Never events are rare given the huge number of treatment episodes in the NHS; 306 were reported in the year 2014-15, and a total of 1188 between April 2012 and December 2015. Never events are key indicators that there have been failures in producing the required systemic barriers to prevent error. Their occurrence can tell commissioners something fundamental about the quality, care and safety processes in an organisation.
The national never events framework requires that after each never event there is an investigation using systematic methodology to identify learning which is then implemented and shared.
The number of never events means that individual NHS organisations are not exposed to the volume of cases necessary to develop high levels of experience and expertise in conducting rigorous investigations which can withstand close scrutiny.
Verita has a wealth of experience in investigation of clinical care and patient safety with over 200 such investigations completed. We have a tried, tested systematic methodology for conducting investigations. Much of our work is helping clients learn from things that have gone wrong and working with their staff to put in place and implement well thought out, enduring improvements.
We can provide advisory support, review or a full investigation service. Our external, independent and systematic investigations command a level of public confidence which is lacking in an internal investigation. Our evidence-based reports and practical, proportionate and appropriate recommendations withstand rigorous internal and external scrutiny and helps NHS organisations meet the statutory duty of candour. Our approach supports learning, protects reputations and makes patients safer. It also leaves busy frontline staff free to focus on delivering high quality care.