When the Never Events framework was introduced in 2009, its purpose was clear: identify a specific category of serious patient safety incidents that shouldn’t occur if the right protective barriers are in place and use these to drive systemic safety improvements across the NHS. It was an approach that made intuitive sense.

After extensive review and consultation with patients, healthcare professionals, patient groups, and safety experts through our online survey and 25 focused discussion groups, we’ve found compelling evidence that the framework isn’t consistently achieving its intended purpose.

The consultation tells a clear story. Two-thirds of respondents told us the current framework is not fit for purpose. But more importantly, they helped us understand why.

One of the strongest messages was about the framework’s unintended consequences. Never Events are often misinterpreted as the ‘worst’ kind of incidents causing anxiety for patients, and leading to disproportionate responses and significant impact on staff wellbeing. Healthcare workers shared powerful testimonies about the personal toll of being involved in Never Events, even when no long-term harm occurred – which is the case for the majority of these incidents.

This misconception can lead to resources being directed toward investigating incidents that meet the Never Event criteria, rather than focusing on events that really matter to patients and might offer greater potential for learning and improvement. The media attention these incidents attract often reinforces this distortion, creating a narrative that doesn’t align with the reality of patient safety improvement.

Our review also revealed that many designated Never Events lack sufficiently robust preventative barriers to justify their classification as ‘wholly preventable’. This undermines the framework’s foundational principle and can create unrealistic expectations.

Conversely, we have evidence that some Never Events, associated with strong barriers, have reduced. For example, the numbers of patients being inadvertently connected to air rather than oxygen, has declined significantly since National Patient Safety Alerts were issued in 2016 and 2021. However, it is also clear that this success is dependent on the effectiveness of the barriers and not solely the designation of something as a Never Event.

Taking all of this evidence into account, we are now looking to identify and test alternatives. Through our discovery phase, we will explore options for an approach that better serves our ultimate goal: improving patient safety across the NHS. While the specific details will be shaped through extensive engagement with stakeholders, we know we need a system that moves beyond simple categorisation to drive meaningful improvement. We have an opportunity to develop something that better reflects the complexities of modern healthcare, while maintaining our fundamental commitment to safety and aligning with the 10 year plan.

Let me be absolutely clear: exploring a different approach isn’t about lowering standards – quite the opposite. England maintains one of the world’s most comprehensive patient safety systems, with approximately three million incidents reported annually. We have robust statutory requirements, comprehensive regulatory oversight through the CQC, and the Learn from Patient Safety Events service. These systems remain unchanged and will continue to ensure thorough incident reporting and learning.

What we’re proposing is to explore a more effective approach that genuinely drives safety improvements. We want a framework that:

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

The discovery process will be thoroughly collaborative, working with patients, NHS staff, and safety experts. We’ll learn from international approaches while ensuring our solution fits England’s unique context.

Patient safety remains our absolute priority. By evolving our approach, we can better support the NHS in delivering safer care for all patients. The strong support shown through our consultation gives us confidence that this is the right direction for the future of patient safety in the NHS.

Read our full consultation findings and next steps here: NHS England » Never Events framework: 2024 consultation findings