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Serious Incidents and Never Events

Serious Incidents and Never Events

Serious incidents can extend beyond incidents which affect patients directly and include incidents which may indirectly impact patient safety or an organisation’s ability to deliver ongoing healthcare. NHS England has published a revised policy and framework (2018), as well as the most up to date list of what constitutes a Never Event (2018).


  • Never Events are incidents that require full investigation under the Serious Incident framework.
  • Never Events are defined as Serious Incidents that are wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers.
  • Each Never Event type has the potential to cause serious patient harm or death.

As with other incidents that are classified as Serious Incidents, Never Events must be reported to both the strategic executive information system (StEIS) and the NRLS until the new patient safety incident management system is in place.


The Never Events reports for England can be found here. At the current time, only England publishes Never Event incidents, but the data may also be held with relevant authorities in Scotland, Wales and Northern Ireland.


Under the Wrong Site surgery category, incorrect skin lesion removals or biopsies are the third most common incident subtype, behind incorrect site blocks and teeth removals. The table below shows some recent statistics:


Total Wrong Site Surgeries

No. of incorrect skin lesion surgeries (removals or biopsies)

April 2018- March 2019*



April 2019- March 2020



April 2020- February 2021*



* Provisional data.


Common Problems

Through reviewing wrong site surgery reports both recent and historical, there are a number of commonalities between different Never Event incidents. Some of them are listed below:

  • Failure to follow the WHO checklist correctly
  • Failure to double check with the patient the site of surgery in situations where the use of mirrors would be beneficial.
  • A fault in communications between doctors, nurses and other healthcare professionals. Junior members of staff need to be able to flag up issues and challenge senior clinicians (in particular, locums) about adherence to surgical procedures and risk to the patient.
  • Misplacement or insufficient management of paperwork relating to the procedure.

All staff involved in surgical operations should be involved and/or represented in clinical governance meetings.


National and Local Safety Standards

In the wider picture, national and local standards have been produced an implemented with the intention of providing a safety structure for the prevention of these serious incidents. The BAD has also produced a National Safety Standard for Invasive Dermatology Skin Procedures (NatSSIP) guidance for ensuring safety procedures in skin cancer. This coincides with the local guidance (LocSSIPs) produced by healthcare trusts to ensure standards of care. LocSSIPs must be used in conjunction with the WHO checklist.


Lessons Learned: Wrong Site Skin Cancer Treatment Review Workshop

On the 19th of May 2021, the BAD held a multidisciplinary workshop on the recent rise in Never Events, with a view to producing a report on lessons learned and recommendations. The workshop was attended the Patient Safety Lead of the Never Events team of NHS England and Improvement, Fran Watts, who gave a presentation on the Never Events overview. This presentation can be viewed here. The Lessons Learned report will be published later in the year.


The BAD provides surgical reviews to help Trusts experiencing serious incidents and Never Events. For more information, or to request a review, please contact

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