Sir, we read the opinion article by Dr Barclay regarding 'Never Events' with interest.1

In view of the comments in the final paragraph it is worth pointing out that this has been an issue of interest to the Association of Dental Hospitals (ADH) for several years, including as shown in work published in this Journal.2

In the English NHS, 'Never Events' were initially introduced in 2009, with 'wrong tooth extraction' being explicitly identified in the 2012 revision. Since then, this has been found to be the most frequent wrong site surgery 'Never Event' reported with most of the reports emanating from hospitals and community services, so clearly dentistry has room to improve on issues of patient safety.3,4

In 2016, NHSI went out to consultation on the Never Events policy and framework and in its submission the ADH made several of the points raised by Dr Barclay.

NHSI of course ultimately decides which views it wishes to follow and the resulting new guidance, to which Dr Barclay refers, was only released in late January of this year (2018) for implementation shortly thereafter at the start of February.

Since then, several ADH member hospitals have raised concerns such that in October 2018, an ADH meeting has been arranged to discuss our individual interpretations of the current guidance with the aim of forming a consensus ADH view.