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Never events: fieldwork begins in April for new thematic review

  • Organisations we regulate

CQC has been asked by the Department of Health and Social Care to examine the underlying issues in organisations that contribute to the occurrence of Never Events.

This topic is important to everyone providing or using services, as a Never Event has a real impact on people’s health and wellbeing. We are reviewing key literature, and are consulting externally and internally with stakeholders. We will be considering how organisations receive and review national safety requirements, as we recognise the need to ensure that the proposed barriers for never events are implemented appropriately.

We will be collaborating with NHS Improvement, building on the existing work of both organisations. We are focusing on the ways services implement national safety requirements and share learning. We will also look at how patients and their families and carers are involved in the processes.

We will be carrying out fieldwork to inform this review from April-June 2018. The review may be linked into part of an inspection, or be a standalone visit.

Never Events

‘Serious 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’

 This review will try to identify the reasons why initiatives supporting the creation of barriers to prevent Never Events – such as the issuing of patient safety alerts and the introduction of National Safety Standards for Invasive Procedures – have not prevented their occurrence more effectively.

The review will also consider the processes collectively known as ‘clinical governance’, and whether these systems are supporting Never Event prevention.

Our fieldwork activity

Local fieldwork – which may include inspection of some elements of care – allows us to gather evidence about how well services work together and to identify good practice and barriers to implementation.

We will undertake fieldwork activity in up to 20 trusts. Trusts have been selected on the basis of a review of nationally available data and evidence, and consideration of CQC’s wider inspection activity. The Never Events review will differ in a number of ways from CQC inspection activity providers may have experienced previously. 

We will not rate providers or individual services. However, intelligence gathered will be shared with the relevant CQC inspection teams and if we identify an issue or concern about the quality and/or safety of care provided by a service that we regulate, this may trigger a focused inspection.

The fieldwork approach

We recognise there is significant variation in how trusts work with local and national stakeholders in relation to implementing the national safety guidance and in considering how the information is managed and monitored.

To ensure our methodology reflects this variation, we have developed a three-stage process:

  1. Desk-based profiling of trusts

Ahead of our visits, we will undertake activity identifying and profiling trusts in relation to the available information around Never Events and implementation of the national requirements.

We will speak to local partners and stakeholders to gather information to inform the overall picture of the trusts’ approach to the implementation.

We may also invite local groups and organisations to provide evidence about people’s experiences and views.

  1. On-site review

 We will use a number of key lines of enquiry to understand the quality and governance of the trust’s implementation of national safety requirement.

We will talk to staff at all levels of the organisation to understand how the trust’s implementation works in practice.

Our team will be led by a CQC inspector, who will be supported by a colleague from NHS Improvement or a Specialist Advisor with relevant safety expertise. The team may include experts by experience, people that have any involvement in national safety requirement implementation, and we may work with partners to carry out additional interviews or group discussions to gather views and experiences locally.

  1. Reporting findings

High-level feedback will be provided by the review lead at the end of the visit, identifying areas of good practice or where improvements could be made. 

Findings from the local fieldwork, together with information from our national data review, work with other industries and support from an expert advisory group, will inform a national report on the state of the implementation of national safety requirements across England. We plan to publish this report in autumn 2018.

Why are we carrying out local fieldwork and inspection activity?

The local activity will allow CQC to:

  • Test how closely our national data review reflects the local picture of how well trusts implement the national safety requirements.
  • Test tools and methods that are being developed that will help to embed consideration of implementation of national safety requirements as part of CQC’s comprehensive inspection activity.
  • Provide feedback to trusts and stakeholders to support the development of local implementation plans for national safety requirements.
  • Support the production of a national report that integrates the fieldwork findings with the national data review to produce recommendations for key audiences.
  • Build a picture of what good looks like for the development and implementation of national safety guidelines.

What are the anticipated benefits for being involved?

We want to ensure that the trusts selected feel a benefit from their involvement. We envisage that some of the opportunities and benefits will be through:

  • Receiving feedback identifying areas of strength and weakness that can support an action planning process.
  • Being able to take part in an open collaborative discussion with the CQC team and cross-sector local stakeholders that is tailored to local issues relating to the implementation of national safety requirements.
  • Considering whether appropriate implementation is an effective barrier against Never Events occurring.
Last updated:
27 February 2018


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