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 existing policy and framework including:
- if it can be further developed to meet its main objective of improving safety culture
- if the current list of incidents defined as Never Events (eg wrong side block, dental extractions) is correct or if we need to redefine this 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 2016 Never Events policy and framework consultation
In response to the consultation and the issues
highlighted, we have decided to:
- remove the option
for commissioners to impose contractual sanctions on trusts when they report a
- incorporate future versions of the Never Events Framework into the wider Serious Incident Framework or successor frameworks.
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, not blaming.
We intend to publish a revised Never Events Framework by the end of the year which will incorporate changes to the list of incidents that are defined as Never Events.
The revised framework will be published as an annex of the Serious Incident Framework and no longer be a standalone policy.
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. We then intend to publish an overall revised Serious Incident Framework around March 2018.
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. Further details to be announced in the near future.
Following the feedback to the consultation, we are now considering how we will use responses to inform:
- an update to the Never Events policy and framework
- a revision to the list of Never Events, including potential refinement of the incident types currently included and possible inclusion of new Never Events that were suggested as part of the consultation
- a project with key partners including providers, commissioners and clinicians, to get a better understanding of how we might improve the sharing of learning as a result of investigations into Never Events