Never Events framework: 2024 consultation findings

In February 2024, NHS England launched a consultation to collect views on the effectiveness of the Never Events framework. The following summarises the findings of the consultation and sets out next steps.

You can also read Evolving our approach to patient safety: The future of Never Events – a blog from Aidan Fowler, National Director of Patient Safety, NHS England.

About Never Events

Never Events are a very specific type of patient safety incident, defined as patient safety 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” A list of incidents that were considered to meet this definition is published in the Never Events list 2018 as part of the Never Events Policy and Framework 2018.

The Never Events framework defines a strong systemic protective barrier as one that is “successful, reliable and represents comprehensive safeguards or remedies that stop a particular safety concern from occurring and causing harm to a patient”; for example, a uniquely designed connector between a syringe/giving device and a line or needle that stops a medicine being given by the wrong route.

Never Events represent a tiny proportion of the total number of patient safety events recorded annually in England, all of which have the potential to support learning and improvement. However, they are often misconceived to be the worst kind of patient safety incidents despite evidence showing that many Never Events do not result in serious long-term patient harm. This misunderstanding means that their designation can have a negative impact on patient safety culture as they can drive blame and a focus on individual fault.

The Never Events Framework consultation

Never Events were introduced in the NHS in 2009 to designate a distinct category of patient safety incidents where it was believed that a specific focus on reporting and a mandated response would drive improvements in patient safety. However, reports published by external bodies, and evidence gathered as part of this consultation shows that in most cases this aim has not been achieved

An initial review of the Never Events Framework in 2023/24 prompted by reports from the Care Quality Commission (CQC) and the Healthcare Safety Investigation Branch (HSIB) [now the Health Services Safety Investigations Body (HSSIB)] identified that some designated Never Events lack sufficiently robust preventative barriers to justify their classification. This led to a public consultation to evaluate the framework’s effectiveness in supporting patient safety improvement.

The 12 week consultation ran from February to May 2024 and asked, via an online survey, ‘on balance do you think the Never Events framework is an effective mechanism to support patient safety improvement and based on the evidence provided in the supporting consultation document which one of the following options do you 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’

Respondents had the option to support their response in free text and to respond on behalf of an organisation or as an individual.

Further insight was gained through 10 virtual focus groups with over 100 stakeholders participating, including patient safety partners, patient group representatives, clinicians, other healthcare staff and regulators.

Key findings

  • there were 854 responses to the online survey, 86% (744) from individuals and 14% (120) on behalf of an organisation
  • only 8% of consultation respondents felt the current Never Event framework was effective
  • 66% of consultation respondents considered the current framework unfit for purpose
  • 48% of respondents advocated for an alternative approach
  • feedback highlighted the ‘Never Event’ terminology creates unintended negative effects on staff morale and blame culture
  • the majority of respondents shared the view that the current framework has limited impact on driving safety improvements

Further detail can be found here: NHS England » Detailed findings from the 2024 consultation on the Never Events framework

Future direction

The consultation findings provide compelling evidence of the need to change the current Never Event framework, and move to a framework which allows us to ensure the list of events is as representative as possible of the things that matter to patients and the NHS.

Option 4 was the preferred way forward from the consultation findings and also reflects the evolving views of key stakeholders, including the CQC. As highlighted in the consultation document, creating a new framework of reportable events will require further engagement and discussion with stakeholders but feedback from the consultation has indicated the new framework should:

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

Exploration of a new approach, aligned with Patient Safety Incident Response Framework (PSIRF) principles, presents an opportunity to create a more effective approach with the flexibility to include patient safety events that really matter to patients and families, and where national learning could be prioritised.

It should be noted that Never Events, regardless of their designation as Never Events, are and will be recorded via existing reporting and response mechanisms (this includes the Learn from Patient Safety Events (LFPSE) service, the Patient Safety Incident Response Framework (PSIRF), the statutory requirements of the Duty of Candour, and as Care Quality Commission (CQC) notifiable incidents).

Next steps

A discovery phase will launch imminently to explore and test alternatives to the Never Events framework. This will be done in collaboration with stakeholders, including patients and NHS staff. We will aim to complete this next phase within six months and will then set out further plans after that.

This work will take international approaches to ‘Never Events’ or ‘sentinel events’ into account, but within the context of the comprehensive reporting processes already in place in England.

This marks an important step forward in the NHS’s commitment to continuous improvement in patient safety, building on the strengths of existing reporting systems while addressing the limitations identified through this comprehensive review.

Interim arrangements for recording and responding to Never Events

While an alternative process is in development, the existing Never Events framework will remain active, and providers must continue recording patient safety events which meet the criteria for Never Events under the ‘Never Event’ category on the Learn from Patient Safety Events (LFPSE) service, with learning responses undertaken in line with PSIRF.