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749475

	registered interest
	date	06/07/2017
	answering body	Leader of the House
	answering dept id	34
	answering dept short name	Leader of the House
	answering dept sort name	Leader of the House
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Leader of the House, when and in which House the Government plans to introduce the Patient Safety Bill.
	tabling member constituency	Kingston upon Hull North
	tabling member printed	Diana Johnson
	uin	3492
	answer	answer is ministerial correction date of answer 11/07/2017 answer text <p>The Government has set out an ambitious programme of 27 bills and drafts bills and noted that additional bills will be announced as the session progresses. The timescales for forthcoming bills and draft bills will be announced in the usual manner in due course.</p><p> </p> answering member constituency South Northamptonshire answering member printed Andrea Leadsom question first answered 11/07/2017 16:11:25 answering member 4117 label Biography information for Andrea Leadsom
	tabling member	1533 label Biography information for Dame Diana Johnson

1019458

	registered interest
	date	03/12/2018
	answering body	Department of Health and Social Care
	answering dept id	17
	answering dept short name	Health and Social Care
	answering dept sort name	Health and Social Care
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health and Social Care, pursuant to the Answer of 17 October to Question 177600 on Patients, how many patient safety incidents were recorded as absconder or missing patient by hospitals in England and Wales in the National Reporting and Learning System in each NHS trust in the latest period for which information is available.
	tabling member constituency	Stockport
	tabling member printed	Ann Coffey
	uin	198237
	answer	answer is ministerial correction date of answer 11/12/2018 answer text <p>During the period 1 October 2017 to 31 March 2018, the National Reporting and Learning System (NRLS) recorded 12,405 cases of ‘missing or absconded patient’ from a National Health Service trust hospital in England and Wales, including incidents involving a mental health patient. This category on the NRLS also includes patients who left without signing a ‘discharge against medical advice’ form and those who failed to return from agreed leave, on time.</p><p> </p><p>The attached tables show a breakdown of these cases by NHS trust for both England and Wales respectively. If a NHS trust does not appear in these tables, this is because the number of incidents is ‘0’.</p><p> </p><p>During the same period, the NRLS recorded 6,186 cases of ‘missing or absconded patient’ involving a mental health patient in England and Wales. This breaks down as 5,946 in England and 240 in Wales. This category on the NRLS also includes patients who left without signing a ‘discharge against medical advice’ form and those who failed to return from agreed leave on time.</p> answering member constituency Gosport answering member printed Caroline Dinenage grouped question UIN 198238 question first answered 11/12/2018 13:31:32 answering member 4008 label Biography information for Dame Caroline Dinenage attachment 1 file name PQ198237,198238.docx title PQ198237,198238 attached table
	tabling member	458 label Biography information for Ann Coffey

857717

	registered interest
	date	08/03/2018
	answering body	Department of Health and Social Care
	answering dept id	17
	answering dept short name	Health and Social Care
	answering dept sort name	Health and Social Care
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health and Social Care, how many independent serious incident reviews were (a) commissioned and (b) completed (c) not completed by NHS England in each month between May 2015 and June 2017; and what the reasons were for the reviews not being completed by 28 February 2018.
	tabling member constituency	Preston
	tabling member printed	Sir Mark Hendrick
	uin	131618
	answer	answer is ministerial correction date of answer 13/03/2018 answer text <p>We do not hold all of the information requested centrally.</p><p> </p><p>NHS England has provided the attached information for the period between September 2016 and June 2017, which includes a monthly status of reported serious incidents with the following investigative status: planned, underway, completed, awaiting clearance or not yet allocated for investigation ‘blank’.</p><p> </p><p>The following points should be noted:</p><p> </p><p>- This information has been collected since August 2016, when NHS England put in place a national system for sub-regional and regional teams to escalate serious incidents via a Serious Incident Desk;</p><p>- NHS England does not hold information at a national level as to why investigations have not yet been completed. Most investigations should be completed within six months of being commissioned, however some may take longer due to the complexity of the incident; and</p><p>- NHS England does not hold information on serious investigations only led by clinical commissioning groups or trusts. The latter has not been included within this response.</p><p> </p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 13/03/2018 12:44:57 answering member 4008 label Biography information for Dame Caroline Dinenage attachment 1 file name PQ131618 attached table.docx title PQ131618 attached table
	tabling member	473 label Biography information for Sir Mark Hendrick

922422

	registered interest
	date	12/06/2018
	answering body	Department of Health and Social Care
	answering dept id	17
	answering dept short name	Health and Social Care
	answering dept sort name	Health and Social Care
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health and Social Care, how many never events were recorded by NHS trusts in each of the last five years.
	tabling member constituency	Ellesmere Port and Neston
	tabling member printed	Justin Madders
	uin	152793
	answer	answer is ministerial correction date of answer 19/06/2018 answer text <p>Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.</p><p> </p><p>National Health Service providers are encouraged to report all Never Events through the National Reporting and Learning System. The Care Quality Commission views failure to report a Never Event as a breach of a provider’s registration requirement and which may attract sanctions.</p><p> </p><p>Below are the total numbers of Never Events for the last five years which are published online by NHS Improvement and can be accessed at the following link:</p><p> </p><p><a href="https://improvement.nhs.uk/resources/never-events-data/" target="_blank">https://improvement.nhs.uk/resources/never-events-data/</a></p><p> </p><p>The last column contains the total of Never Events reported by NHS trusts.</p><p> </p><table><tbody><tr><td><p>Year</p></td><td><p>Total number of Never Events</p></td><td><p>Total number of Never Events from NHS trusts</p></td></tr><tr><td><p>2013/14</p></td><td><p>338</p></td><td><p>322</p></td></tr><tr><td><p>2014/15</p></td><td><p>306</p></td><td><p>288</p></td></tr><tr><td><p>2015/16</p></td><td><p>442</p></td><td><p>412</p></td></tr><tr><td><p>2016/17</p></td><td><p>445</p></td><td><p>414</p></td></tr><tr><td><p>2017/18 (provisional data subject to change as local investigations take place)</p></td><td><p>469</p></td><td><p>434</p></td></tr></tbody></table> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 19/06/2018 10:18:13 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	4418 label Biography information for Justin Madders

926528

	registered interest
	date	18/06/2018
	answering body	Department of Health and Social Care
	answering dept id	17
	answering dept short name	Health and Social Care
	answering dept sort name	Health and Social Care
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health and Social Care, what assessment he has made of the potential merits of introducing into NHS England a scheme analogous to the Scottish National Patient Safety Programme.
	tabling member constituency	South West Bedfordshire
	tabling member printed	Andrew Selous
	uin	154631
	answer	answer is ministerial correction date of answer 21/06/2018 answer text <p>We note the Scottish National Patient Safety Programme aims to improve the safety and reliability of health and social care, and reduce harm.</p><p> </p><p>Like Scotland, our aim is to improve patient safety and for the National Health Service to be one of the safest healthcare systems in the world.</p><p> </p><p>Following the tragic events at Mid Staffordshire NHS Foundation Trust, the Government has introduced a number of significant programmes to promote and encourage better regulation, greater transparency and candour, and a culture of learning in the NHS in England, drawing from other safety critical industries.</p><p> </p><p>To further drive a culture of learning, the NHS trusts are required to review and investigate deaths of their patients and publish the learning and steps they are taking to improve patient safety. An independent Healthcare Safety Investigation Branch (HSIB) was set up in April 2016 and is now conducting major safety investigations into the most serious risks for patients, with a specific focus on system-wide learning and improvement. The HSIB’s remit was extended in April 2018 to include the investigations of early neonatal deaths, term stillbirths and cases of severe brain injury in babies as well as all cases of maternal death. Work is underway to further improve medicines safety including the accelerated rollout of electronic prescribing in hospitals, monitoring higher risk prescribing practice linked to hospital admissions, and addressing so called ‘human factors’ that contribute to errors.</p><p> </p><p>In June 2018, the Government announced a further package of measures to improve patient safety including a new National Clinical Improvement Programme that will provide NHS consultants with confidential data on their clinical results and help improve patient outcomes, the introduction of a system of medical examiners and the intention to extend the Learning from Deaths programme to general practice and ambulance trusts to promote learning and enable health organisations and healthcare professionals to learn from one another.</p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 21/06/2018 16:56:59 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	1453 label Biography information for Andrew Selous

934259

	registered interest
	date	03/07/2018
	answering body	Department of Health and Social Care
	answering dept id	17
	answering dept short name	Health and Social Care
	answering dept sort name	Health and Social Care
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health and Social Care, pursuant to the Answer of 19 June 2018 to Question 152793 on Patients: Safety, whether any steps have been taken to determine the reason for the increase in never events.
	tabling member constituency	Ellesmere Port and Neston
	tabling member printed	Justin Madders
	uin	160274
	answer	answer is ministerial correction date of answer 09/07/2018 answer text <p>The Government is committed to eradicating Never Events and ensuring best practice is shared throughout the health care system.</p><p>That is why in December 2017, the Secretary of State commissioned the Care Quality Commission (CQC) to undertake a safety thematic review of Never Events, under Section 48 of the Health and Social Care Act 2008.</p><p>The CQC’s review, which is expected to report in autumn 2018, will examine the underlying issues in National Health Service trusts in England that contribute to the occurrence of Never Events and identify the learning that can be applied to wider safety issues.</p><p>The ‘Never Events Policy and Framework’ was revised in March 2015 and the definition of Never Events changed to provide further clarity over their purpose, and; to ensure incidents are easily identifiable when they occur and are not dependent on the severity of outcome of the incident.</p><p>The list of Never Events was reviewed at the same time to ensure that they were all compliant with the revised definition and to consider any new issues that were appropriate to be introduced as Never Events into the NHS in England.</p><p>Further revisions to the Never Events policy and framework and an updated Never Events list were published in January 2018. Therefore it is not possible to compare the number of Never Events reported on an annual basis.</p><p>As mentioned in my earlier reply to Question <a href="https://www.parliament.uk/business/publications/written-questions-answers-statements/written-question/Commons/2018-06-12/152793/" target="_blank">152793</a>, NHS providers are encouraged to report all Never Events, and the CQC regards failure to report a Never Event, a breach of a provider’s registration requirement.</p><p>The number of Never Events reported by independent providers is also increasing as they report more incidents to our National Reporting and Learning System.</p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 09/07/2018 16:40:10 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	4418 label Biography information for Justin Madders

984845

	registered interest
	date	10/10/2018
	answering body	Department of Health and Social Care
	answering dept id	17
	answering dept short name	Health and Social Care
	answering dept sort name	Health and Social Care
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health and Social Care, how many patient safety incidents were recorded as absconder or missing patient by hospitals in England and Wales in the National Reporting and Learning System in each care setting in the latest period for which information is available.
	tabling member constituency	Stockport
	tabling member printed	Ann Coffey
	uin	177600
	answer	answer is ministerial correction date of answer 17/10/2018 answer text <p>During the period 1 October 2017 to 31 March 2018 National Reporting and Learning System (NRLS) recorded 12,398 cases of “missing or absconded patient” across England and Wales. This category on the NRLS includes patients who left without signing a ‘discharge against medical advice’ form and those who failed to return from agreed leave on time, rather than solely reports of patients who absconded or were reported missing.</p><p> </p><p>A breakdown by care settings for both England and Wales is provided in the following table.</p><p> </p><p>Incidents reported as “Missing or absconded patient”, by care setting for England and Wales</p><table><tbody><tr><td><p>Care Setting</p></td><td><p>England</p></td><td><p>Wales</p></td><td><p>Total</p></td></tr><tr><td><p>Acute / general hospital</p></td><td><p>5,781</p></td><td><p>146</p></td><td><p>5,927</p></td></tr><tr><td><p>Ambulance service</p></td><td><p>15</p></td><td><p>0</p></td><td><p>15</p></td></tr><tr><td><p>Community and general dental service</p></td><td><p>1</p></td><td><p>0</p></td><td><p>1</p></td></tr><tr><td><p>Community Nursing, medical and therapy service (incl. community hospital)</p></td><td><p>312</p></td><td><p>57</p></td><td><p>369</p></td></tr><tr><td><p>Community optometry / optician services</p></td><td><p>0</p></td><td><p>0</p></td><td><p>0</p></td></tr><tr><td><p>Community pharmacy</p></td><td><p>0</p></td><td><p>0</p></td><td><p>0</p></td></tr><tr><td><p>General practice</p></td><td><p>4</p></td><td><p>0</p></td><td><p>4</p></td></tr><tr><td><p>Learning disabilities service</p></td><td><p>87</p></td><td><p>2</p></td><td><p>89</p></td></tr><tr><td><p>Mental health service</p></td><td><p>5,754</p></td><td><p>239</p></td><td><p>5,993</p></td></tr><tr><td><p>Total</p></td><td><p>11,954</p></td><td><p>444</p></td><td><p>12,398</p></td></tr></tbody></table><p><strong> </strong></p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 17/10/2018 13:48:41 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	458 label Biography information for Ann Coffey

100186

	registered interest
	date	21/10/2014
	answering body	Department of Health
	answering dept id	17
	answering dept short name	Health
	answering dept sort name	Health
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health, whether missed or inadequate hydrocortisone administration is included in the NHS list of Never Events.
	tabling member constituency	Oxford East
	tabling member printed	Mr Andrew Smith
	uin	211233
	answer	answer is ministerial correction date of answer 28/10/2014 answer text <p>Missed or inadequate hydrocortisone administration is not currently included in the list of ‘never events’.</p><p> </p><p> </p><p> </p><p>We can confirm that the current list of Never Events is under review and there is a consultation underway which opened online on the 6 October 2014 and closes on 31 October 2014.</p><p> </p> answering member constituency Mid Norfolk answering member printed George Freeman question first answered 28/10/2014 15:28:25 question first ministerially corrected 28/10/2014 16:30:53 answering member 4020 label Biography information for George Freeman previous answer version 24770 answering member constituency Battersea answering member printed Jane Ellison answering member 3918
	tabling member	95 label Biography information for Mr Andrew Smith

142210

	registered interest
	date	06/11/2014
	answering body	Department of Health
	answering dept id	17
	answering dept short name	Health
	answering dept sort name	Health
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health, how many patient safety incidents have been reported to the National Reporting and Learning System in each month since May 2010.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	213780
	answer	answer is ministerial correction date of answer 18/11/2014 answer text <p>We do not hold information on the number of patient safety incidents that have occurred in England in each year since 2000. Patient Safety Incidents occurring in the National Health Service are reported to the National Reporting and Learning System (NRLS) whose primary purpose is to enable learning from patient safety incidents. The NRLS was established in late 2003 as a largely voluntary scheme for reporting patient safety incidents, and therefore it does not provide the definitive number of patient safety incidents occurring in the NHS. However, from 1 April 2010 it became mandatory for all providers registered with the Care Quality Commission (including all NHS trusts and foundation trusts) in England to report all serious patient safety incidents to the Care Quality Commission. To avoid duplication of reporting, providers of NHS services are encouraged to report all incidents resulting in death or severe harm to the NRLS which then reports them to the Care Quality Commission.</p><p> </p><p> </p><p> </p><p>At present, more than 100,000 patient safety incidents (including those resulting in no harm) are reported to the NRLS each month. However, these data are collated on a quarterly, rather than monthly basis. Detailed breakdowns on incidents reported are published twice-yearly and can be accessed via the following link:</p><p> </p><p> </p><p> </p><p><a href="http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/" target="_blank">http://www.nrls.npsa.nhs.uk/resources/collections/quarterly-data-summaries/</a></p><p> </p><p> </p><p> </p><p>The most recent spreadsheet providing quarterly data for the number of patient safety incidents reported to the NRLS from October 2003 to June 2014 is attached.</p><p> </p><p> </p><p> </p><p>The NRLS is a dynamic reporting system, and the number of incidents recorded as occurring at any point in time may increase as a greater proportion of incidents are reported. Experience in other industries has shown that as an organisation’s reporting culture matures, staff become more likely to report incidents.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter grouped question UIN 213775 question first answered 18/11/2014 16:22:48 answering member 3932 label Biography information for Dr Dan Poulter attachment 1 file name NRLS Quarterly Data Workbook- Patient Safety Incidents.xls title Patient Safety Incidents- October 2003- June 2014
	tabling member	4078 label Biography information for Paul Uppal

142212

	registered interest
	date	06/11/2014
	answering body	Department of Health
	answering dept id	17
	answering dept short name	Health
	answering dept sort name	Health
	hansard heading	Patients: Safety
	house id	1
	legislature	25259 pref label House of Commons
	question text	To ask the Secretary of State for Health, how many patient safety alerts have occurred in each month since May 2010.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	213781
	answer	answer is ministerial correction date of answer 18/11/2014 answer text <p>Patient safety alerts are a crucial part of NHS England’s work to alert the healthcare system rapidly to risks and provide guidance on preventing potential incidents that may lead to harm or death. They are publications providing urgent information to healthcare providers via the Central Alerting System. Prior to the establishment of NHS England, patient safety alerts were issued by the National Patient Safety Agency (NPSA).</p><p> </p><p> </p><p> </p><p>We do not record the number of patient safety alerts issued by month; however, a list of alerts with their issue dates for the period 2013-2014 is attached.</p><p> </p><p> </p><p> </p><p>A full list of alerts issued by NPSA from 2002-2012 can be viewed at:</p><p> </p><p> </p><p> </p><p><a href="http://www.nrls.npsa.nhs.uk/alerts/" target="_blank">http://www.nrls.npsa.nhs.uk/alerts/</a></p><p> </p><p> </p><p> </p><p><strong> </strong></p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 18/11/2014 16:15:31 answering member 3932 label Biography information for Dr Dan Poulter attachment 1 file name Patient safety alerts.xlsx title List of Patient Safety Alerts 2013-14
	tabling member	4078 label Biography information for Paul Uppal