The Secretary of State for Health and Social Care asked the CQC to work with NHS Improvement to look at issues in NHS trusts that contribute to Never Events taking place.

Never Events are incidents with the potential to cause serious patient harm or death that are wholly preventable if national guidance or safety recommendations are followed.

The CQC wanted to understand what makes it easier – or harder – for the people and organisations in the NHS to prevent Never Events and to learn from other industries and countries.

The review sought to answer 4 questions:

How do trusts regard existing guidance to prevent Never Events?
How effectively do trusts use safety guidance?
How do other system partners support the implementation of safety guidance?
What can we learn from other industries?