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Never Events policy

Implementation of a policy on Never Events was identified in High Quality Care for All: NHS Next Stage Review Final Report as a key priority for the NHS in England.



The purpose of the Never Events policy is to provide further impetus to improving patient safety through greater transparency and accountability when serious patient safety incidents occur. It also demonstrates how local commissioning can act as a lever for safer care.



Implementation of the policy is expected to:

  • Increase awareness of patient safety

  • Strengthen existing reporting and response processes for serious incidents

  • Increase implementation of preventative guidance by providers

  • Reduce the risk of Never Events occurring

  • Lead to more comprehensive reporting of Never Events



Implementation of the policy will be phased, with the first phase running from April 2009 to March 2010. During the first phase the policy builds on existing local and national processes for reporting of serious incidents.


Following preliminary feedback from the NHS, initial data from the Reporting and Learning System and recommendations in The operating framework for the NHS in England 2010/11, an update of the Never Events framework has been published, which outlines new aspects for 2010/11.



  1. The NPSA worked with stakeholders to co-produce a core list of Never Events for use during 2009/10.

  2. PCTs will use the core list as the basis for implementation during 2009/10. They will meet with providers before the start of the year and encourage them to implement preventative guidance related to each Never Event.

  3. During the year, PCTs will use contractual obligations to require providers to report any occurrences of Never Events to the PCT as Serious Untoward Incidents.

  4. If a Never Event occurs providers will undertake a root cause analysis investigation into the incident and develop an action plan.

  5. PCTs will inform their Boards of any Never Events that occur among their providers and the actions they are taking to prevent recurrence.

  6. PCTs will publicly report on Never Events as part of annual quality reporting arrangements.

  7. The NPSA will publish an annual report on implementation across the NHS in England including the lessons that have been learned.