FOI request
a) Who is responsible for reporting a never event?
b) Does the possibility of a never event occurring, still get investigated?
c) If an NHS hospital trust complaints team during the process gets brought forward, the possibility of a never event possibly occurring on a family member, what steps are they meant to take/follow and within what timeframe?
d) Within what timeframe of being made aware should a never event/the possibility of one get reported? Is it two days?
e) Who needs to be made aware about a never event/the possibility of one?
f) Who investigates a never event?
g) What happens if a never happened over two years, but has only been identified now and was never initially reported?
h) Who is responsible for investigating a failure to report a never event?
i) If in fact a never event did occur two years but never reported, who investigates failure to report was a deliberate act?
j) Can you get involved investigating a never event?
Decision
Response part one: questions a to i
We would advise that you approach NHS England with regards to these elements of your request.
NHS England have created guidance on never events for the National Health Service.
You could also access their FOI process.
Response part two: question j
HSSIB can investigate a never event, but only if the issue fulfils our criteria. We do not investigate individual cases or replace other investigation processes available to an individual patient, family member or carer.
If you have a healthcare concern with regards to a never event (or any type of health concern), you can report it to HSSIB using our online form.
In addition, you may find it helpful to have a look at previous ‘never event’ issues we have investigated in the past, including an analysis of our reports on never events.
Never events can be searched for on our patient safety investigations page – simply type ‘never events’ into the ‘Quick find’ field.