Never Events framework consultation 2024

In February 2024, NHS England launched a consultation seeking views on whether the existing Never Events Framework remains an effective mechanism to support patient safety improvement.

The outcome of the consultation was published on the 16 September 2025 NHS England » Never Events framework: 2024 consultation findings. This signals the start of a discovery phase to explore the preferred option of a new approach to the Never Events framework, by exploring and testing alternatives in collaboration with stakeholders, including patients and NHS staff.

Important notes on the provisional nature of this data

To support learning from Never Events we are committed to publishing this data as early as possible. However, because reports of apparent Never Events are submitted by healthcare providers as soon as possible, often before local investigation is complete, all data is provisional and subject to change.

Because of the complex combination of incidents identified as Never Events when first reported, patient safety incidents designated as Never Events at a later date, and incidents initially reported as Never Events that on investigation are found not to meet the criteria, our monthly provisional Never Event reports provide cumulative totals for the current financial year. This is to ensure the information provided is as consistent and as accurate as possible.

This provisional report is drawn from the StEIS system and includes all patient safety incidents with a reported incident date between April 2025 and August 2025, and which on the 26 September 2025 were designated by their reporters as Never Events.

Data on Never Events for 2023/24 and previous years can be found on the NHS England website. Once sufficient time has elapsed after the end of the 2024/25 reporting year for local incident investigation and national analysis of data, we will produce a final whole-year report of Never Events, which will replace this provisional data.

Summary

When data for this report was extracted on 26 September 2025, 183 patient safety incidents on the StEIS system were designated by their reporters as Never Events and had a reported incident date between April 2025 and August 2025, of these 183 incidents:

• 178 patient safety incidents appeared to meet the definition of a Never Event in the Never Events list 2018 (published 28 February 2018). This number is subject to change as local investigations are completed.
• 5 patient safety incidents did not appear to meet the definition of a Never Event.

More details are provided in the tables on the following pages.

Table 1: Never Events April 2025 – August 2025 by month of incident

Note: As described above, a further 5 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly. Numbers are subject to change as local investigations are completed.

 Source: Reported NHS Never Events from StEIS

Table 2: Never Events April 2025 – August 2025 by type of incident with additional detail

Note: As described above, a further 5 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly. Numbers are subject to change as local investigations are completed.

Source: Reported NHS Never Events from StEIS

Table 3: Never Events April 2025 – August 2025 by healthcare provider

Note: As described above, a further 5 patient safety incidents did not appear to meet the definition of a Never Event and the relevant organisations have been asked to review accordingly. Numbers are subject to change as local investigations are completed.

Source: Reported NHS Never Events from StEIS