The NHS strives to learn from its mistakes but is often criticised for failing to investigate incidents properly, and for failing to share lessons learned more widely.

This report is a redacted report from a Never Event investigation. The Trust involved wishes to share the report widely, to share the generic learning from the incident. Hopefully it will also stimulate discussion and thought about the process and format of such investigations.

Please click here to read and share the full report.

Update: The Trust involved is pleased to report that the implant manufacturers have considered this incident carefully and have now changed their implant labelling to more clearly identify the differences between products. This is a very positive step by the manufacturer which they were under no legal obligation to do.

Update: There have been very constructive conversations with senior staff at MHRA about the issues raised concerning implant labelling. The MHRA is fully aware of the issues and is looking at how these can be better addressed, bearing in mind the regulatory and legal frameworks that exist, and that manufacturers market their products internationally not just in the UK.