This page provides detailed findings from the 2024 consultation on the Never Events framework. Further information, including a summary of the consultation outcomes and details of next steps can be found on our main Never Events framework: 2024 consultation findings webpage.
Survey response
There were 864 responses to the online survey:
- 86% (744) from individuals; 52 were from individuals who identified themselves as patient safety partners or members of the public, with the remaining working across health and social care in a variety of roles (clinicians, managers, governance, regulation)
- 14% (120) on behalf of an organisation: 52 for providers of NHS healthcare, 27 for a professional body or regulator, 15 for an integrated care board or NHS England, and 26 for an independent organisation, charity or other arm’s length body.
Over 62% (538) of respondents described their organisation as in the acute sector, which is unsurprising given focus group feedback that the current Never Events list is acute focused.
Option preferences
The breakdown of favoured option across all respondents was:
- Option 1– no change, continue with the existing framework: 8% (70)
- Option 2 – abolish the Never Events framework and list: 18% (152)
- Option 3– revise the list of Never Events to only include those with current barriers that are ‘strong, systemic, protective’: 26% (224)
- 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’: 48% (418)
The option preference order was the same for individuals and organisations – option 4 the most popular, followed by option 3 and option 2. Option 1 (to keep the status quo) was the least favoured approach. The option preference order was also the same across organisations of different types (provider of NHS healthcare, integrated care board (ICB) or NHS England, professional body or regulator, and others).
Thematic analysis
Free text feedback from the survey was analysed together with insights from the focus groups to provide a fuller picture of people’s preferred options on the future of the framework.
Feedback was largely in agreement with the 3 arguments for change put forward in the consultation guidance:
- Hierarchy of controls: This is a system of determining which actions will best control exposure to a hazard or mitigate the risk of an incident occurring. It is used most often in the context of health and safety (Centre for Disease Control and Prevention, 2015), but was adapted to examine clinical safety risks in the context of Never Events. Application of the hierarchy of controls to the Never Events Framework identified that not all controls in the current Framework meet the definition of a Never Event.
- Impact on staff: The use of the term ‘Never Event’ for incidents that will inevitably occur seems misplaced, and the subsequent scrutiny can have significant negative impact on staff wellbeing and their careers. We know staff are often subject to significant scrutiny in the aftermath of a Never Event by both their organisation and regulatory bodies, and national policy requirements mean that these events trigger intensive responses regardless of the potential for learning and improvement.
- Effectiveness as a mechanism for improving safety: Assessment of trends in the occurrence of Never Events is challenging because the Never Events list and definition have been reviewed and updated regularly since their introduction. However, data does indicate that where the prevalence of some Never Events has reduced, these are those Never Events with stronger controls, such as elimination, substitution and engineering controls. The prevalence of those Never Events with weaker controls remains relatively static, indicating that their inclusion on the framework does not drive down their frequency.
A recurring theme across the survey responses and the focus groups was the perceived punitive effect of the term ‘Never Event’ on staff, with many respondents associating it with a blame culture which had a negative impact on staff and could be confusing to the public. Feedback highlighted the media’s and the public’s misperception that ‘Never Event’ refers to the seriousness of an incident and how unacceptable it is, not that an incident has occurred because of problems with implementing strong controls that mitigate the risk. This misperception exacerbates the impact on staff.
Option 1 (no change)
Almost half of the 8% (70) of survey respondents who selected this option justified their recommendation to continue with the current Never Events framework with comments. Their rationales were mixed but centred on a belief that without the Never Events framework there would be a lack of public accountability. Only 3 respondents felt the term ‘Never Event’ was well understood and should be maintained for consistency. In contrast, the focus groups were unanimous that the framework needed to be revised.
Option 2 (abolish the framework)
The negative impact on staff of the term Never Event was a strong rationale among the 18% (152) of survey respondents who selected this option, alongside the lack of evidence that the framework drives safety improvement. People argued that the mandated requirement to complete patient safety incident investigations (PSII) in the Never Events framework means focus and time are disproportionately given to investigations into these incidents at the cost of prioritising resources for improvement based on an assessment of the organisation’s safety profile as advocated by the Patient Safety Incident Response Framework (PSIRF).
Option 2 is preferred by the Health Services Safety Investigations Body (HSSIB) on the basis that “the designation of some patient safety incidents as ‘Never Events’ is not evidence-based, does not drive improvement and exposes staff to undue scrutiny.” Feedback in the focus groups also made this argument.
Option 3 (revise the Never Events list)
Survey respondents across the 3 change options (2, 3 and 4) commented that it was problematic that the Never Events list included events that are not wholly preventable because ‘strong, systemic barriers’ are lacking. However, among the 26% (224) selecting option 3, there was a general acceptance that controls based on elimination or substitution would meet the ‘wholly preventable’ definition and that events with people-focused controls should not be described as Never Events.
The rationale for supporting option 3 in survey responses and focus group feedback centred on the Never Events framework being an established concept and that list revision to only include strong, systemic barriers in line with the hierarchy of controls would resolve the current issues. Some focus group members also mentioned that the Never Events framework is used as a lever to prioritise funding for equipment or improvement projects.
Of the 109 respondents who commented, 10 stated that they would only support a revised list if their speciality event type (for example, surgical, nasogastric tube or blood transfusion events) remained on the list. As the hierarchy of controls outlined in the consultation document made it clear that such events would not remain on the list, option 3 may not be their preferred option.
Option 4 (revise the definition and process)
48% of respondents (418) felt the current framework should be replaced with an alternative process, one which does not require all relevant incidents to be ‘wholly preventable’. There were strong similarities between the comments given in support of option 2 (to abolish the framework) and option 4, with both arguing in line with the three central arguments of the consultation:
- that under the hierarchy of controls not all Never Events meet the definition
- that Never Events trigger a disproportionate response in terms of allocation of resources that would be better targeted at improvement
- that designation of incidents as Never Events can have a negative impact on staff
The consultation document described 2 potential implementation models but emphasised that further work would be needed to agree a suitable model and that other options would also be considered.
When considering what an alternative process would look like, respondents emphasised the importance of alignment with PSIRF, including adopting its core principles: compassionate engagement of patients, families and staff; proportionate response; application of a range of system-based approaches to learning; and supportive oversight focused on improvement. However, opinions diverged on how best to align a revised framework with PSIRF. The immaturity of PSIRF was a recurring theme in focus groups (noting these took place during 2023 and early 2024), with discussions about whether PSIRF on its own can remove the need for a Never Events framework, whether this is an aspiration when PSIRF is more firmly embedded, or whether something separate but aligned to the PSIRF principles is needed.
Option 4 was favoured by respondents describing themselves as patients or members of the public, as well the Patients Association and AvMa. Focus group members felt a new process should focus on improvement, using learning to drive changes only possible at a national level. The acute focus of the current Never Events list was also a topic for discussion and the suggestion made that a new process could be more inclusive of events in mental health, community services and primary care.
Feedback from HSSIB and the CQC
The consultation document explicitly described option 3 as “meeting the recommendations of the CQC and HSIB”. However, both organisations have changed their opinion since making recommendations in reports published in 2018 and 2021 respectively.
HSSIB’s preferred option is now to abolish the Never Events Framework (option 2), highlighting that “even with system focused controls in place, events may not be ‘wholly preventable’”.
CQC’s preferred option is now a new process that aligns with PSIRF (option 4), providing this removes the negative connotations for staff of the term Never Events. CQC noted that “the concept of strong, systemic protections in healthcare is very different compared to other safety critical sectors. Healthcare is inherently dependent on people, whereas in other safety critical industries, those strong systemic barriers can largely be automated, and people are there as a last line of defence”.