When you agree to surgery, you put complete trust in the hands of your medical team. You expect everyone involved to understand what procedure you’re having, why you’re having it, and—most importantly—where it should be performed.
While many assume wrong-site surgery is the result of a freak accident or a careless surgeon, the truth is that the NHS reports regular wrong-site surgeries every year. In fact, one UK hospital carried out three wrong-site surgeries in just three months in 2024.
Wrong-site surgery can mean operating on the wrong limb, wrong organ, wrong side of the body, or even performing the wrong procedure entirely. The physical and emotional consequences can be life-changing for both the patient and their families.
This article looks at how miscommunication can lead to wrong-site surgeries and what legal rights you have when something goes terribly wrong in the operating room.
What are Never Events?
In the UK, wrong-site surgery is considered a ‘Never Event’ — a surgical mistake that is “wholly preventable” when safety protocols are followed.
The NHS reported 403 Never Events between April 2024 and March 2025, with the most common being:
- Administration of medication by the wrong route (14)
- Wrong-site surgery (185)
- Retained foreign object post-procedure (106)
- Wrong implant/prosthesis (50)
- Misplaced naso- or oro-gastric tubes (23)
What measures are in place to prevent wrong-site surgery?
In 2004, the Joint Commission released the Universal Protocol to address the ongoing occurrence of wrong-site surgeries. The Universal Protocol is a checklist with three clear steps that help prevent wrong-site surgery:
1. Check everything before the operation
Before your operation begins, the medical team must verify all relevant documents and information, including:
- Your identity
- The planned procedure
- The side/site to be operated on
The team should also check consent forms, medical records, and imaging (e.g., X-rays or scans). All of these details should be confirmed with you whilst you’re still awake and aware.
This verification process helps catch any discrepancies between what’s written in your notes and what’s actually planned.
2. Mark the operative site
The surgical site must be clearly marked with a pen or marker.
The mark must be visible after the patient is positioned, and after the surgical site is draped.
3. Pause for a ‘time-out’
The last safety check happens immediately before your surgery. The entire surgical team stops all activity for a ‘time-out’ to confirm they’re operating on the correct patient, at the correct site, and performing the proper procedure.
This pause is the final opportunity to catch any errors, and the procedure cannot begin until every team member agrees that all details are correct.
Causes of wrong-site surgery
Wrong-site surgery rarely begins in the operating room. The errors tend to happen much earlier—often in busy outpatient departments or incomplete handovers.
Poor communication
Verbal communication problems can be particularly risky in outpatient settings. In one wrong-site surgery case, a patient’s surname resembled another patient’s first name, and they responded to the wrong call.
Staff handovers present another communication risk. When different team members treat you at various stages of your care, information can get lost or misinterpreted.
The physical environment also affects communication quality; for example, noisy waiting areas can increase the chance of miscommunication about your identity and intended procedure.
Checklist fatigue and complacency
Hospitals have extensive safety protocols, such as the Universal Protocol and the WHO Surgical Safety Checklist, that are intended to prevent wrong-site surgeries. However, over time, these protocols can feel like ‘tick-box exercises’ rather than meaningful safety steps.
Time pressures can also worsen checklist fatigue. When your team faces heavy workloads and tight schedules, they may feel pressured to complete safety checks quickly rather than thoroughly.
According to one study, failure to follow policy/protocol was the leading contributor to wrong-site surgery.
The surgical marking process fails
The surgical site marking process provides final visual confirmation of the operative site; however, marking failures can happen.
Staff can mark the wrong side of the body, place marks that wash off during preparation, or have marks covered by surgical drapes, making them invisible at the start of the operation.
The consequences of wrong-site surgery
A procedure performed on the wrong patient or wrong site can cause both medical complications and long-term physical damage.
Physical harm from wrong-site surgeries can include:
- Chronic pain that persists after the incorrect procedure
- Permanent disability requiring ongoing care
- Damage to vital organs
- Infection and sepsis from unnecessary surgical wounds
- Scarring and tissue damage
Nearly half of patients affected by wrong-site surgery are required to get another operation to fix the original mistake. Emotional trauma is also not uncommon in these circumstances, so the loss of trust in doctors and hospitals can make future operations even more frightening.
Is wrong-site surgery automatically considered negligence?
Almost always, yes.
A strong medical negligence claim for wrong-site surgery may happen when:
- The consent form was incorrect or incomplete
- Documentation conflicted, but no one investigated
- Staff failed to confirm the site, procedure, or side
- The surgical site wasn’t marked appropriately
- The wrong site was prepared or draped without proper cross-checking
Wrong-site surgeries are among the clearest forms of medical negligence because the harm is rarely contested and usually obvious.
What does a clinical negligence expert do for wrong-site surgery claims?
At Friends Legal, our medical negligence team looks for evidence of a clear failure to follow accepted safety protocols (e.g., proper site marking, surgical checklist, and time-out procedures).
Our wrong-site surgery claims lawyers also work with independent medical professionals to build the strongest possible case.
We reconstruct the chain of events step-by-step by reviewing:
- Clinic consultation records
- GP referral notes
- Pre-operative assessments
- Surgical marking documentation
- Operating theatre logs and staff witness accounts
We identify where the process broke down, who had responsibility at each stage, and whether earlier checks would’ve prevented the error.
Contact our Wrong-Site Surgery Negligence Solicitors
Wrong-site surgery can shape the rest of your life. If you have unanswered questions about what went wrong, our clinical negligence lawyers can help you understand your rights and options following wrong-site surgery.
Contact us today to discuss your case with our specialist team.
