Since this page was originally published we have now published a revised Never Events policy and framework and Never Events list.
Summary of 2016 consultation on Never Events policy and framework
The Never Events framework explains that the occurrence of a Never Event may highlight potential weaknesses in how an organisation manages fundamental safety processes.
In Autumn 2016 we held a consultation to get a better understanding of aspects of the policy and framework that was in place at that time, including:
- if it could be further developed to meet its main objective of improving safety culture
- if the list of incidents that were then defined as Never Events (eg wrong side block, dental extractions) was correct or if we needed to redefine the list in line with the overall principles of the policy and framework.
Summary of responses to the October 2016 consultation on the Never Events policy and framework.
Our response to the consultation
In response to the consultation and the issues highlighted, we decided to:
- remove the option for commissioners to impose sanctions on trusts when they report a Never Event
- make revisions to the list of Never Events, including two additional types of Never Event.
- incorporate the Never Events framework into future versions of the wider Serious Incident Framework or successor frameworks.
Removal of option to impose financial sanctions
The consultation responses argued that the existence of an option for commissioners to impose contractual sanctions reinforced the perception of a ‘blame culture’. This could lead to important lessons to improve patient safety both locally and nationally being lost due to an inappropriate focus on individuals.
There is no reduction in the focus that should be placed on preventing Never Events. This is about emphasising the importance of learning from their occurrence.
Changes to the Never Events list
Details of the rationale for the amendments made to the Never Events list can be found in appendix C of the Never Events list 2018. Reasons, why any of the incidents proposed through the consultation have not been included in the final Never Events 2018 list, can be found in the document below.
Incorporate the Never Events framework into future versions of the wider Serious Incident Framework
A combined Never Events and Serious Incident Framework with an agreed list of ‘preventable’ events will provide a simpler, more aligned and integrated framework, reducing complexity and the perception that organisations need in some way to treat Never Events differently from other kinds of Serious Incidents. A combined framework will support a more proportionate and effective approach to all Serious Incidents.
Thematic review of Never Events
The Secretary of State has also asked the Care Quality Commission to conduct a thematic review to get a better understanding of what can be done to prevent the occurrence of Never Events. The review will be carried out in collaboration with NHS Improvement.