Surgical Never Events in NHS England: Causes, Compensation & Safety Improvements

Introduction

Serious surgical errors, though rare, are among the most concerning patient safety incidents in healthcare.

In England, these events are defined as serious, largely preventable errors that occur during surgical procedures. They have wide-reaching consequences not only for the affected patients but also for the healthcare providers involved. The NHS, as part of its commitment to improving patient safety, collects data and investigates these events to understand their causes and reduce their occurrence.

In this report, we will delve deeper into what constitutes a surgical Never Event, how common these mistakes are, the hospitals where they are more likely to occur, the financial costs to the NHS, and what steps are being taken to prevent them in the future.

What is a Surgical ‘Never Event’?

Surgical Never Events are defined as incidents that should not occur under any circumstances if proper safety protocols are followed.

The term ‘Never Event’ was introduced in the UK to highlight avoidable and high-risk situations that can be minimised or entirely prevented through the application of existing best practice guidelines and safety protocols.

While errors can occur in any medical environment, Never Events are considered especially serious because they are largely preventable.

The list of surgical Never Events is managed and periodically updated by NHS England. These include a variety of surgical errors, such as:

Wrong Site Surgery: This occurs when a surgical procedure is performed on the wrong patient, body part, or side of the body. For example, a surgeon might mistakenly operate on the wrong knee, eye, or limb. This error can lead to significant harm to the patient and, in some cases, may require corrective surgery.
Retained Foreign Object Post-Procedure: This refers to surgical items such as sponges, swabs, needles, or surgical instruments being left inside a patient after surgery. This is usually discovered post-operatively when the patient experiences complications. Retained foreign objects can lead to infections, severe pain, and require additional surgeries to remove them.
Mis-selection of Strong Potassium Solution: This occurs when a potassium solution, typically used to correct low potassium levels in the blood, is mistakenly selected or administered in the wrong concentration or form. This error can have severe consequences for the patient, including heart arrhythmias or even death.
Failure to Install Functional Collapsible Shower or Curtain Rails: This error pertains to incidents where a hospital fails to provide safe fixtures that are intended to prevent patient falls or other accidents in areas such as bathrooms. While less common, such failures can still contribute to patient harm.
Misplaced Naso- or Oro-gastric Tubes: These tubes are used for feeding patients who cannot eat orally. If misplaced, for example, if the tube is inserted into the lungs rather than the stomach, this can lead to choking, aspiration pneumonia, or other severe complications.

These events are defined as ‘Never Events’ because they are preventable with the appropriate protocols, checks, and oversight in place. When they do occur, it signals a breakdown in these systems and processes.

How Common Are Serious Surgical Errors?

While serious surgical errors and specifically Never Events are rare (in the context of the total number of surgeries performed annually), they still represent a significant issue for the NHS.

In the last year alone (2023-2024), there were 370 recorded instances of Never Events in NHS England hospitals, slightly down from 384 in the previous year.

Although the numbers have decreased marginally, the actual rate remains concerning given the potential for patient harm.

To put this in perspective, with approximately 66,000 surgical procedures being conducted in England each year, the overall rate of Never Events is low.

The rate for 2023-2024 stands at around 0.6%, meaning that for every 1,000 surgeries, there were approximately six incidents of surgical Never Events.

This low rate should reassure patients that these errors are uncommon, but the fact that they still occur is an issue that requires ongoing attention.

The most common types of surgical mistakes within the Never Event category are:

Wrong Site Surgery – 48% of all Never Events (179 cases)
Retained Foreign Object Post-Procedure – 22% of all Never Events (81 cases)

Interestingly, the months of August, November, and January saw the highest frequency of Never Event surgical mistakes. This could be linked to factors like staff shortages during peak holiday seasons, increased surgical pressure, or other systemic issues, highlighting the need for careful monitoring and support during particularly high-demand periods.

Are Surgical Mistake More Common at Some Hospitals?

While surgical Never Events are rare, there are notable differences in the frequency of these events across various NHS Trusts.

Some hospitals report more Never Events than others, which can be attributed to a range of factors including hospital size, reporting culture, and differences in safety protocols.

University Hospitals Birmingham NHS Foundation Trust had the highest number of claims (24) for surgical Never Events from 2014 to 2024, followed by Leeds Teaching Hospitals NHS Trust and Manchester University NHS Foundation Trust, each with 19 claims.

Despite the variation in the number of claims, this does not necessarily mean that one hospital is less safe than another. The reporting practices at each Trust may differ, and larger hospitals naturally conduct more surgeries, increasing the likelihood of errors being detected and reported. However, it’s clear that more attention is needed in hospitals with higher incidences of Never Events.

According to NHS England Never Event reports, hospitals are actively working to improve safety practices, and each NHS Trust is required to carry out an internal investigation whenever a Never Event occurs to determine the root causes and take steps to prevent recurrence.

Many Trusts are also said to be adopting digital safety systems, team training programs, and independent audits to identify weaknesses in their procedures and processes.

How Much Compensation is being paid out for Serious Surgical Errors?

Surgical Never Events not only cause harm to patients but also incur significant financial costs to the NHS.

Between 2014 and 2024, a total of 774 claims were made to NHS Resolution for compensation related to surgical Never Events.

Of these, 574 claims were successful, resulting in payouts totalling £37.6 million. The average compensation per claim was approximately £65,000.

The breakdown of claims by type of surgical Never Event is as follows:

Wrong Site Surgery: The most common surgical Never Event, responsible for 61% of all claims (469 cases). The total payout for these claims amounted to £23.3 million, with an average compensation of £62,000 per claim.
Retained Foreign Object Post-Procedure: The second most common error, with 205 claims filed (26% of total claims). These claims resulted in £10.5 million in compensation payouts, with an average compensation of £51,000 per claim.

Some hospitals also face higher financial costs due to a combination of the number of claims and the size of individual settlements.

For example, Northern Care Alliance NHS Foundation Trust paid out the highest amount for surgical Never Events, totalling £4.7 million, followed by Barts Health NHS Trust at £3.9 million.

Northern Care Alliance also had the highest average surgical Never Event claim value at £366k.

Why Do Surgical Never Events Happen?

The persistence of surgical Never Events, despite strict safety protocols, is partly due to a variety of systemic and human factors.

The Care Quality Commission’s (CQC) thematic review of 2018, published in the report “Opening the Door to Change”, identified several key challenges in the healthcare system that contribute to these errors:

High Workload and Staff Shortages: Surgeons, nurses, and other staff are often overburdened by heavy workloads and time pressures. This can lead to lapses in attention, rushed procedures, or failure to follow safety protocols properly.
Insufficient Time for Safety Protocols: Medical staff are sometimes unable to allocate enough time for proper pre-surgery checks or post-operative care due to busy schedules. The review suggested that the volume of safety guidelines may overwhelm staff, who struggle to implement them effectively in fast-paced environments.
Inadequate Communication: A lack of clear communication among surgical teams, especially in high-pressure environments, can lead to misunderstandings or mistakes. For instance, failure to double-check patient identity or surgical site before proceeding can result in wrong site surgeries.
Systemic Issues and Lack of Support: The NHS system, while largely successful, is sometimes plagued by issues such as underfunding, inadequate staffing levels, and insufficient training in safety practices. These systemic challenges hinder effective implementation of safety measures.

What Needs to Be Done to Reduce the Number of Serious Surgical Errors?

We believe that reducing the occurrence of surgical Never Events requires a multi-faceted approach that focuses on improving training, enhancing communication, addressing staffing issues, and strengthening safety protocols.

Key actions could include:

Training and Awareness: Surgeons and healthcare staff must be continually trained in the latest safety procedures, including checks before and after surgery. Regular drills and refreshers on these protocols are vital in maintaining a culture of safety.
Improved Communication: Hospitals should implement structured communication frameworks, such as the WHO Surgical Safety Checklist, which can help surgical teams ensure that every procedure follows established safety protocols.
Better Resourcing and Staffing: Addressing staff shortages and ensuring that the surgical teams are adequately staffed will help reduce stress and the likelihood of errors. Hospital management should prioritize the recruitment and retention of staff in critical areas.
Investing in Technology: Digital tools and technologies that track patient identity, surgical site, and procedure details can help ensure that errors like wrong site surgeries are avoided. Enhanced electronic health records (EHR) systems could also streamline patient information and improve safety.

How Can You Claim if You’ve Been Affected by a Surgical Error?

If you or a loved one has been affected by a surgical Never Event or other serious surgical error, it’s important to know that you have legal rights to seek compensation.

You can contact our medical negligence specialists who can guide you through the process of filing a claim. To learn more, visit our page on surgical errors.

Our sources and methodology

Primary source:

We issued an FOI request to NHS Resolutions for information on surgical ‘Never Events’ claims recorded and paid out by Trusts in England for the last 10 years (FOI Request (FOI_6783) – NHS Resolution, Received 22nd November 2024. Claims in relation to surgical never events, between 2014 and 2024.)
They advised that NHS Resolution doesn’t hold information about all Never Events, but rather only those that resulted in claims, and specifically focused on the following ‘types’ of surgical mistakes made…
Wrong site surgery
Retained foreign object post procedure
Mis-selection of a strong potassium solution
Failure to install functional collapsible shower or curtain rails
Misplaced naso- or oro-gastric tubes

Other sources:

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