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Never Events

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.

A core list of Never Events was introduced by the National Patient Safety Agency for the NHS in April 2009. Welsh Government has issued a Welsh Health Circular WHC 2022(020) July 2022 with a Policy Statement, the Never Events list has been reviewed and updated.


Please note the following changes to the Never Event List July 2022:

  • Wrong tooth extraction is no longer a Never Event - Confirmation letter to the NHS from July 2021.
  • Undetected oesophageal intubation is currently suspended from the list (see WHC link above).
  • Administration of medication by the wrong route - the ‘intravenous administration of a medicine intended to be administered by the epidural route’ cannot be considered a Never Event during the transition period for NRFit™ devices.

Further reviews will be completed working with NHS England.