records from the relevant NHS Trust or private provider. This includes operation notes, consent forms, investigation reports, and discharge summaries. Witness statements and supporting documentation are also collected to build a clear timeline of events.
3. Independent Medical Expert Review
An independent expert in the appropriate medical field reviews the evidence. They assess whether the care fell below a reasonable standard and whether that failure directly caused your injury. Their report is crucial in proving liability and identifying the full impact on your health and future. Further experts may be instructed to address condition and prognosis, care needs, and the valuation of losses (quantum).
4. Letter of Claim
Once supportive expert evidence is secured, a formal Letter of Claim is sent to the healthcare provider. This sets out what went wrong, why it amounted to negligence, the injuries suffered, and the financial losses incurred. The Letter of Claim is sent under the Pre‑Action Protocol for the Resolution of Clinical Disputes.
5. Defendant’s Investigation and Response
The NHS Trust or private provider usually has four months to investigate and respond under the Pre-Action Protocol. They may admit liability, deny the claim, or admit part of it. Claims against NHS bodies are generally managed by NHS Resolution on behalf of the Trust.
6. Negotiation and Settlement
If liability is admitted, negotiations begin to agree compensation. This can include damages for pain and suffering, loss of earnings, rehabilitation, care needs, home adaptations, and long-term support. Interim payments may be secured in serious cases. Settlement may involve formal ‘without prejudice’ offers and can proceed alongside rehabilitation planning, with interim payments sought where appropriate.
7. Court Proceedings (If Necessary)
If liability is denied or a fair settlement cannot be reached, court proceedings may be issued to protect your position within the legal time limit. Even then, the majority of cases resolve before trial, but issuing proceedings ensures the matter can progress toward a judicial decision if required. The court will manage the case through directions, and interim applications may be needed to resolve issues such as disclosure or expert evidence.
Throughout the process, your solicitor manages deadlines, communication, and evidence gathering, allowing you to focus on recovery while your claim is handled with care and precision. Where appropriate, interim payments can be obtained to fund treatment and care while the claim progresses.
Final Thoughts
Never Events represent the sharpest edge of patient safety failure – incidents that should have been entirely preventable.
While most NHS care is delivered to a high standard, the existence of hundreds of such incidents within reporting periods demonstrates that improvement remains essential. Timely access to records, clarity about the provider’s investigation and learning, and early consideration of limitation can protect your position.
If you or a loved one has experienced a Never Event, specialist legal advice can help you understand your position and what steps may be taken next.