The removal of both ovaries instead of one and operating on the wrong patient are among the hundreds of times NHS surgeons have made errors over the last five years, new data has revealed.
English hospitals performed 661 cases of surgery on the wrong patient or body part between 2020 and 2025, the figures show, marking a 46 per cent rise over that timeframe, with serious harm caused to patients in 7 per cent of incidents.
“Wrong-site surgery” is a medical error where an invasive procedure is performed on the wrong patient, body part or site on the body, with many of these incidents classified as “never events” by the NHS, meaning they are considered entirely preventable.
Campaigners have warned that patient safety must be prioritised amid the “very concerning” increase in some “never events”.
Great Western Hospitals NHS Foundation Trust was found to be responsible for the mistaken removal of two ovaries on a patient in October 2024, which was recorded as causing “severe harm”. This can cause immediate surgical menopause in premenopausal patients, as well as infertility and issues with estrogen levels.
At least five incidents where the wrong patient was operated on were revealed across different trusts, including a bronchoscopy, which involves a tube being inserted through the nose or mouth into the lungs, and a biopsy, the removal of a piece of tissue, cells, or fluid from the body.
Meanwhile, Newcastle-upon-Tyne Hospitals NHS Foundation Trust was found to be the worst offender overall, recording 44 cases over the past five years.
The new figures, obtained by Medical Negligence Assist via Freedom of Information requests, saw 661 cases reported between 2020 and 2025. But the true figure is likely to be even higher, as only 72 of the 117 contacted NHS Trusts responded, and some of those that did reply declined to specify exact figures to protect patient confidentiality.
And a shocking rise was seen over the five years, with 69 incidents recorded in 2020 and 101 in 2025.
Paul Whiteing, chief executive of Action against Medical Accidents (AvMA), the UK’s patient safety charity, said: “It is very concerning that we continue to see an increase in some never events. Behind every one of these events is a patient who will suffer harm, sometimes serious and life-changing and possibly life-threatening. It is vital that the NHS continues to invest in patient safety and gives it the priority it needs. Good care must be safe care. And if it is not then trust in the NHS will be lost.”
In total, 46 cases were reported that involved the patient suffering serious harm, including the double ovary excision and an incident where the wrong anatomy was removed. Meanwhile, 236 were recorded as involving moderate harm to the patient, such as the wrong tooth being extracted, incorrect scars being removed, or botox being injected into the neck instead of the mouth. Some 292 cases were cited as causing low harm, such as biopsies or anaesthesia being erroneously applied.
Other incidents include an injection being done in the wrong eye, the wrong lobe of the thyroid gland being removed, and an incision being made in the wrong finger.
Wrong-site surgeries were recorded as happening for a number of reasons – often human error, but also when procedures and safety checklists were not followed, due to issues with communication and organisation, or as a result of environmental factors such as lighting, temperature and inadequate equipment.
Gareth Lloyd, head of department at Medical Negligence Assist, warned: “The increase in the numbers demonstrates that these ‘never events’ are becoming common, and is something that everyone should be concerned about as the consequences can range from the catastrophic to unnecessary scarring to avoidable pain and discomfort. These ‘never events’ can be avoided and more needs to be done to tackle the issue, especially in those trusts that have seen the highest numbers.”
According to the data, 27 trusts recorded 10 or more wrong-site surgeries over the past five years.
Alongside Newcastle, Manchester University NHS Foundation Trust also reported a notable figure, with 22 cases – however, neither of these two trusts reported cases involving serious harm to patients.
However, University Hospitals of Morecambe Bay NHS Foundation Trust reported 23 cases, with two of those involving serious harm to patients. There were 20 instances recorded by North West Anglia NHS Foundation Trust, 13 of which involved serious harm.
An NHS spokesperson said: “While these kinds of incidents are very rare, they are completely unacceptable – and the NHS has robust procedures in place to ensure they are fully investigated, with effective action taken to improve care for future patients.
“We recognise there is more to do and the NHS is supporting frontline teams to strengthen patient safety, including through better recording and response to incidents and rolling out a national programme of training for staff.”
Dr Lucia Pareja-Cebrian, joint medical director at Newcastle Hospitals, said: “We have a culture and approach where we actively encourage all staff to openly report incidents, apologise to those patients and families involved and investigate thoroughly, to ensure we learn what needs to change to prevent any future occurrence.”
A spokesperson for Great Western Hospitals NHS Foundation Trust said: “We are so very sorry for the pain and long-term impact caused following these patients’ surgery. We strive to provide high-quality, safe care to every patient, however unfortunately, on these occasions, clinical practice fell short of the standard we expect.
“We are committed to learning from any mistakes that are made to ensure they don’t happen again and have shared the findings of the investigations we have carried out, along with the actions we have taken to make our care as safe as possible, with the patients concerned.”
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