Responding to the analysis of the Healthcare Safety Investigation Branch's national learning report on Never Events, NHS Providers' deputy chief executive Saffron Cordery said:

"Patient safety is a major priority for trust leaders, and they are mindful that safety incidents can have profound effects on patients and staff.

"We welcome the analysis and insights generated by this latest report, and the recognition of the level of complexity in which care is being delivered.

"It is sensible for NHS England and NHS Improvement to act on the recommendations to revise the Never Events list, and to look at how steps to prevent such events can be strengthened.

"Staff across the NHS workforce work extremely hard to provide safe care. It is critical that they are supported with the most effective recommendations and approaches.

"Steps are still needed to minimise the likelihood of these events occurring, with a continuing emphasis on learning from events when they do happen."