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<p>NHS England does not investigate individual ‘never events’ since this is the responsibility
of the provider of care within which the serious incident occurred.</p><p> </p><p>
</p><p> </p><p>Never events are types of Serious Incidents as defined by the Serious
Incident Framework (available online at: <a href="http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf"
target="_blank">http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf</a>)
and must be reported to the Strategic Executive Information System (STEIS) and investigated
in accordance with this Framework. There are 25 never events categories defined in
the current list within the companion Never Events Policy Framework which is available
online at:</p><p> </p><p> </p><p> </p><p><a href="https://www.gov.uk/government/publications/healthcare-never-events-policy-framework-update"
target="_blank">https://www.gov.uk/government/publications/healthcare-never-events-policy-framework-update</a></p><p>
</p><p> </p><p> </p><p>The number of never events reported is published monthly by
category on NHS England’s website:</p><p> </p><p> </p><p> </p><p><a href="http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/"
target="_blank">http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/</a></p><p>
</p><p> </p><p> </p><p>Although there are two never event categories directly relevant
to mental health (13. ‘Suicide using non-collapsible rails’ and 14. ‘Escape of a transferred
prisoner’), never event reports are not classified by care setting.</p><p> </p><p>
</p><p> </p><p>There were 338 never events reported to the STEIS in financial year
2013/14, one of which involved the escape of a transferred patient from a mental health
facility. In 2012/13 290 never events were reported to STEIS, one of which again involved
the escape of a transferred patient from a mental health facility. There were no reports
in either year associated with the category ‘suicide using a collapsible rail’. Mental
health patients may have experienced never events in other categories.</p><p> </p><p>
</p><p> </p><p>As described within the Serious Incident Framework, it is the provider
of the care, within which the serious incident occurred, that is responsible for reporting,
investigating and responding to the serious incident. Commissioners are accountable
for quality-assuring the robustness of their providers’ investigations and the development
and implementation of effective actions by the provider, to prevent recurrence of
similar incidents. Serious incident investigations should be closed by the relevant
commissioner when they are satisfied that the investigation report and action plan
meet the required standard. Providers and commissioners are expected to establish
mechanisms for monitoring on-going or long-term actions to ensure they are fully implemented.</p><p>
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