Revised NHS policies on never events and serious incidents

NHS England has revised its policy on so-called 'never events' and published a new definition of what is a never event.

  • Never events list reduced from 25 to 14
  • New definition focuses on national systems
  • Incidents must be reported and acted on

The number of events on the 2015/6 list of 'never events' published by NHS England has been reduced from 25 to 14 and still includes incidents such as wrong site surgery, retained instruments after surgery and the wrong route of administration for chemotherapy.

Never events are defined by NHS England as incidents where there are or should be systems in place, at a national level, to make such errors "wholly preventable".

Several of the original categories of events have been amalgamated and others have been removed completely. Wrong site surgery now includes surgical interventions performed on the wrong patient or the wrong site, and this includes the extraction of the wrong tooth (excluding milk teeth).

The new 'never event' framework is designed to be read in conjunction with the serious incident framework and policy, which has also been updated.

NHS England explains that serious incidents in healthcare are "adverse events, where the consequences to patients, families and carers, staff or organisations are so significant or the potential for learning is so great, that a heightened level of response is justified."

It states that serious incidents include acts or omissions in care that result in unexpected or avoidable death, or unexpected or avoidable injury resulting in serious harm. 

While 'never events' have the potential to cause serious patient harm or death, this outcome is not required for the incident to be categorised as a 'never event'. The emphasis has been put on identifying problems within the system rather than on the outcome of the incident.

The new framework clearly identifies the roles and responsibilities of those involved and emphasises the need for early information-sharing with patients and/or their families in line with the statutory duty of candour. The MDU has published guidance on the duty of candour, which was introduced for NHS bodies such as trusts and foundation trusts in November 2014 and was extended to cover all other care providers registered with the CQC in England in April 2015.

Although organisational leaders are accountable and responsible for ensuring that incidents are reported and acted upon, doctors and dental professionals should bear in mind that the policy recommends consideration of disciplinary action against an individual if there is a deliberate failure to disclose information.

The MDU has previously questioned the usefulness of defining certain incidents as 'never events' and proposed that it would be more helpful to improve overall patient safety than to focus on specific types of event. Nevertheless, clinicians need to be aware of which incidents are covered in the new guidance and what action to take.

This guidance was correct at publication 19/06/2015. It 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.

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