Royal Devon University Healthcare NHS Foundation Trust recorded 16 wrong-site surgery cases during the five-year period
Royal Devon & Exeter Hospital (Image: Copyright Unknown)
A Devon health trust says it is working hard to reduce the number of botched surgeries after figures showed 16 cases performed on the wrong patient or body part between 2020 and 2025.
The phenomenon, known as ‘wrong-site surgery’, is a medical error where surgeons perform an invasive procedure on the wrong patient, the incorrect body part, or the wrong side of the body – such as operating on the left limb instead of the right.
Information obtained through Freedom of Information requests shows that Royal Devon University Healthcare NHS Foundation Trust recorded 16 wrong-site surgery cases during the five-year period. One of these incidents was confirmed to have resulted in severe harm.
The types of wrong-site surgery identified included anaesthetic administration to the wrong location, biopsies performed on incorrect lesions, and the removal of the wrong anatomical structure.
Of the 16 cases, nine were formally examined as Serious Incidents under either the former Serious Incident Framework or the newer Patient Safety Incident Response Framework, which the Trust implemented in 2023.
One incident caused severe harm, while three patients were reported to have experienced moderate harm. A further six cases resulted in minor harm during this period, although more detailed timelines have not been disclosed in order to safeguard patient confidentiality. The Trust highlighted several causes of wrong-site surgery, such as incomplete or incorrect site marking, incorrect safety procedures being followed, complex patient physiology, communication issues, and human error linked to distraction or a lapse in concentration.
Within the NHS, these incidents are typically categorised as ‘Never Events’, meaning they are considered wholly preventable when proper safety checks and protocols are followed.
A statement by the Royal Devon Trust, which operates Royal Devon and Exeter Hospital, North Devon District Hospital and other smaller centres, said: “We take patient safety really seriously and have developed robust processes for governance and learning to minimise events such as wrong site surgery and the impact of those events on our patients.
“The majority of these events result in low or no harm and when they do occur, we respond proportionately to investigate. Findings are presented to our national safety standards for invasive procedures working group, and patient safety committee, to identify any additional learning.
“We implemented the new patient safety incident response framework in 2023 and have seen a reduction in these types of events since then. As part of this process all events are reported to NHS England, even if they do not result in patient harm.”
The situation in Devon reflects a wider national picture. Across England, reports of wrong-site surgery have increased by 46 per cent over the past five years. Medical Negligence Assist submitted FOI requests to 117 NHS Trusts, with 69 providing responses. Together, these trusts reported a total of 647 wrong-site surgery incidents during the period reviewed. Annual figures rose from 69 cases in 2020 to 101 cases in 2025. Nationwide, 46 of these incidents – approximately 7 per cent – resulted in severe harm. Examples included the removal of the wrong anatomy or performing surgery to remove two organs when only one was intended. A further 236 cases caused moderate harm, such as the extraction of the wrong tooth, removal of an incorrect scar, or botox being administered to the wrong area. Low-level harm was recorded in 292 incidents, most commonly involving incorrect biopsies or anaesthetic errors. Only 174 cases, around 27 per cent of the total, were classified as causing no harm to patients. The Newcastle upon Tyne Hospitals NHS Foundation Trust reported the highest number of wrong-site surgery incidents, with an astonishing 44 cases recorded over the five-year period. Gareth Lloyd, head of department at Medical Negligence Assist, said: “It has recently been reported that there has been a significant increase in the numbers of wrong site surgeries taking place within the NHS. These wrong site injuries or incidents are known as ‘Never Events’, with the clue being in the title, and it used to be the case that these events never took place. “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. “If you feel the care provided to you didn’t meet the expected standard, it’s important to understand your legal rights. Raise the issue with the Trust in question and seek legal advice as soon as you can. Making a claim won’t impact your care, and it can help deal with the issues that have developed as a result of the negligence.”
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