Management of investigations and serious incidents policy

The purpose of this policy is to ensure that risks associated with serious incidents are identified and managed in accordance with best practice and in line with the expectations of the NHS Resolution, the Health and Safety Executive, the Care Quality Commission, NHS England and NHS Improvement, Clinical Commissioning Groups and the public.

Publication date:
01 September 2019
Date range:
September 2019 - September 2022

Appendix 2 Never events list 2018

Full details can be found here


1. Wrong site surgery
2. Wrong implant/prosthesis
3. Retained foreign object post procedure


4. Mis-selection of a strong potassium solution
5. Administration of medication by the wrong route
6. Overdose of insulin due to abbreviations or incorrect device
7. Overdose of methotrexate for non-cancer treatment
8. Mis-selection of high strength midazolam during conscious sedation

Mental Health

9. Failure to install functional collapsible shower or curtain rails Involves either:

  • failure of collapsible curtain or shower rails to collapse when an inpatient attempts or completes a suicide
  • failure to install collapsible rails and an inpatient attempts or completes a suicide using non-collapsible rails.


10. Falls from poorly restricted windows. A patient falling from a poorly restricted window. This applies to:

  • windows ‘within reach’ of patients; this means windows (including the window sills) that are within reach of someone standing at floor level and that can be exited/fallen from without needing to move furniture or use tools to climb out of the window
  • windows located in facilities/areas where healthcare is provided and that patients can and do access
  • where patients deliberately or accidentally fall from a window where a fitted restrictor is damaged or disabled, but not where a patient deliberately disables a restrictor or breaks the window immediately before they fall
  • where patients can deliberately overcome a window restrictor using their hands or commonly available flat-bladed instruments as well as the ‘key’ provided.

11. Chest or neck entrapment in bed rails

Entrapment of a patient’s chest or neck between bedrails or in the bedframe or mattress, where the bedrail dimensions or the combined bedrail, bedframe and  24
mattress dimensions do not comply with Medicines and Healthcare products Regulatory Agency (MHRA) guidance.

Setting: All settings providing NHS-funded care including care homes, and patients’ own homes where equipment for their use has been provided by the NHS.

12. Transfusion or transplantation of ABO-incompatible blood components or organs
13. Misplaced naso- or oro-gastric tubes

14. Scalding of patients

Patient scalded by water used for washing/bathing.


  • scalds from water being used for purposes other than washing/bathing (e.g. from kettles)

15. Unintentional connection of a patient requiring oxygen to an air flowmeter