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Editors Note

The NHS Never Events consultation took place from February to May 2024. It has now closed and NHS England is reviewing the feedback. A final update on the Never Events framework is expected but has not yet been published.

What Are Never Events?

In the NHS, Never Events are defined as serious preventable patient safety incidents that should not occur if robust safeguards are in place. Examples include wrong site surgery, retained surgical swabs or fatal medication errors.

The NHS Never Events framework was introduced in 2009 to draw attention to these rare but serious incidents. The concept originated from the U.S. National Quality Forum, which first coined the term. The aim was clear: highlight errors that should not happen and strengthen patient safety systems.

But many frontline staff argue that the phrase Never Event is misleading and unhelpful.

Why Healthcare Staff Dislike the Term

For clinicians, nurses and theatre staff the phrase feels unrealistic. They argue:

• Unrealistic expectations. Healthcare systems are complex and no environment is error free. Even with safeguards in place mistakes can still occur
• The word “never” is unrealistic. It implies an absolute guarantee when in reality even strong barriers sometimes fail
• Impact on morale. Being associated with a Never Event can damage trust and confidence among staff.
• The framework has often felt punitive. Historically Never Events were tied to reputational damage and financial penalties. This discouraged openness and created a culture of blame rather than learning

As a result some believe the term undermines transparency and damages morale. Staff feel stigmatised when linked to a Never Event which can reduce trust and confidence across teams.

The NHS Consultation on Never Events

Recognising these concerns NHS England launched a public consultation in 2024 to review the framework. The consultation ran from February to May 2024 and invited views from healthcare staff, regulators and patient groups.

The consultation offered four options:

1. Keep the framework and list as it is
2. Abolish the framework entirely
3. Revise the list to include only incidents with robust safety barriers
4. Redefine the term Never Event to reflect that not all incidents are completely preventable

The review followed evidence from the Care Quality Commission and the Healthcare Safety Investigations Branch which found that not all Never Events are supported by barriers strong enough to guarantee prevention.

What Stakeholders Said

NHS England published detailed findings from the consultation in July 2024. Key points included:

• 864 responses were received, 86% from individuals and 14% from organisations (NHS England findings)
• 8% wanted to keep the framework unchanged
• 18% favoured abolishing the framework
• 26% supported revising the list to include only events with robust barriers
• 48% , the largest group, wanted the framework redefined and reshaped to reflect that not all incidents can be guaranteed preventable

Where Things Stand Now

The consultation closed in May 2024 and NHS England is now considering responses. A final decision on the future of the Never Events framework has not yet been published. Patient safety leaders and frontline staff are awaiting clarity on whether the term will be redefined, revised or replaced.

The findings however suggest that a majority favour redefining or reshaping the framework rather than keeping it as it is or scrapping it entirely. What is clear is that the NHS recognises that language matters. The next stage must balance ambition with realism and build a just culture that supports staff to report errors without fear while still keeping patients safe.

The Future of NHS Never Events

Whether the word never remains or not the goal stays the same: reduce serious incidents, support staff and protect patients.

If the term is updated it could encourage a more open culture where learning takes priority over blame. This would strengthen patient safety systems across the NHS and help staff work with confidence in complex environments.

Key Takeaways

• Never Events are serious preventable NHS safety incidents that should not occur
• Many staff dislike the term calling it unrealistic and punitive
• The NHS consultation closed in May 2024 with 864 responses and most favoured redefining or reshaping the framework
• Final decisions are still pending but the future framework must support learning not blame to reduce harm and support staff

References

• NHS England: Never Events Framework Consultation 2024
• NHS England: Detailed findings from the 2024 consultation
• NHS England: Consultation findings summary page
• AHRQ PSNet: Never Events Primer
• U.S. National Quality Forum