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 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 have now received responses to our recommendations, which are shared below.

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.


We agree that the systemic barriers for some Never Events are not as strong as others and following on from CQC’s thematic review ‘Opening the Door to Change’ commenced a programme of work to review the list of Never Events to identify which barriers are not as strong as was initially thought.

We are grateful to HSIB for their contributions so far to this work. Review of the Never Events Framework and Never Events List will be an ongoing process, as it has been since its first iteration in 2009.

Response received 16 April 2021

NHS England and NHS Improvement

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.


We are not aware of significantly stronger barriers that are felt to be possible at this point, so there is no specific work we can commission at present.

We would welcome any suggestions from HSIB, based on the evidence that has been collected in preparation for this national learning report, of potential strong and systemic barriers that could be considered further.

As I know HSIB appreciates, there are many ways in which NHS England and NHS improvement encourages and supports innovators and innovations, and supports the commissioning of research by the DHSC and NIHR.

We will act on any future developments through those routes that have potential to provide strong and systematic barriers.

We will also of course continue to support providers to consistently implement established barriers, including the elimination of air flowmeters.

Response received 16 April 2021

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.


The Centre for Perioperative Care ( has already instituted a NatSSIPs working group with wide membership and clear terms of reference. An initial meeting in January 2021 has occurred. We have started on the plan to review and revise the National Safety Standards for Invasive Procedures (NatSSIPs).

We will seek views on the practicalities of what might work in any clinical setting where invasive procedures are undertaken.

We will review the current NatSSIPs, literature and reports indicating where revision may be required.

We will involve our Board members and advisory group members to identify different perspectives. We aim to produce a revised version of NatSSIPs, in particular with increased standardisation of safety critical steps that are common across organisations.

We will keep HSIB informed of our progress with the work throughout the project. We will consider different audiences and staff groups and whether specific education is required.

We will seek assistance, including from HSIB, with ensuring that our revised NatSSIPs are disseminated widely and used as part of a monitoring framework to assist uptake.


  • CPOC to institute a NatSSIPs working group. TIMELINE: Dec 2020 - done.
  • First meeting of NatSSIPs working group. TIMELINE: Jan 2021 - done.
  • Further meetings and electronic consultation on key issues identified in the review of current NatSSIPS. TIMELINE: Jan - Sept 2021.
  • Drafting a revision of NatSSIPs. TIMELINE: 2021.
  • Dissemination plan. TIMELINE: 2021.

Response received 9 March 2021

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