Never events can result in serious patient harm and indicate serious underlying organizational safety problems. This study analyzed never events occurring between 2012 and 2020 in the National Health Services and categorized 51 common never events into four categories – wrong site surgery (40% of events); retained foreign objects post-procedure (28%); wrong implant/prosthesis (13%); and non-surgical/infrequent never events (19%). Awareness of these themes may support focused efforts to reduce their incidence and development of specific local safety standards.