New data has revealed that the University Hospitals Birmingham NHS Foundation Trust is responsible for the highest number of NHS ‘Never Events’, with 13 catastrophic completely avoidable errors occurring in the past year.

Patient Claim Line analysed the latest data published by NHS England, which shows reported ‘Never Events’ from the past year (April 2024-March 2025).

Never Events are serious, wholly preventable patient safety incidents that should never occur if healthcare providers have implemented existing national guidance or safety recommendations.

Even a single Never Event acts as a red flag that an organisation’s systems for implementing existing safety advice and alerts may not be robust.

In the past year, 403 safety incidents reported were determined to meet the definition of a ‘Never Event’, with the most incidents occurring in July (48).

Never Events April 2024 to March 2025 by month of incident
Month
Number of Never Events
April
34
May
29
June
32
July
48
August
40
September
38
October
31
November
29
December
30
January
35
February
36
March
21
Total
403
Wrong site surgery (having an operation at the wrong location) was found to be the most common ‘Never Event’ incident with 185 occurring in the past year, with the most common types including wrong side/site procedures, wrong site blocks, wrong skin lesions removed as well as injections to the wrong side/site.

This was followed by retained foreign objects post procedure (equipment / dressing left inside following surgery) (106), with a wrong implant or prothesis the third most common type of incident occurring in NHS organisations across England (50).

Never Events April 2024 to March 2025 by type of incident

Description of Never Event
Count
Wrong site surgery
185
Incision to wrong organ/structure
4
Incision to wrong side/site
5
Injection to wrong organ/structure
10
Injection to wrong side/site
20
Not known
1
Procedure intended for another patient
9
Procedure not part of the surgical plan
2
Procedure not required
4
Removal of organ/structure when surgical plan was to conserve it
3
Wrong organ/structure
1
Wrong procedure
3
Wrong side/site procedure
46
Wrong site block
41
Wrong skin lesion removed/biopsy
36
Retained foreign object post procedure
106
Disposable item of equipment/part of disposable item of equipment
10
Guide wire
23
Surgical instrument/part of surgical instrument
17
Surgical needle/part of surgical needle
3
Surgical swab
19
Throat pack/swab
2
Vaginal swab/pack
32
Wrong implant/prosthesis
50
Feeding tube
1
Femoral nail
1
Fracture fixation prosthesis
3
Hip
6
Implant not required
1
Intra uterine contraceptive device
4
Knee
11
Lens
15
Not known
1
Screws
3
Stent
2
Surgical plate
1
Thumb
1
Misplaced naso- or oro-gastric tubes
23
Apparently misleading pH result
11
Placement checks not described or not clearly described
2
X-ray misinterpretation; no indication ‘four criteria’ used
10
Administration of medication by the wrong route
14
Oral medication given intravenously
12
Oral medication given subcutaneously
2
Overdose of insulin due to abbreviations or incorrect device
11
Insulin withdrawn from an insulin pen
5
Wrong syringe
6
Unintentional connection of a patient requiring oxygen to an air flowmeter
4
Patient connected to air rather than oxygen
4
Mis-selection of high strength midazolam during conscious sedation
3
High strength midazolam administered
3
Overdose of methotrexate for non-cancer treatment
3
Methotrexate prescribed and administered more than the intended weekly dose
3
Transfusion or transplantation of ABO-incompatible blood components or organs
3
Transfusion not required
1
Wrong blood
2
Falls from poorly restricted windows
1
Window restrictor not fitted or failed
1
Total
403
The University Hospitals Birmingham NHS Foundation Trust was found to have the highest number of Never Events occurring, standing at 13 incidents

This was followed by the University Hospital Southampton NHS Foundation Trust with 11 incidents, and the Royal Free London NHS Foundation Trust with 10.