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Never Events Framework 2009-10

Reference number
Issue date01 February 2009

Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented. Primary Care Trusts (PCTs) are required to monitor the occurrence of Never Events within the services they commission and publicly report them on an annual basis.


The Never Events Framework 2009/10 sets out guidance for PCT commissioners on implementing the Never Events policy. It explains the Never Events process and actions to take.


This guidance has been developed following wide stakeholder input. Implementation of the Never Events policy is designed to provide further impetus to increase patient safety through greater transparency and accountability when serious patient safety incidents occur. It will also inform new ways in which local commissioning can act as a lever for safer care.


The framework includes a description of a core list of Never Events for use during 2009/10, a suggested implementation plan for PCTs and highlights the existing guidance available to prevent Never Events.

Never Event Framework
Never Event Framework - 1.35 MB 0860 - Never Event Framework 2009-10 - 2009-11 - V1
Never Events: process overview
Never Events: process overview - 156 KB A one-page overview for providers and PCTs. [0860 D- Never Events: process overview - 2009-02 - V1]
Never Events core list
Never Events core list - 151 KB A one-page overview for provider/ PCT discussion. [0860 - Never Event core list - 2009-02 - V1]
Never Events provider action plan
Never Events provider action plan - 148 KB A one-page action plan for provider/ PCT discussions. [0860 b - Never Event provider action plan - 2009-02 - V1]
Never Events PCT action plan
Never Events PCT action plan - 205 KB A two-page action plan for preparing for implementation and throughout the year. [0860 - Never Events PCT action plan - 2009-11 - V1]