This national learning report analyses the findings of the investigations previously carried out by HSIB concerning incidents classified as never events.

Our national learning reports can be used by healthcare leaders, policymakers, and the public to:

  • Aid their knowledge of systemic patient safety risks
  • Understand the underlying contributing factors
  • Inform decision making to improve patient safety

The information in these reports is also used to inform future HSIB investigations or programmes of work.

Never events

‘Never events’ are patient safety incidents that are defined as being wholly preventable. They are considered wholly preventable because guidance or safety recommendations are in place at a national level and should have been implemented by all providers in the healthcare system. This should act as a strong systemic barrier to prevent the serious incident from happening.

National learning report summary

In this national learning report, our previous never event national investigation reports have been analysed to look at themes in the factors that contributed to these incidents happening.

Our previous published never event national investigation reports include:

Our ongoing national investigations looking into never events include:

We are using the Safety Engineering Initiative for Patient Safety (SEIPS) model to carry out the analysis. SEIPS provides a framework for understanding structures, processes and outcomes in healthcare, and their relationships.

Safety recommendations

We have made three safety recommendations as a result of this report - two to NHS England and NHS Improvement and one to the Centre of Perioperative Care.

We expect a response to our safety recommendation within 90 days of publication of the investigation report. The responses will be shared here when they're available.

NHS England and NHS Improvement

It is recommended that NHS England and NHS Improvement revises the Never Events list to remove events, such as those presented in this national learning report, that do not have strong and systemic safety barriers.

It is recommended that NHS England and NHS Improvement develops and commissions programmes of work to find strong and systemic safety barriers for specific incidents where barriers are felt to be possible but are not currently available.

Centre for Perioperative Care

It is recommended that the Centre for Perioperative Care reviews and revises the National Safety Standards for Invasive Procedures (NatSSIPs) policy to increase standardisation of safety critical steps that are common across all procedures.

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