NHS Never Events 2024/25: Data, Impact, and What It Means for Patient Safety

What are Never Events?

Never Events are classified by the NHS as serious and preventable incidents that should not occur when healthcare providers adhere to established safety protocols and national guidance. These events, such as performing surgery on the wrong site or administering the wrong medication, highlight critical lapses in patient safety systems.

NHS England notes that a recurring pattern or unusually high number of Never Events at a particular trust may signal systemic issues or gaps in clinical governance. Alarmingly, even a single Never Event is regarded as a red flag for unsafe practice.

In addition to the direct risks posed to patients, including severe injury or death. Never Events can also lead to significant legal and financial consequences for NHS trusts, with some cases resulting in substantial compensation payouts to affected individuals.

What different types of Never Events are there?

The latest provisional data from NHS England records the Never Events under several categories. For 2024/25, the Never Events recorded fell into the following categories.

• Wrong site surgery
• Retained foreign object post-procedure
• Wrong implant/prosthesis
• Misplaced naso or oro gastric tubes
• Administration of medication by the wrong route
• Overdose of insulin due to abbreviations or incorrect device
• Unintentional connection of a patient requiring oxygen to an air flowmeter
• Overdose of methotrexate for non-cancer treatment
• Unintentional connection of a patient requiring oxygen to an air flowmeter
• Transfusion or transplantation of ABO-incompatible blood components or organs
• Mis-selection of high strength midazolam during conscious sedation
• Falls from poorly restricted windows

Do Never Events require investigation?

NHS providers are encouraged to learn from mistakes, with all reported Never Events requiring a patient safety incident investigation (PSII) to identify root causes and drive improvement.

The growing number of incident reports by NHS staff supports local learning and safety enhancements. Staff are urged to continue reporting Never Events via StEIS, conducting PSIIs in line with guidance, and submitting all patient safety events to LFPSE to help identify and address potential risks.

What Never Events occurred in 2024/25?

As part of the provisional data release, NHS England detailed specific Never Events that occurred across England.

Blackwater Law has reviewed the data to highlight some of the most concerning.

Across the NHS, there were 101 incidents where a foreign object was left inside a person after their procedure. These range from swabs, needles and parts of surgical equipment. Incidents like this led to needed, further surgery for the patient as well as a higher risk of infection.

There were 9 separate occasions where a patient received a procedure that was meant for someone else, and 2 incidents where a patient had an organ or structure removed when it should have been preserved, and one person fell from a window that was not properly secured.

How many Never Events were there in 2024/25?

The latest provisional data released earlier his month shows a total of 375 Never Events, shared across 375 NHS hospital trusts and other healthcare providers between 1st April 2024 and 28th February 2025

The number of Never Events has been gradually increasing over the last couple of years, in 2023/24 there were 370 Never Events, recorded across the NHS.

What Never Event was the most common?

In 2024/25, the most common Never Event across the NHS was patients undergoing a procedure on the wrong site or side, which occurred 39 times. This highlights the continued need for rigorous safety checks, clear communication, and adherence to protocols such as the surgical safety checklist to prevent such avoidable errors and protect patient safety.

The Never Event that was most common in 2022/23 was patients having the wrong skin lesion removed or tested by biopsy

Which NHS trusts had the most Never Events in 2024/25?

As part of the provisional data release, NHS England provides the number of Never Events that occurred at named trusts.

The trust that recorded the most Never Events between 1st April 2024 and 28th February 2025 was University Hospitals Birmingham NHS Foundation Trust. They recorded 13 Never Events in total. The trust also recorded the highest number of Never Events in 2023/24, where they recorded 11.

Behind them, University Hospital Southampton NHS Foundation Trust, Royal Free London NHS Foundation Trust and University Hospitals of Derby and Burton NHS Foundation Trust all recorded between 9-11 never events between 1st April 2024 and 28th February 2025

Guy’s and St Thomas’ NHS Foundation Trust also in London followed behind with 8 Never Events in total.

The Ten NHS Trusts with the most recorded Never Events are as follows:

• University Hospitals Birmingham NHS Foundation Trust- 13
• University Hospital Southampton NHS Foundation Trust- 11
• Royal Free London NHS Foundation Trust- 10
• University Hospitals of Derby and Burton NHS Foundation Trust- 9
• Guy’s And St Thomas’ NHS Foundation Trust- 8
• Great Western Hospitals NHS Foundation Trust- 7
• Leeds Teaching Hospitals NHS Trust- 7
• Northwest Anglia NHS Foundation Trust- 7
• Northern Care Alliance NHS Foundation Trust- 7
• Blackpool Teaching Hospitals NHS Foundation Trust- 6

The impact of Never Events

As discussed, Never Events can have devastating impacts when it comes to patient safety. Never Events can lead to serious, permanent injury axs well as death.

Commenting on the latest figures, Jason Brady, Partner & Head of Blackwater Law said: “The number and nature of the recorded incidents area concern because they are all serious, preventable failures in patient care.

At Blackwater Law, we regularly witness the lasting impact they have-not only on those directly affected, but also on their loved ones who must deal with the consequences.

If you suspect that you or a loved one has suffered because of a Never Event, you could be entitled to claim compensation for your injuries.’’

For free initial advice on your claim, contact one of our expert team today, who can help you start your claim.