If you or a loved one has been affected by a serious mistake during NHS treatment, you may have come across the term "never event". These are incidents that the health service says should simply not happen. In this blog, we explain what a never event actually is, give some examples, and look at what it can mean for a clinical negligence claim.
What does "never event" mean?
A never event is a type of serious patient safety incident that is considered wholly preventable. The key word is "preventable". These aren't just unfortunate outcomes or recognised risks of treatment; they are incidents that national guidance and safety checks exist to prevent and which should have been caught by safeguards before they reached the patient.
Protective measures are supposed to be built into everyday hospital procedures, including checklists, verification steps, labelling systems and similar safeguards. Therefore, a never event occurring at all is treated as a red flag, suggesting that somewhere along the line an established safety process broke down.
Common examples of never events
NHS England keeps a national list of incident types that qualify as never events. Some of the most frequently reported include:
Wrong-site surgery – for example, an operation performed on the wrong limb, organ or part of the body.
Wrong-patient surgery – performing surgery on the wrong patient.
Retained foreign object post-procedure – surgical items such as swabs or instruments left inside a patient after an operation.
Wrong implant or prosthesis – fitting a device that does not match what was planned for the patient.
Administering medication by the wrong route – for example, giving a medicine intravenously when it was only meant to be taken orally, or vice versa.
Misplaced naso- or oro-gastric tubes – where a tube ends up in the lungs rather than the stomach and this is not identified before use.
This is not a complete list, but it gives a sense of the type of error involved: fundamental checks that, on paper, should be almost impossible to miss.
Why are never events reported nationally?
NHS trusts are required to report never events, and NHS England publishes the figures. This is not about naming and shaming individual clinicians; it is about transparency and learning. By tracking where and how often these incidents occur, the NHS can look for patterns, identify weaknesses in particular procedures or trusts, and push for changes to reduce the risk of repeat incidents.
Trusts also have a statutory duty of candour, which means they are legally required to be open and honest with patients or their families when something has gone wrong with their care. This includes explaining what happened and what is being done about it.
Does a never event automatically mean negligence?
Not necessarily, and this is an important distinction.
A never event confirms that something went wrong and that an established safety barrier failed. It does not automatically prove that a patient suffered harm as a direct result, or that the legal test for clinical negligence has been met.
Because never events involve a clear and preventable failure, they are often strong evidence for establishing a breach of duty. However, each case still needs to be considered on its own facts, including what injury or harm resulted and whether it can be linked to the incident.
What to do if you've been affected
If you believe you or a family member has experienced a never event, it is worth:
- Asking the trust for a full explanation under the duty of candour.
- Requesting a copy of any internal incident investigation.
- Keeping a record of what you were told and by whom.
- Seeking advice from a clinical negligence solicitor, especially if you are unsure whether what has happened meets the requirements for a claim.
How Stephensons can help
Our clinical negligence team regularly advises people affected by never events and other serious NHS treatment failures. We can help you understand what has happened and provide honest advice on whether you have grounds for a claim.
Contact us today on 0161 696 6165 to speak with one of our specialist medical negligence solicitors.
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