NHS Never Events: what are the trends?

January 2026 has seen the publication of the latest NHS data on ‘never events’.

NHS never events are a set of clearly defined, serious patient‑safety incidents which are wholly preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented. The theory behind having this category of reportable events is that never events may highlight potential weaknesses in how an organisation manages fundamental safety processes. They are different from other patient safety incidents as the overriding principle is that even a single never event occurring acts as a red flag that an organisation’s systems for implementing existing safety advice and alerts may not be robust. While each never event type has the potential to cause serious patient harm or death, this does not need to have occurred as a result of a specific incident for it to be categorised as a never event.

What is a never event?

Never events are included in a national list published by the NHS that is periodically reviewed and revised. It was last updated in 2021. A number of categories of event are listed – ranging from wrong site surgery and wrong implants, retained foreign objects post surgery and medication errors to certain scenarios surrounding hospital falls and burns.

A defining feature of such events is that strong systemic barriers – not merely training or policy – exist to prevent these incidents from occurring. With the right controls and safety processes, they should not occur at all. These controls might include:

• standardised surgical checklists
• clear labelling systems
• technological safeguards
• procedural ‘hard stops’
• double‑checking protocols
• equipment design changes
• strict medication administration rules

The NHS frameworks emphasise that human error alone is not the sole issue in such events,  although it is the cause in some cases. Often the underlying issue is a system failure that allowed the error to reach the patient – this might be complexity of process implementation, poor communication, inadequate resourcing or even simple design issues such as similar looking equipment or labelling.

How the NHS responds to never events

When a never event occurs, the organisation must undertake the following processes:

Immediate patient support

Ensuring patient safety, communicating openly, and beginning the duty of candour process.

Internal investigation

Using tools like root‑cause analysis or systems‑based investigations (eg SEIPS or human‑factors‑focused approaches).

Organisational learning

Actions may include:

• revising protocols
• improving training
• redesigning equipment or workflows
• implementing stronger systemic barriers

External reporting

Trusts report never events to NHS England, which publishes national data to promote transparency and improvement.

The trends

So, having addressed what never events are, what are the trends?

In January 2026 the NHS published data for the period April – November 2025. During that time, 274 events were reported which met the criteria for being a never event. The published report breaks down the type of incident and also the healthcare provider – so trends are clearly visible. For this period, the vast majority of the reported never events surrounded surgery – 116 of the 274 reported incidents related to wrong site surgery and 73 of the incidents related to items retained post surgery – swabs, equipment etc.  Both of these types of incident reflect a failure of the most basic safety procedures surrounding surgery.  They were spread across 120 healthcare providers and most only had one incident reported in the relevant period. However, 13 of the providers had five or more never event incidents in this seven month period which should prompt consideration of whether standard safety procedures are operating as they should. The highest number of incidents reported by one provider was nine at Manchester University NHS Foundation Trust.

Obviously this is a snapshot of an eight month period, but how do those figures compare to previous reporting periods? April – October 2024 had slightly fewer reported incidents – 255 vs 274 – but that was a shorter period. Wrong site surgery was still the highest recorded type of incident – 101 events – and retained foreign objects post surgery was the next most significant reported event – 67 in the period. The number of providers reporting incidents was broadly the same – 116 – but the incidence of multiple events from one provider was much less – only six providers had five or more events. The highest number in this period was University Hospitals of Derby and Burton NHS Foundation Trust and University Hospitals Birmingham NHS Foundation Trust.

The period reported prior to that covers a whole year – April 2023 – March 2024. During this time, 370 incidents were reported that met the never event criteria. The same high level of surgery related events was reflected (179 wrong surgery site and 81 retained foreign object). This time the events were spread across 136 healthcare providers, 20 of which reported five or more incidents – the highest being 11 (University Hospitals Birmingham NHS Foundation Trust).

Obviously the reporting periods are all slightly different but the data does serve a purpose. The whole process of never events is designed around spotting healthcare providers who may have systemic issues in implementing core safety procedures and taking action. The data produced is reassuring in some respects – the numbers are broadly stable across three years. There is no significant increase in reported incidents and in the vast majority of cases a healthcare provider is reporting only one event over a six to twelve month period, with the number of multiple events apparently reducing. Allowing for numbers of patients and the unavoidable input of human error from time to time, that seems quite an encouraging picture.

However, as shown in my article about NHS claim data in 2025, gathering the data is one thing, using it effectively is another. What these stats do tell us is that by far the highest area of failings is linked to surgical procedures and that certain trusts/providers have a consistently higher number of reported incidents. We must hope that this information is put to good use – why are core safety procedures around surgery not being followed, how can compliance be improved and why is this happening more in some places than others? Is that simply a question of patient volume, or does it represent something more fundamental?

Injury claims arising from never events

The never event framework and its aims are good but its value depends on whether it is being used to make a real difference to patient care – not least because in the vast majority of cases injury caused by a never event provides the basis for a medical negligence claim which is likely to succeed. Incurring costs for failings that should be preventable with adherence to core procedures is a ‘fixable’ problem. Our experience – in the course of acting on some quite serious injuries and large claims arising from never events – certainly is that there is rarely a defence to injury caused by a never event. This experience follows the data – while we do deal with a number of never event claims involving the use of wrong implants and some cases involving falls, burns and misplaced nasogastric tubes, the vast majority have involved wrong site surgery or retained foreign bodies post surgery.

As we continue to watch the data, it will become clear whether figures begin to trend downward and these events lead to revised guidance that ultimately improves patient safety.