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Post Viva-voce, re-submission, PhD Thesis - V1.0 N.Roberts -%0D%0A 141225_Redacted.pdfDr. Nigel Roberts is the Associate Divisional Director at Stockport NHS Foundation Trust. The author of this report has worked in theatres since 1998 and commenced his career at Chesterfield and North Derbyshire Royal Hospital as a Support Worker before completing his ODP training in 1998. The author has gone on to publish fourteen research papers, participated in numerous blogs on the patient safety learning hub, spoke at seventeen conferences, two of these were international, designed the latest NatSSIPs 8 flowchart and successfully obtained a PhD, Professional Doctorate, Doctor of Philosophy on the 15th January 2026. The author is also a nationally recognised speaker on patient safety and the Deputy Chair of the national network of Theatre Managers in the UK and Ireland. As part of the authors PhD output, the author has created the first Never Event group in the United Kingdom that enables the cyclical learning of previous Never Events.
Thesis: Why are intra-operative surgical never events still occurring in NHS operating theatres?
Wrong site surgery
Wrong implant/prosthesis
Retained foreign object post procedures
Research, Publications and Thought Leadership
Research, Publications and Thought Leadership
Nigel Roberts has published across peer reviewed academic literature, professional operating theatre journals, and national patient safety platforms. His work focuses on surgical safety, human factors, never events, checklist design, and the practical application of safety standards within NHS operating theatres.
This body of work reflects a consistent commitment to improving perioperative safety through research, service evaluation, frontline insight and system level learning.
Peer reviewed publication
Peer reviewed publication
Why are surgical ‘Never Events’ still occurring: A Delphi study research sample across NHS England operating theatres • Perioperative Care and Operating Room Management • 2023 • Volume 32
Professional journal articles
Professional journal articles
Surgical Safety Checklist – Literature review • The Operating Theatre Journal • 2021 • Issue 374
‘Never Event’ audit at the University Hospitals of Derby and Burton following Covid-19 • The Operating Theatre Journal • 2022 • Issue 376
LocSSIPs – An audit of NHS England Hospital Trust operating theatres • The Operating Theatre Journal • 2022 • Issue 378
Human Factors • The Operating Theatre Journal • 2022 • Issue 380
Human Factors • The Operating Theatre Journal • 2022 • Issue 381
Human Factors • The Operating Theatre Journal • 2022 • Issue 382
Surgical Fires: Why are they not classed a Never Event? • The Operating Theatre Journal • 2022 • Issue 383
Service Evaluation of the current World Health Organisation’s Surgical Safety Checklist in Spine surgery at the University Hospitals of Derby & Burton (UHDB): Could this lead to a change at NHS Improvement? • The Operating Theatre Journal • 2022 • Issue 384
Study Round One – A study across NHS England Hospital Trust Operating Theatres • The Operating Theatre Journal • 2022 • Issue 387
Delphi Study Round Two – A study across NHS England Hospital Trust Operating Theatres • The Operating Theatre Journal • 2023 • Issue 388
Delphi Study Round Three – A study across NHS England Hospital Trust Operating Theatres • The Operating Theatre Journal • 2023 • Issue 389
Surgical Fires – Why aren’t surgical fires classed as a ‘Never Event’? • Clinical Services Journal • 2023 • Volume 22, Issue 1
Understanding checklist challenges • Clinical Services Journal • 2023 • Volume 22, Issue 2
A deeper dive into safe surgery barriers • Clinical Services Journal • 2023 • Volume 22, Issue 3
Safe Surgery Checklists: final conclusions • Clinical Services Journal • 2023 • Volume 22, Issue 4
National patient safety blogs
National patient safety blogs
Surgical Fires: Why are they not classed as ‘Never Events’? • Patient Safety Learning Hub • 2022
Why are intra-operative surgical ‘Never Events’ still occurring in NHS operating theatres? • Patient Safety Learning Hub • 2022
Delphi Study round one – A study across NHS England Hospital Trust operating theatres • Patient Safety Learning Hub • 2022
Delphi study round two – A study across NHS England hospital Trusts operating theatres • Patient Safety Learning Hub • 2022
The National Safety Standards for Invasive Procedures (NatSSIPs2) – NatSSIPs 2 combined with the WHO checklist infographic • Patient Safety Learning Hub • 2023
Why are surgical ‘Never Events’ still occurring: A Delphi study research sample across NHS England operating theatres • Patient Safety Learning Hub • 2023
PIT stop (prosthesis/implant timeout) checklist • Patient Safety Learning Hub • 2023
Speaking engagements and conference presentations
Speaking engagements and conference presentations
NPAG, NHS Theatre Managers, London • August 2022
Future Strategy Show, ExCeL London (in partnership with the Royal College of Surgeons of England) • November 2022
NatSSIPs National Meeting • March 2023
National Performance Advisory Group Meeting, Theatre Managers from across NHS England Conference, Coventry • May 2023
The Association for Perioperative Practice (AfPP) 2023 Conference, University of York • August 2023
The Operating Room Global – International Conference • September 2023
Future Surgery 2023, ExCeL London (in partnership with the Royal College of Surgeons of England) • November 2023
The Operating Room Global – International Conference • February 2024
NPAG Theatres and Decontamination Conference, Coventry Arena • May 2024
Association of Perioperative Practitioners (AfPP), University of Warwick • August 2024
Association of Anaesthesia Associates Conference 2024, The Assembly House, Norwich • October 2024
Paragon Veterinary Practice, Wakefield • February 2025
AJ Bell Stadium, Manchester • February 2025
Rotherham District General Hospital • March 2025
NPAG Theatre Managers, Coventry Arena • May 2025
The Operating Room Global – International Conference • August 2025
AfPP, Nottingham • September 2025
Association of Perioperative Practitioners (AfPP), Wyboston Lakes Resort • August 2026 – NatSSIPs.
Advisory and speaking enquiries
Advisory and speaking enquiries
For advisory, consultancy, speaking or training enquiries relating to surgical safety, human factors, never events, NatSSIPs, LocSSIPs, checklist design or perioperative governance, please click below.
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