The Care Quality Commission is to investigate the “barriers” that prevent hospitals from implementing rules designed to prevent never events.

Chief inspector of hospitals Professor Ted Baker said at a board meeting yesterday that the CQC’s ongoing review of never events in the NHS would look at why clear guidance after incidents of patient harm was not universally acted on by providers.

Prof ted baker

Professor Baker said making sure guidance is ‘reliably implemented is a real challenge’

Health and social care secretary Jeremy Hunt ordered the regulator to carry out a review of never events last year, amid concerns the number of harmful incidents was not falling.

There were 442 never events in 2016-17, including 179 cases of wrong site surgery, 107 retained foreign objects, 59 wrong implants and 40 misplaced nasogastric tubes.

In 2015-16, there were 424 never events including 179 wrong site surgeries, 109 retained foreign objects, 49 wrong implants and 26 misplaced nasogastric tubes.

Professor Baker said: “There is an issue for the NHS that there is a lot of guidance but actually making sure it is reliably implemented on the ground is a real challenge to the system…

“We are trying to explore why guidance isn’t implemented effectively. We are doing a review of never events and looking at the barriers of implementing of guidance.”

The CQC will share best practice it has found during its review, to help improve responses to incidents.

The regulator is expected to deliver its final report in the autumn.