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Never Events are serious, largely preventable patient safety incidents that should not occur if the available preventative measures have been implemented.


  • Never Events Framework 2009/10 (pdf, 1Mb) is now available

The NPSA has worked with stakeholders to co-produce the Never Events Framework 2009/10 (pdf, 1Mb).  It sets out guidance for PCT commissioners on implementing the Never Events policy and builds on existing processes and mechanisms.  It covers the:

Implementation of the Never Events policy forms part of the wider agenda for improving and assuring patient safety across the NHS.


High Quality Care for All: NHS Next Stage Review Final Report proposed that a policy on Never Events should be introduced in the NHS in England from April 2009.   

The NHS in England: Operating Framework for 2009/10 states that Primary Care Trusts (PCTs) will monitor the occurrence of Never Events within the services they commission and publicly report them on an annual basis.


The NPSA will work closely with the NHS throughout the year to review implementation of the Never Events policy, process and core list.  What we learn will help develop the framework for future years.


If you have any questions that arise from implementing the Never Events policy, please contact enquiries@npsa.nhs.uk.


If you feel that a regional event or online seminar would help with implementing the Never Events policy, please also contact enquiries@npsa.nhs.uk.

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