As the NHS sought comments for its review of the never events policy and framework in 2016, the MDU responded by making it clear that the term 'never events' is a misnomer. Furthermore, to attempt to prioritise 'never events' over other patient safety incidents - which might provide equally useful lessons to improve patient safety - is misleading and potentially harmful.
NHS England's objective with the never events policy and framework is to improve patient safety by learning from a list of specific clinical incidents, in the hope of eradicating the occurrence of these incidents.
But creating an artificial distinction between patient safety incidents, that prioritises 'never events' over other, equally serious incidents, the MDU says, could lead to valuable learning opportunities being missed and wider weaknesses in safety systems and governance being overlooked.
The MDU believes the concept of 'never events' should be abolished, not least because, as NHS England acknowledges, they do happen - and repeatedly. All patient safety incidents should have equal priority and be investigated thoroughly, as they all provide opportunities for learning. NHS organisations should be encouraged to adopt a wider focus when investigating what has gone wrong, why it has gone wrong and how better safety can be achieved in the future.
The MDU believes there should be a more realistic approach and a more open acknowledgement that all clinical care involves risk. Openness about this risk is needed to help both patients and staff to understand that things can go wrong and put measures in place to mitigate those risks. But when things do go wrong, it is important to find out as soon as possible what happened, why and to work out how similar incidents can be avoided.
A 'never events' policy may have the opposite effect to the one intended, because it can attach a stigma to these events that spreads to those associated with them and can serve to reinforce a culture of blame, rather than one of openness and learning from experience.
The never events policy and framework review is currently underway.
This page was correct at publication on 28/02/2017. Any guidance is intended as general guidance for members only. If you are a member and need specific advice relating to your own circumstances, please contact one of our advisers.