The NHS in England is one of the only healthcare systems in the world that is this open and transparent about patient safety incident reporting, particularly around Never Events. We are clear that we need to openly tackle these issues, not ignore them.
We publish provisional Never Events data every month as an update of the cumulative total for the current financial year. The data is published in the following formats:
- the overall provisional number of Never Events reported in the current financial year to date – these are displayed by month
- the provisional number of each type of Never Event reported, with a more detailed breakdown of sub categories of Never Event
- the provisional number of each type of Never Event reported by an organisation
Provisional 2020/21 data: 1 April – 31 December 2020
- Never Events 1 April – 31 December 2020 – A provisional summary of Never Events that have been reported as occurring between 1 April – 31 December 2020.
Provisional 2018/19 data: 1 April 2018 to 31 March 2019
- Never Events 1 April 2018 – 31 March 2019 – A provisional summary of Never Events that have been reported as occurring between 1 April 2018 and 31 March 2019
Final data from 2019/20
Each year, once sufficient time has elapsed for local incident investigation and national analysis of data to take place, we publish a final whole-year report which supersedes our monthly provisional reports.
- Never Events data summary for 2019/20 – This report provides a summary of Never Events that have occurred between 1 April 2019 and 31 March 2020.
Final data from 2017/18
- Never Events data summary for 2017/18 – This report provides a summary of Never Events that have occurred between 1 April 2017 and 31 March 2018.
Final data from 2016/17
- Never events data summary for 2016/17 – This report provides a summary of Never Events that have occurred between 1 April 2016 and 31 March 2017.
Final data from 2015/16
- Never events data summary for 2015/16 – This report provides a summary of Never Events that have occurred between 1 April 2015 and 31 March 2016.
Final data from 2014/15 and earlier
- Data on never events published by NHS England – NHS England Patient Safety section stored in the National Archives.
Comparing the 2016/17 and 2015/16 data with previous years
It is not possible to compare the number of Never Events reported in the 2016/17 and 2015/16 final updates with reports covering previous years. This is because the Never Events Policy and Framework and the Never Events list was revised in March 2015.
The NHS has become better at incident reporting which is also expected to have led to an increase in the numbers of reported Never Events. In addition, the numbers of Never Events reported by independent providers is also increasing as they report more incidents to our national systems to support learning.
The following points should be considered regarding the increase in the numbers of Never Events reported in 2015/16:
In April 2013 a much more robust process was also introduced to ensure all Never Events were designated as such on the STEIS incident reporting system, and we also clarified the definition of Retained Foreign Objects Post Procedure type of Never Events to ensure providers and commissioners understood more clearly which incidents should be declared as Never Events.
- the definition of what constitutes a Never Event was amended as it now requires the potential to cause serious harm/death rather than actual harm to have occurred
- many of the definitions of Never Events on the Never Events list have been refined e.g. Wrong Site Surgery now includes wrong site blocks (42 reported 2015/16), a clarification was made that wrong tooth extraction is a Never Event (33 reported 2015/16) and the list now includes wrong level spinal surgery (11 reported 2015/16)
- wrong site surgery was clarified to include surgical interventions done outside the operating department environment and includes line insertions e.g. Hickman, central lines etc
- wrong implant/prosthesis was amended to remove the requirement for further surgery to replace the incorrect implant/prosthesis and the occurrence of complications