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If a Never Event occurs

Providers are expected to:

  1. Report the incident to own risk management system

  2. Communicate with the patient or service user, family or their carer as soon as possible about the incident in line with the Being open policy

  3. Report to the relevant PCT that a Never Event has occurred using the agreed route.

  4. Report the incident to the NPSA’s Reporting and Learning System. This can be done through existing arrangements or through the online Healthcare staff eForm

  5. Undertake a comprehensive root cause analysis or significant event audit of the incident to understand what went wrong, how and why

  6. In parallel, managers are encouraged to use the Incident Decision Tree to inform their decision on what initial action to take with the staff involved in the incident. This ensures a consistent and fair approach

  7. Implement changes that have been identified and agreed following the root cause analysis or significant event audit

  8. Discuss the learning and corrective/preventative actions following the occurrence of the Never Event with the PCT

PCTs are expected to:

  1. Monitor any Never Events that have occurred and discuss them during the regular reviews of Serious Incidents with providers

  2. Monitor and regularly discuss provider implementation of action plans developed from root cause analysis investigations

  3. Ensure the frequency and types of incident being reported are reviewed regularly by the PCT Board together with the actions providers are implementing to prevent further occurrence.

  4. Publicly report on Never Events as part of annual quality reporting arrangements, identifying:

    • the frequency and type of Never Events that have occurred in commissioned providers; and

    • a summary of the types of actions that these providers have implemented following a root cause analysis or significant event audit