Safety recommendation
HSSIB recommends that NHS England incorporates the findings of the interim report into its review of the Never Events policy, with specific focus on considering removing retained surgical swabs as a sub-set of retained foreign object Never Events.
Response:
NHS England launched the public consultation into the Never Event framework in February 2024, which incorporates the findings of HSSIB’s interim report ‘Retained surgical swabs: themes identified from a review of NHS serious incident reports’.
The consultation is being held following the findings of reports from the Care Quality Commission (CQC) and HSIB/HSSIB 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 including one in relation to ‘retained foreign object post procedure’ held by the National Patient Safety Team throughout 2021/22.
The consultation asks for views on whether, on balance, the Never Events framework is still considered an effective mechanism to support patient safety improvement; and for a preferred option for its future to be selected. The consultation closes on 5 May 2024, with the initial findings expected to be published in Autumn 2024.
Response received on 28 February 2024.