Revised Never Events policy and framework

The Never Events policy and framework sets out the NHS’s policy on Never Events. It explains what they are and how staff providing and commissioning NHS-funded services should identify, investigate and manage the response to them. It is relevant to all NHS-funded care.


Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.

Revised Never Events policy and framework and Never Events list 2018

The revised Never Events policy and framework and updated Never Events list was published in January 2018, to become active upon initiation of the update to the 2017–2019 NHS Standard Contract on 1 February 2018.

Reviewing the 2018 Never Events List

The December 2018 CQC report ‘
Opening the door to change’ argues that for a number of sub-types of Never Events the strength of the barriers is variable and potentially not as strong as originally thought. As a result, we are currently working to systematically review the barriers for each type of Never Event to identify if they are truly strong and systemic, starting with those that occur most frequently.

Our review of the Never Events list is being conducted through a series of focus groups in collaboration with experts from the relevant medical royal colleges and other organisations with an interest in Never Events.  As we complete each review, we will update the Never Events list accordingly, and any changes will be highlighted below:

Wrong tooth removal: Wrong tooth removal was originally included on the Never Events list as part of a broad category of wrong site surgery Never Events. However, as part of our current review of sub types of Never Events, working with partners including the Royal College of Surgeons: Faculty of Dental Surgery, the British Dental Association, the Faculty of General Dental Practice, the Association of Dental Hospitals, the Association of Peri operative Practice, the College of Operating Department Practitioners and the Healthcare Safety Investigation Branch, it was concluded that the available barriers to prevent the removal of wrong teeth are considered not strong enough to prevent this type of incident from occurring in all cases.

For example, patients often had different numbers and locations of teeth, e.g. as a result of previous dental work or due to their individual dental anatomy. Removal of the wrong tooth is now specifically excluded from the definition of ‘wrong site surgery’. The change will come into effect from 1 April 2021.

This clarification only applies to wrong tooth extraction and does not impact on the requirement to report and investigate other forms of wrong site surgery or the wider Never Events list as described in the Never Events policy and framework. Wrong tooth extraction incidents should still be reported as patient safety incidents and managed according to local risk management policies.

The Healthcare Safety Investigation Branch (HSIB) published a national learning report in January 2021 analysing 10 investigations it carried out into Never Events. We are currently considering our response to this report.

Previous updates to the 2018 Never Events List

Local anaesthetic blocks for dental procedures: A further update was made to the Never Events list in May 2019 to clarify that ‘local anaesthetic blocks for dental procedures’ is excluded from the ‘wrong site surgery’ category of Never Event. The definition of the Wrong Site Surgery Never Event states that this includes wrong site blocks (including blocks for pain relief).

After extensive consultation with the professional organisations for dental surgery, it has been agreed that it should be clarified that wrong site infiltration of local anaesthetic for dental procedures (sometimes referred to as dental blocks) should not be reported as a Never Event as the systemic barriers are not strong enough to prevent these types of incidents from occurring. The Never Events list was therefore amended in May 2019 to add ‘local anaesthetic blocks for dental procedures’ to the list of exclusions under the ‘wrong site surgery’ category of Never Event.

Undetected oesophageal intubation: The Never Events list was also previously revised on 31 January 2018 as the ‘undetected oesophageal intubation’ category of Never Event has been temporarily suspended pending further clarification.

Providers will not need to report this category of incident as a Never Events until the suspension has been lifted.

Previous versions of the Never Events policy and framework and Never Events list

The January 2018 revised Never Events policy and framework supersedes the previous version published by NHS England in March 2015. The March 2015 framework and Never Events list, as well as previous versions, can be viewed on the archived NHS Improvement site.

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