Never Events framework: 2024 consultation findings (NHS England, 16 September 2025)

Summary

In February 2024 NHS England launched a consultation to collect views on the effectiveness of its Never Events policy and framework. This article summarises the findings of the consultation and sets out next steps for revising the definition of and process for Never Events.

Content

Never Events are defined as patient safety incidents that are “wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers”.

NHS England held a 12 week consultation that ran from February to May 2024 asking, via an online survey, ‘on balance do you think the Never Events framework is an effective mechanism to support patient safety improvement and based on the evidence provided in the supporting consultation document which one of the following options do you prefer for its future?’

• Option 1: no change; continue with the current framework
• Option 2: abolish the Never Events framework and list
• Option 3: revise the list of Never Events to only include those with current barriers that are ‘strong, systemic, protective’
• Option 4: revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’

Key findings

• There were 854 responses to the online survey, 86% (744) from individuals and 14% (120) on behalf of an organisation
• Only 8% of consultation respondents felt the current Never Event framework was effective
• 66% of consultation respondents considered the current framework unfit for purpose
• 48% of respondents advocated for an alternative approach
• Feedback highlighted the ‘Never Event’ terminology creates unintended negative effects on staff morale and blame culture
• The majority of respondents shared the view that the current framework has limited impact on driving safety improvements

Future direction and next steps

NHS England state that as a result of these findings Option 4 is the preferred way forward, revise the definition of and process for Never Events to create a new system that does not require all relevant incidents to be ‘wholly preventable’. Reflecting the consultation's findings, they state that a new framework should:

• Focus on learning rather than meeting a definition based on strength of barriers
• Reflect the patient safety events that are of significant concern to patients and the NHS
• Be better at including patient safety events across sectors and settings, including mental health and primary care
• Align with Patient Safety Incident Response Framework (PSIRF) principles of proportionate learning and response
• Support a just culture where staff feel confident to report and learn
• Direct resources toward activities that have the greatest potential for improvement
• Better recognises the complexity of healthcare delivery

To take this forward, NHS England had said they have launched a ‘discovery phase’ to explore and test alternatives to the Never Events framework. This will be done in collaboration with stakeholders, including patients and NHS staff. They state that they will aim to complete this next phase within six months and will then set out further plans after that.

While an alternative process is in development, the existing Never Events framework will remain active.

Related reading

• NHS England, Detailed findings from the 2024 consultation on the Never Events framework, 16 September 2025.
• Dr Aiden Fowler, Evolving our approach to patient safety: the future of Never Events, 16 September 2025.
• Patient Safety Learning, Never Events: The Big Debate, 2 May 2024.