Never Events in the NHS – how to learn from them


Despite the tireless work of medical professionals across the NHS, occasionally serious incidents occur which can clearly have a huge impact on the lives of patients and their families. Some of these are completely avoidable and so to provide a framework with which organisations can learn from, and ultimately improve patient care, a list of Never Events was published.

Rather than apportion blame, designating a serious incident as a Never Event allows the underlying cause to be determined which can be applied far beyond the department in which it occurred. Never Events are defined by the NHS as:

“serious, largely preventable patient safety incidents that should not occur if healthcare providers have implemented existing national guidance or safety

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.

Never Events differ from serious incidents in that even a single Never Event acts as a red flag that an organisation’s safety advice / alert systems may not be robust. Never Events are rare given the huge number of treatment episodes in the NHS; 384 were reported in the year 2022-23, with 364 in 2021-2022 and 407 in 2020-2021. But their very existence, along with the similarity between year on year cases, suggests additional efforts may be needed to ensure NHS organisations learn from these incidents.

Never Events NHS Data 2023

The latest data released by the NHS was on 23 May 2023 covering the period 1 April 2023 – 30 April 2023, where 27 serious incidents were designated as Never Events:

  • 9 incidences of wrong site surgery
  • 7 incidences of retained foreign object post procedure
  • 4 incidences of wrong implant / prosthesis
  • 4 incidences of misplaced naso or oro gastric tubes
  • 1 incident of adminisatration of medication by the wrong route
  • 1 incident of overdose of insulin due to abbreviations or incorrect advice
  • 1 incident of transfusion or transplantation of ABO-incompatible blood components or organs

These numbers are subject to change as local investigations are completed. The report also states 3 serious incidences did not meet the definition of a Never Event.

In total there were 23 NHS trusts which reported at least 1 Never Event, with 20 trusts reporting a single Never Event and 4 reporting 2 each.

Never Events NHS investigations

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.

If you would like to know more about how Verita can help your organisation learn from Never Events, please get in touch or book a free 30 minute consultation with us. Verita also provides a patient safety training course for healthcare professionals to gain an understanding into the investigative process.

Verita is an independent team providing investigations consultancy work with organisations in a variety of sectors throughout the UK


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