|‘Never’ events do happen but we rarely remember the lessons learnt|
In September 2017, the CQC was tasked to carry out a review of the issues that contribute to the occurrence of ‘Never Events' in NHS trusts in England.
Never Events are serious, largely preventable safety incidents that should not occur if the available preventative measures are implemented. They include things like wrong site surgery or foreign objects left in a person’s body after an operation. Whilst they are rare – 469 cases have been provisionally reported between April 2017 and March 2018 – incidents can have devastating consequences for the patient, their family and the NHS.
CQC have been progressing with this work in collaboration with NHS Improvement. This has involved site visits to a number of NHS trusts, focus groups with frontline staff, interviews with patients and work with experts from other safety critical industries.
Although the CQC are still gathering evidence, some themes are starting to emerge: