Hospitals report 20 instances of surgical procedure carried out on mistaken affected person or physique half
Kent NHS trusts recorded at least 20 ‘never events’ between 2020 and 2025, including two people receiving injections in the wrong eye causing moderate physical harm
The incidents occurred in Kent Hospitals (stock)(Image: Stock image/Cover Images)
Hospitals across Kent have documented at least 20 instances of operations being carried out on the incorrect patient or wrong body part during the period from 2020 to 2025, according to recently disclosed data. Two individuals received injections in the wrong eye at Maidstone and Tunbridge Wells NHS Trust, resulting in what has been classified as moderate physical harm to those affected.
Additionally, the same trust experienced four further episodes of wrong-site operations, including a nerve block being delivered to the incorrect side in May 2021, with a repeat occurrence in August 2025. There were also two instances of biopsies being extracted from the wrong side in November 2022 and February 2025, though these were deemed to have caused “low physical harm”.
The most recent injection into the incorrect eye occurred in October 2025 and remains under investigation, although preliminary assessment suggests it resulted in moderate physical harm. Overall, MTW trust documented six episodes of wrong-site operations during the five-year timeframe.
These incidents are labelled as “never events”, meaning they are classified as serious occurrences that are entirely preventable when appropriate safeguards are implemented.
The hospital trust stated its priority is delivering “safe, high-quality care” to the local community and acknowledged that whilst never events were uncommon, when they occur, a thorough review is conducted to ensure lessons are learnt and enhancements are implemented.
The information was secured via a Freedom of Information request by Medical Negligence Assist, a firm which offers legal assistance to potential victims of suspected medical errors. The report also disclosed that East Kent Hospitals University NHS Foundation Trust has logged 14 incidents in the past five years.
This tally included three instances of the incorrect tooth being removed, occurring in March 2020, April 2024 and November 2024.
On two separate occasions, the wrong skin lesion was biopsied, and there were two cases of anaesthetic block being administered on the incorrect side.
Shockingly, twice the wrong patient underwent a procedure. In March 2021, a patient received a scope procedure they weren’t scheduled for, which is a test to examine the inside of the body.
Then in September 2022, the wrong patient underwent a biopsy procedure. Both incidents were categorised as a “never event”.
Other examples included the excision of the wrong skin lesion, a scope procedure performed on the incorrect side, an erroneous nerve procedure and a wrong-side block procedure.
The EKT stated that two of the incidents resulted in no harm to the patient, eight caused minimal harm necessitating extra observation or minor treatment, whilst four incidents caused moderate harm, defined as “significant but not permanent harm” requiring additional treatment.
When questioned about the causes of these surgical errors, the trust cited factors such as a “busy, distracting environment theatre list changes and mixed lists error on waiting list form”.
Other root causes or contributing factors were listed as “change in anatomy multiple teeth requiring extraction multiple skin lesions” and also “awareness of presence of annotated X-ray/diagram”.
In the past five years, six of the wrong-site surgery incidents at the trust occurred in 2024, one in 2023, three in 2022, one in 2021 and three in 2020. There were none in 2025.
Wrong-site surgery relates to any incident falling under the following definition: “A medical error where a procedure is performed on the wrong patient, the wrong body part, or the wrong side of the body.”
Medway NHS Foundation Trust had fewer than five incidents in five years, so could not disclose the data to protect patient confidentiality.
However, fewer than five cases suggest there was at least one. The hospital disclosed that causes included “human error a different theatre being used to the usual one, therefore patient positioned differently a new trolley being used clinic list was of a high volume and low complexity meaning a high turnaround of patients”.
It said that all incidents were categorised as “no harm”. Dartford and Gravesham NHS trust did not disclose any information because of the small number of cases.
In response to the data, a spokesperson for EKT, MTW and Medway NHS Foundation Trust said: “Our hospitals in Kent and Medway care for over two-and-a-half million patients every year and our priority is to provide safe, high-quality care to our local communities. “While never events are very rare, when they happen, we carry out a detailed review to ensure any learning is shared and improvements are made.”
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