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.
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.
- Never Events list 2018 (revised 31 January 2018) – This document was revised on 31 January 2018 as the ‘undetected oesophageal intubation’ category of Never Event has been temporarily suspended pending further clarification (see below). A further update was made in May 2019 to clarify that ‘local anaesthetic blocks for dental procedures’ is excluded from the ‘wrong site surgery’ category of Never Event (also see below).
- Recommendations from National Patient Safety Agency alerts that remain relevant to the Never Events list 2018 – This document highlights barriers identified in Patient Safety Alerts issued by the former National Patient Safety Agency that NHS organisations still need to routinely consider as part of clinical governance and ensure are embedded in clinical practice to prevent Never Events
Following a query raised in relation to the new ‘undetected oesophageal intubation’ category of Never Event, that category of Never Event has been temporarily suspended from the 2018 Never Events list while the query is resolved. Providers will not need to report this category of incident as a Never Events until the suspension has been lifted. Reporting of all other Never Events in the 2018 list should continue.
Revisions to the Never Events policy and framework have been made following a consultation with stakeholders at the end of 2016.
In response to the consultation and to further support learning from Never Events, the main changes to the revised policy and framework are:
- the removal of the option for commissioners to impose financial sanctions on trusts reporting Never Events
- to align the Never Events policy and framework with the Serious Incident framework, to achieve consistency across the two documents (a revised Serious Incident framework will be published later in 2018)
- revisions to the list of Never Events, including two additional types of Never Event.*
*Details of the rationale for amendments to the Never Events list can be found in appendix C of the 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 via NHS England.