Never Events

I say: What?

The soon-to-be-defunct NHS England has been reviewing the Never Events Framework with a public consultation. We can surmise the public hasn't heard about the consultation, but let’s move on.

They say they have compelling evidence of the need to change the current Never Event framework, and move to a framework which ensures the list of events is as representative as possible of the things that matter to patients and the NHS.

In England’s NHS, there were 392 reported never-event incidents from 1 April 2023 to 31 March 2024, with 370 meeting this definition. Yet, roughly two million patient safety incidents and over 20,000 serious incidents went unnoticed and uninvestigated.

The never event list includes procedures such as wrong-site surgery, wrong implant or wrong route of administration of a drug. However, the list is overly restrictive and misses most of the critical never events that shouldn't happen and go unreported.

That is, until the death of a three-year-old child requires the coron…