The incidents, classified as “wrong-site surgery” errors, occurred at Salisbury NHS Foundation Trust between 2020 and 2025, and involve procedures performed on the wrong patient, body part or side of the body, such as operating on the left limb instead of the right.
Of the 18 cases recorded in Salisbury, six took place in 2025 alone, representing a third of the total.
Judy Dyos, chief nursing officer at Salisbury NHS Foundation Trust, said: “Any medical intervention that is considered to meet the wrong site criteria is automatically classified as a Serious Incident, even where little or no harm has occurred.
“Some descriptions can sound alarming, for example, a wrong-site procedure may be related to a minor procedure such as a mole removal, but all are treated with the utmost seriousness.
“We are committed to a full duty of candour in every case, openly discussing what happened and the learning identified to strengthen our systems and processes.
“All Never Events and Serious Incidents are reported publicly at Trust Board meetings, with appropriate limits to protect patient confidentiality.
“A respect for patient confidentiality means we are unable to comment in detail.
“We are proactive in reporting and unwavering in our commitment to continuous improvement and patient safety.”
Out of the 18 incidents, five were classified as serious under the former Serious Incident Framework.
Following the introduction of the Patient Safety Incident Response Framework in 2023, an additional five reached the threshold for serious incident classification, bringing the total to ten serious incidents over the five-year period.
While none of the cases resulted in severe or life-threatening harm, five patients experienced moderate harm, and another five suffered low-level harm.
Seven incidents occurred between 2020 and 2022, compared with six in 2025 alone.
Salisbury District Hospital (Image: Spencer Mulholland)
The Salisbury figures are part of a wider national trend, with wrong-site surgery reports across England rising by 46 per cent.
Medical Negligence Assist, who obtained the data through Freedom of Information requests, found that 647 wrong-site surgery incidents were reported nationwide between 2020 and 2025, based on responses from 69 out of 117 NHS trusts.
The annual number of reported cases increased from 69 in 2020 to 101 in 2025.
Of the national incidents, 46 (about seven per cent) resulted in serious harm.
Examples included the excision of the wrong anatomical structure or the removal of two organs during one procedure.
A further 236 cases caused moderate harm, such as removing the wrong tooth, excising the wrong scar or administering Botox to the neck instead of the mouth.
Low-level harm was reported in 292 cases, often involving incorrect biopsies or anaesthetic errors.
Only 174 incidents, around 27 per cent, were recorded as causing no harm.