low-risk pregnancy while being cared for in a health care facility Patient death or serious disability associated with hypoglycemia, the onset of which occurs while the patient is being cared for in a healthcare facility Death or serious disability (kernicterus) associated with failure to identify and treat hyperbilirubinemia in neonates Stage 3 or 4 pressure ulcers acquired after admission to a healthcare facility Patient death or serious disability due to spinal manipulative therapy Any incident in which a line designated for oxygen or other gas to be delivered to a patient contains the wrong gas or is contaminated by toxic substances Patient death or serious disability associated with a burn incurred from any source while being cared for in a healthcare facility Patient death or serious disability associated with the use of restraints or bedrails while being cared for in a healthcare facility Any instance of care ordered by or provided by someone impersonating a physician, nurse, pharmacist, or other licensed healthcare provider Abduction of a patient of any age Sexual assault on a patient within or on the grounds of the healthcare facility Death or significant injury of a patient or staff member resulting from a physical assault (i.e., battery) that occurs within or on the grounds of the healthcare facility As of 2019, 11 states have mandated reporting for never events, and an additional 16 states have mandated reporting for serious adverse events including never events. United Kingdom The National Patient Safety Agency produced a list of eight core never events in March 2009: Wrong site surgery Retained instrument postoperation Wrong route administration of chemotherapy Misplaced nasogastric or orogastric tube not detected before use Inpatient suicide using non-collapsible rails Escape from within the secure perimeter of medium or high security mental health services by patients who are transferred prisoners In-hospital maternal death from post-partum haemorrhage after elective caesarean section Intravenous administration of mis-selected concentrated potassium chloride NHS England produced a report on 148 reported never events in the period from April to September 2013 highlighting particular hospitals with more than one such event. In 2021 there were still about 500 never events each year in the English NHS. According to Jeremy Hunt a hospital can get as many as 108 safety related instructions in a year. NHS Improvement has produced monthly and cumulative annual reports since 2015, when the definition of what constitutes a Never Event in the