From Drill Bits Left Inside Patients to Mistaken Removal of Ovaries: Substantial Increase in ‘Never Events’ Recorded by the NHS

The NHS recorded a substantial increase in ‘Never Events’ between April 2021 and March 2022—including nearly 100 incidents of foreign objects such as scalpel blades, wire cutters, and drill bits being accidentally left inside patients.

The official data revealed 407 incidents of medical negligence that are described as “so serious they should never happen” in the NHS. This is the equivalent of more than one life-threatening incident per day, which is a concerning increase from a total of 364 in the previous year.

What are NHS ‘Never Events’?

‘Never Events’ are named as such because they describe medical incidents that should never occur under any circumstances.

To quote NHS England, they are “serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.”

Some examples of ‘Never Events’ include:

  • wrong-site surgery
  • mismatched blood transfusion
  • retained foreign objects inside a patient after a procedure
  • wrong implants/prosthesis
  • administering medication by the wrong route,
  • and delivering the wrong dose of medication, among others.

Such events typically have catastrophic health and financial implications for affected patients and healthcare providers.  For the full list of NHS events please see  full ‘Never Events’ list by NHS Improvement.

What were the 407 Never Events?

A breakdown of the 407 Never Event incidents was noted in the NHS England report published    May 12 2022.

Table 2: Never Events 1 April 2021 – 31 March 2022 by type of incident with additional detail*

  Type and brief description of Never Event                                                Number
Wrong site surgery171
Angiogram intended for another patient1
Biopsy from wrong breast1
Biopsy of mediastinal mass rather than pleura1
Biopsy of wrong lobe of lung1
Bone marrow biopsy intended for another patient1
Botox injection to wrong area of mouth1
Cervical biopsies taken instead of colon1
Colposcopy intended for another patient1
Embolisation to the wrong area of the kidney1
Excision of skin tags rather than removal of cyst1
Excision of vaginal tissue instead of anal tissue1
Eye injection that was not required1
Flexible sigmoidoscopy intended for another patient2
Gastric dilatation intended for another patient1
Gastroscopy intended for another patient2
Haemorrhoids removed rather than repair of anal fistula1
Incision to wrong area of buttock1
Incision to wrong aspect of ankle1
Incision to wrong finger3
Incision to wrong part of leg1
Incision to wrong side of head1
Incision to wrong toe1
Injection to foot rather than ankle1
Injection to foot rather than hip1
Injection to wrist rather than thumb1
Injection to wrong area of hip1
Injection to wrong breast2
Injection to wrong eye6
Injection to wrong finger joint2
Injection to wrong finger/s4
Injection to wrong shoulder1
Injection to wrong toe joint1
Injections to lumbar spine rather than neck1
Insertion of radioactive plaque to the wrong area of the eye1
Knee aspiration intended for another patient1
Lumbar puncture rather than fluid drainage from lung1
Nerve root block intended for another patient1
Not described3
Position of laser eye surgery not the intended procedure1
Rectal drain intended for another patient1
Release of elbow nerve rather than muscle1
Removal of ovaries when surgical plan was to conserve them1
Resection of wrong eye muscle during squint surgery1
Toe procedure intended for another patient1
Unknown1
Unnecessary procedure2
Wound debridement intended for another patient1
Wrong aspect of knee1
Wrong aspect of knee biopsied1
Wrong ear1
Wrong eye1
Wrong finger1
Wrong hand1
Wrong labial cyst removed1
Wrong lung decompressed1
Wrong lymph node excision1
Wrong side angiogram2
Wrong side angiogram incision1
Wrong side angioplasty3
Wrong side angioplasty incision1
Wrong side burr holes1
Wrong side chest drain2
Wrong side hernia incision1
Wrong side lung biopsy1
Wrong side pacemaker placement1
Wrong side spinal injection3
Wrong side spinal surgery1
Wrong side stent removed1
Wrong side ureteric stent1
Wrong side ureteric stent removed1
Wrong side ureteroscopy2
Wrong site block46
Wrong site botulinum injection1
Wrong skin lesion biopsy6
Wrong skin lesion removed16
Wrong thyroid lobe removed1
Wrong type of stoma – stomach rather than colon2
Wrong side of head1
Procedure to breast that had not been consented1
Gastroscopy instead of colonoscopy1
Biopsy from wrong kidney1
Retained foreign object post procedure98
Bolt from surgical forceps1
Catheter used as part of a surgical procedure1
Dental mouth prop1
Dilatation balloon sheath1
Guide wire – central line6
Guide wire – chest drain2
Guide wire – femoral line2
Guide wire – PICC line2
Guide wire – supra pubic catheter1
Guide wire – vascath3
K wire1
Laparoscopic specimen bag2
Ophthalmic port1
Ophthalmic trocar1
Part of a drill bit not identified as missing at the time of the procedure3
Part of a guide wire – PICC line1
Part of a k wire1
Part of a pair of wire cutters1
Part of a suture anchor introducer1
Part of an intra uterine contraceptive device introducer1
Part of uterine manipulator1
Raney cranial clip1
Scalpel blade1
Screw from spinal instrumentation not identified as missing at the time of the procedure1
Small piece of metal from knee instrumentation not identified at the time of the procedure1
Surgical swab21
Throat pack1
Trial shoulder prosthesis1
Unknown1
Vaginal swab32
Valve from breast prosthesis1
Bite block1
Part of bladder instrumentation1
Ribbon gauze not identified as missing at the time of the procedure1
Wrong implant/ prosthesis47
Aortic valve1
Breast implant1
Hip12
Intra uterine contraceptive device3
Knee11
Lens9
Mandibular plate1
Shoulder1
Vascular access device2
Wrong locking bolts for femoral nail1
Wrong side plate1
Wrong side radial plate1
Wrong side wrist plate2
Wrong type of ureteric stent1
Misplaced naso or oro gastric tubes and feed administered31
Apparently misleading pH test result6
Placement checks not described or not clearly described11
X-ray misinterpretation; no indication ‘four criteria’ used14
Administration of medication by the wrong route21
Oral medication given intravenously18
Oral medication given subcutaneously3
Unintentional connection of a patient requiring oxygen to an air flowmeter13
Patient connected to air instead of oxygen13
Overdose of insulin due to abbreviations or incorrect device11
Insulin withdrawn from an insulin pen2
Wrong syringe9
Transfusion or transplantation of ABO incompatible blood components or organs7
Wrong blood transfused7
Falls from poorly restricted windows3
Window restrictor failed3
Mis selection of high strength midazolam during conscious sedation2
Wrong strength midazolam selected and administered2
Overdose of methotrexate for non-cancer treatment2
Methotrexate overdose prescribed and administered2
Mis selection of a strong potassium solution1
Potassium selected inadvertently1
Total                                                                                                                  407

Foreign Objects Left Inside Patients

The accepted standard during a surgical or medical procedure is for healthcare providers to have a protocol or formal counting/checking process in place to keep tabs on the tools before and after surgery. The goal is to ensure foreign objects are not left inside patients – yet in the NHS, there were 98 such incidents in a year. Some of the items left inside a patient by mistake include:

  • Vaginal swabs (the most common foreign item left after a medical procedure, with 32 cases)
  • Surgical swabs (left behind in 21 instances)
  • A pair of wire cutters
  • Parts of a drill bit (left on 3 occasions)
  • Part of a scalpel blade
  • A part from surgical forceps
  • Guide wires

Sharp or hard items like scalpels, wire cutters, and forceps can cause internal injuries or even perforate organs. Softer objects like medical sponges or swabs leave patients at risk of infection, sepsis, or organ blockage. These conditions can be life-threatening if allowed to go untreated.

Other ‘Never Events’ Reported

In addition to the retained foreign objects, The NHS reported hundreds of serious medical negligence incidents in the year leading to March 2022. These ‘Never Events’ include:

  • Surgery or invasive procedures were performed on the wrong site of the body – in 171 cases. Some incidents under this category of negligence include 6 patients who were injected in the wrong eye
  • The wrong surgery or treatment was carried out. This included a woman whose ovaries were removed when the intention was to conserve them, and another who had a breast procedure without their permission.
  • The wrong prosthesis/implant was placed before or during a medical procedure in a total of 47 instances. This includes wrong hip implants (12 times) and wrong knee implants (11 times).
  • There were 13 times when patients were unintentionally connected to an air flowmeter instead of an oxygen flowmeter.
  • Seven people were given the wrong blood transfusion.
  • An insulin overdose was given 11 times.
  • There were two cases where an overdose of Methotrexate (an immunosuppressant) was administered.
  • Three falls from poorly fitted windows

The already alarming number of serious events in the past year could further increase with 29 more incidents under investigation to determine whether they fit the definition of a ‘Never Event’.

The data also uncovered differences in ‘Never Events’ reported across England’s NHS trusts, as shown below:

  • Manchester University NHS Foundation Trust reported – 11 errors
  • Nottingham University Hospitals NHS Trust – 10 errors
  • Sandwell and West Birmingham University Hospitals NHS Trust – 10 errors
  • Gloucestershire Hospitals NHS Foundation Trust – 9 errors
  • Liverpool University Hospitals NHS Foundation Trust – 9 errors
  • University Hospitals of Leicester NHS Trust – 9 errors
  • Worcestershire Acute Hospitals NHS Trust – 9 errors

According to an NHS spokesperson: “While these events are extremely rare, and NHS staff are working hard to provide safe care to patients, it is important that events are reported and learned from so that they can be prevented in the future.”

A spokesperson from the Department of Health and Social Care echoed the above sentiments saying, “Patient safety is a top priority for the government and these unfortunate events – although very rare – can have a serious physical and psychological impact on patients.

“We are implementing the NHS Patient Safety Strategy which is designed to support staff to provide safe care and learn lessons.

“There are record numbers of nurses, doctors and overall staff working in the NHS, and we have set out our plan to tackle the COVID backlog, backed by record investment.”

Claiming Compensation for a Never Event

Devonshires Claims’ medical negligence solicitors are members of the Action Against Medical Accidents (AvMA) and the Association of Personal Injury Lawyers (APIL).

Our medical negligence compensation service provides:

  • A free no-obligation case evaluation
  • Advice on the probability of success for a Never Event claim and the amount of compensation you could potentially obtain
  • Friendly, compassionate and experienced claims experts
  • No Win No Fee agreement i.e. you will not incur any costs if your claim is not successful*.
  • Access to a network of medical experts and specialist barristers

If you or a family member has been affected by a ‘Never Event’, you may be able to claim compensation for medical negligence. For a free no-obligation case evaluation contact our experienced ‘No Win No Fee’ Medical Negligence Solicitors. Our experts work hard to secure victims of medical negligence the justice and compensation they deserve.

Contact our claims experts today on today on 0333 900 8787, email admin@devonshiresclaims.co.uk or complete our online form.

Get in touch

Devonshires Claims
Ground Floor
30 Finsbury Circus
Finsbury, London
EC2M 7DT