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The Never Events process

  1. Commissioners within PCTs should draw up the list of Never Events that will be used locally (including the core list) and meet with their providers to ensure a shared understanding of roles and responsibilities.
  2. Provider reporting of Never Events to their PCTs should be part of existing requirements for reporting of Serious Untoward Incidents.
  3. Providers should ensure that they have implemented national standards and guidance to prevent the occurrence of Never Events.
  4. If Never Events occur, providers should use existing mechanisms to report the incident (locally to the PCT that a serious incident has occurred and nationally to the NPSA). Providers should carry out a root cause analysis of why the event occurred and discuss learning and preventative action with the PCT.
  5. PCT Boards should receive regular reports on the incidence of Never Events and the actions providers are taking to prevent their occurrence. At the end of the year, it is expected that PCTs will publicly report on Never Events and their incidence as part of their annual reporting on quality and safety.
  6. Patient Safety Action Teams (PSATs) will support PCTs with commissioning and support providers in carrying out local investigations.
  7. The NPSA will support implementation through this website, learning from the occurrence of Never Events and evaluate the policy. An annual report will be produced.


Related tools are available here.