Never events

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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.



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).


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.