Learning from Never Events

Published: 10 July 2018 Page last updated: 12 May 2022

Last September the Secretary of State for Health and Social Care asked us to carry out a review of the issues that contribute to the occurrence of ‘Never Events' in NHS trusts in England.

Never Events are serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented. They include things like wrong site surgery or foreign objects left in a person’s body after an operation. Whilst they are rare – 469 cases have been provisionally reported between April 2017 and March 2018 – incidents can have devastating consequences for the patient, their family and the NHS.

We have been progressing with this work in collaboration with NHS Improvement. This has involved site visits to a number of NHS trusts, focus groups with frontline staff, interviews with patients and work with experts from other safety critical industries.

Our four questions:

  • How is the guidance to prevent Never Events performing?
  • How do trusts use the safety guidance?
  • How do other system partners support trusts with the implementation of safety guidance?
  • What can we learn from other industries?

Early themes

Although we are still gathering evidence, some themes are starting to emerge:

  1. The high risk nature of healthcare is not always reflected by culture and practice. Clinicians have a tradition of autonomy that allows them to deal with complex situations and provide the right treatment. But under pressure this is all too often prioritised at the expense of proven safety protocols and policies.
  2. Embedding safety may need to be a fundamental part of every role, and this could have implications for training and learning throughout people’s careers.
  3. It may be that trusts need to manage risks more proactively, as well as responding to incidents when they occur.

Our report is due for publication later in the year. It will promote the positive work being done in trusts and will share learning and good practice, as well as identifying what additional support or guidance could help organisations to reduce the risk of things going wrong. The report will also look at how we can improve how we assess safety, inform NHS Improvement's future work and make recommendations for NHS trusts and other bodies.

Learning from Never Events: July 2018 update