NHS England: Never Events framework consultation (closes at midnight on 5 May 2024)

Summary

The NHS England National Patient Safety Team is seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement.

The consultation runs from the 7 February until the 7 May 2024.

Content

Never Events are defined by the NHS as:

“Serious 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. Strong systemic protective barriers are defined as barriers that must be successful, reliable and comprehensive safeguards or remedies – for example, a uniquely designed connector that stops a medicine being given by the wrong route.”

 NHS England are holding a consultation on the current Never Events Framework following the findings of reports from the Care Quality Commission report, Opening the door to change, and the Healthcare Safety Investigation Branch’s analysis of Never Events, that highlighted for several types and sub-types of Never Events the barriers are not strong enough to make an incident wholly preventable, as well as further focus groups held by the National Patient Safety Team throughout 2021/22. 

The consultation asks whether on balance, respondents think that the Never Events framework is an effective mechanism to drive patient safety improvement; and bearing in mind the evidence in the consultation document, which one of the following options they 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’.

The consultation will close at midnight on 5 May 2024.