Hundreds of patients subjected to NHS blunders that 'should never happen' In addition there were 41 of the wrong implant being used, which may happen in knee or hip replacement and only discovered after the operation is complete. Nasal or oral feeding tubes were found to be in the correct place or had become dislodged in 23 cases. The NHS Commissioning Board is setting up a task force to look at surgical never events, in order to make sure that these events are eradicated. Sir Bruce Keogh, NHS Medical Director and Jane Cummings, Chief Nursing Officer, have also written to the NHS highlighting the figures. Health Secretary Jeremy Hunt said: "We know that transparency saves lives and improves care. The NHS treats a million people every 36 hours, and we know that the vast majority of these patients have excellent care. But the NHS needs to do more to really tackle these events. The NHS Commissioning Board is now setting up a task force to eradicate these never events from NHS surgery. NHS Medical Director Sir Bruce Keogh said: "NHS Leaders should examine these figures and the guidance that sits alongside them and really focus on driving them out of the NHS. There are simple ways to prevent them occurring, like the Surgical Safety Checklist, and everyone working in the NHS should ensure that the checklist is being followed.