UK Government

Department of Health (National): Putting patient safety back at the heart of the NHS

Press Release   •   Feb 24, 2011 10:31 GMT

NHS never events list to be extended to 25

An extended list of events that should never happen during care in the NHS has been unveiled today along with a powerful financial disincentive, as the Government affirms that substandard care will not be tolerated in the NHS.

After engaging publicly with health partners like the NHS, health professionals, the Royal Colleges and the public, the current list of eight never events is to be extended to 25, and will now include events like:

  • severe harm/death due to transfusing the wrong type of blood;
  • severe scalding; and
  • severe harm/death due to misidentifying patients by failing to use standard wristband identification processes

“Never events” can cut a life unnecessarily short or result in serious impairment. It is important that the NHS tackles this issue head-on and continuously strives to provide the safe and high quality care patients expect. The NHS will still have a statutory requirement to report all serious patient safety incidents to the National Reporting and Learning System and to the CQC. Reporting of patient safety incidences plays a fundamental role in ensuring that the NHS learns the lessons from its mistakes, and makes sure they are never repeated.

Health Secretary, Andrew Lansley said:

"Our ambition is to modernise the NHS so that people have the highest quality healthcare, and live healthier, independent lives.

“Improving patient safety is central to this. We have identified 25 preventable incidents – “never events” – which should never happen in a high-quality healthcare service and for which payment can be withheld across the NHS.

“Never events” will be enshrined in the NHS Standard Contract, meaning that payment from GPs or other commissioners will be withheld where care falls short of the acceptable standard. The measures will help to protect patients and give commissioners the power to take action if unacceptable mistakes do happen.”

NHS Medical Director, Professor Sir Bruce Keogh said:

"The extended list includes avoidable incidents with serious adverse consequences for patients. No one wants these to happen, therefore we should not have to pay hospitals when these events occur. This will send a strong signal to leaders of the organisation to learn from their mistakes so they don't happen again."

There were 111 “never events” last year and more generally, medical errors of all kinds have been estimated to cost the NHS around £2bn a year. It is clear that safer care is cheaper care and that resources can and should be used to develop better health outcomes from the start of treatment rather than in putting things right when they have avoidably gone wrong.

Where "never events" do occur in the NHS, commissioners will now have the power to withhold payment for this extended list of events to NHS providers. “Never events” are so serious that the Government is defining the list of events on a national basis. However, it is right that local commissioners decide to what extent they will recover the costs of care associated with a “never event”. Commissioners will be able to cap the amount recovered if they choose to.

Notes to editors

1. For further information, contact the Department of Health press office on 020 7210 5221

2. A “Never event” is a very serious, largely preventable patient safety incidents that should not occur if the relevant preventative measures have been put in place.

3. It is estimated that never events themselves cost the taxpayer at least £35,000 each a year (or £3.9 million based on 111 events experienced during the year between Jul 2009 and Jun 2010).

4. Cost recovery relates to the cost of the care episode in which the “never event” occurred, and if appropriate the cost of the care needed to treat the consequences of the “never event”. Commissioners have the discretion to waive cost recovery if they agree with the provider that this is appropriate.

5. To ensure cost recovery is proportionate, commissioners can consider using caps on the maximum amount of money they recover. For certain “never events”, it may not be possible to distinguish the costs of the relevant procedure from the extremely large costs of a significant period of care, such as the cost of a long period of inpatient care. This means the commissioner could impose a very large financial penalty on the provider. Where there is the potential for this to be an issue, commissioners and providers should discuss what principles to apply in advance, while agreeing contracts. We have suggested they agree to cap cost recovery to the equivalent of a month’s inpatient stay, or at a monetary level of, for example, £10,000.

6. The full list of the 25 “Never Events”-

1. Wrong site surgery (existing)
2. Wrong implant/prosthesis (new)
3. Retained foreign object post-operation (existing)
4. Wrongly prepared high-risk injectable medication (new)
5. Maladministration of potassium-containing solutions (modified)
6. Wrong route administration of chemotherapy (existing)
7. Wrong route administration of oral/enteral treatment (new)
8. Intravenous administration of epidural medication (new)
9. Maladministration of Insulin (new)
10. Overdose of midazolam during conscious sedation (new)
11. Opioid overdose of an opioid-naïve patient (new)
12. Inappropriate administration of daily oral methotrexate (new)
13. Suicide using non-collapsible rails (existing)
14. Escape of a transferred prisoner (existing)
15. Falls from unrestricted windows (new)
16. Entrapment in bedrails (new)
17. Transfusion of ABO-incompatible blood components (new)
18. Transplantation of ABO or HLA-incompatible Organs (new)
19. Misplaced naso- or oro-gastric tubes (modified)
20. Wrong gas administered (new)
21. Failure to monitor and respond to oxygen saturation (new)
22. Air embolism (new)
23. Misidentification of patients (new)
24. Severe scalding of patients (new)
25. Maternal death due to post partum haemorrhage after elective caesarean section (modified)


NDS Enquiries 
Phone: For enquiries please contact the issuing dept