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First do no harm. The report of the Independent Medicines and Medical Devices Safety Review. 2020. http// (accessed 28 February 2024)

Scandal of the NHS ‘never-events’: Bungling hospital medics are wrongly removing ovaries and leaving drill bits INSIDE patients once a day, shocking audit reveals… so is YOUR trust one of the worst offenders?. 2023. http// (accessed 28 February 2024)

Healthcare Safety Investigation Branch. Investigation report: Never Events - analysis of HSIB's national investigations. 2021. http// (accessed 28 February 2024)

NHS England. Provisional publication of Never Events reported as occurring between 1 April and 31 December 2023. 2024a. http// (accessed 28 February 2024)

NHS England. Never Events framework consultation. 2024b. https// (accessed 28 February 2024)

NHS Improvement. Never Events policy and framework. 2018. http// (accessed 28 February 2024)

Professional Standards Authority. Safer care for all. 2022. http// (accessed 28 February 2024)

NHS patient safety timeline. 2023. http// (accessed 28 February 2024)

The Hughes report: the hidden trade-offs in no-fault compensation schemes. 2024. http// (accessed 28 February 2024)

Be careful about what you wish for in NHS patient safety reform

07 March 2024
Volume 33 · Issue 5


John Tingle and Amanda Cattini discuss some recent reports on potential changes to litigation procedures for patient harm cases and to the Never Events framework

A period of reflection is always needed in professional endeavours. We need to ensure that what we are doing is still relevant and effective. Reflecting on professional reforms keeps our practice vibrant and healthy, avoiding stagnation. Emerging problems can be identified and strategies for prevention discussed along with any necessary recalibration and fine-tuning. The NHS has been no sloth when it comes to health regulatory, governance and patient safety reforms. Over the years, official inquiries and investigations into tragic patient safety crises in hospitals and elsewhere have spawned several reforms (Sirrs, 2023), and these span decades. The result is that we have a complex system of NHS healthcare regulation and governance that is confusing for both patients and staff:

‘Patients struggle to navigate the complaints system and it may take some time to find the correct organisation to complain to.’

Cumberlege, 2020: 30

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