NHS providers are encouraged to learn from mistakes and any organisation that reports a Never Event is expected to conduct its own investigation so it can learn from and take action on the underlying causes.

This report presents an analysis of the local investigation reports into 38 surgical Never Events from across England that occurred between April 2016 and March 2017 (the last full year with data available).

Although commissioned as part of our evaluation of the implementation of the national surgical safety standards for invasive procedures (NatSSIPs) — the learnings presented in the report will support providers to improve patient safety.