Never event framework consultation

Closed 5 May 2024

Opened 7 Feb 2024


The NHS England National Patient Safety Team is seeking views on whether the existing Never Events Framework remains an effective mechanism to drive patient safety improvement.

Never Events are defined as patient safety incidents that are ‘wholly preventable because guidance or safety recommendations that provide strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers’ (Never Event Framework, NHS England, 2018).

The consultation is being held following the findings of reports from the CQC and HSIB that highlighted for several types and sub-types of Never Events the barriers are not strong enough to make an incident wholly preventable, as well as further focus groups held by the National Patient Safety Team throughout 2021/22.

Upon considering the supporting evidence in the consultation documents (available below), the consultation asks for views on whether, on balance, the Never Events framework is still considered an effective mechanism to drive patient safety improvement; and for a preferred option for its future to be selected. Please ensure you have read the supporting evidence in the consultation document before proceeding to the survey questions.

The consultation launched on 5 February and is running for 12 weeks until 5 May 2024. 

Following the consultation closure, we will review the responses and engage further with stakeholders, including patient representatives, on the next steps.

Consultation documents


  • All interested stakeholders


  • Patient safety