NHS England and NHS Improvement
HSIB recommends that NHS England and NHS Improvement should review the Never Events policy and framework and include content to explicitly define the criteria that need to be satisfied for any control to be considered a ‘strong systemic protective barrier’.
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. Part of this review is also to explore the criteria for a strong systemic protective barrier to identify if this can be clearly defined.
The review of the Never Events Framework and Never Events List will continue to be an ongoing process, as it has been since its first iteration in 2009. We are grateful to HSIB for this recommendation which will continue to support this review process.
We note that the HSIB report also records a safety action A/2021/037 “NHS England and NHS Improvement has reviewed ‘wrong tooth extraction’ against the criteria for a Never Event (as set out in the Never Events policy and framework) and, after due consideration, has removed it from the list of published Never Events with effect from 1 April 2021.”
HSIB defines Safety Actions as “actions required during an investigation to immediately improve patient safety”. The removal of ‘wrong tooth extraction’ from the detailed definition of wrong site surgery was made in the Never Events List revised in February 2021.
As we know HSIB appreciates, this change arose from workstreams commenced after ‘Opening the Door to change’ was published, including workshops with experts in dental surgery that we invited the HSIB investigators to attend. This change was motivated by the need to focus investigation where it can be most effective rather than any immediate patient safety concerns.
Response received on 7 July 2021.