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1568112

	registered interest
	date	18/01/2023
	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 the Department has made of the number of patients who are avoidably harmed during routine medical procedures and surgeries.
	tabling member constituency	Hendon
	tabling member printed	Dr Matthew Offord
	uin	126603
	answer	answer is ministerial correction date of answer 24/01/2023 answer text <p>The National Reporting and Learning System (NRLS) provides a national database of reported patient safety incidents for the National Health Service in England. This data is published as official statistics alongside commentary. Within NRLS data, it is not possible to determine easily if the reported incidents took place during medical procedures and surgery that can be considered ‘routine’. The most recent publication for 2021/22 was published in October 2022 and available at the following link:</p><p><a href="https://www.england.nhs.uk/patient-safety/national-patient-safety-incident-reports/national-patient-safety-incident-reports-13-october-2022/" target="_blank">https://www.england.nhs.uk/patient-safety/national-patient-safety-incident-reports/national-patient-safety-incident-reports-13-october-2022/</a></p><p>The total number of patient safety incidents reported was 2,345,815. Most incidents are reported as causing no harm, 70.6% or low harm, 26.0%. Fewer than 4% of incidents reported caused higher degrees of harm, of which 0.5% were categorised as severe harm or death. NHS England reviews information in these two categories to characterise new, emerging and under-recognised risks and determine how they might be addressed.</p><p>The Learn from Patient Safety Events service will this year fully replace the NRLS. It will change the way information is collected to make it easier for providers to record and learn from patient safety incidents.</p><p>The Government continues to pursue higher patient safety standards and a transparent, learning culture in order to support the NHS to achieve continuous improvement in safety and to reduce harmful events happening in the first place.</p> answering member constituency Lewes answering member printed Maria Caulfield question first answered 24/01/2023 14:34:19 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4006 label Biography information for Dr Matthew Offord

1581586

	registered interest
	date	27/01/2023
	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 reported as a result of ambulance service delays in each year since 2010.
	tabling member constituency	Slough
	tabling member printed	Mr Tanmanjeet Singh Dhesi
	uin	134052
	answer	answer is ministerial correction date of answer 01/02/2023 answer text <p>Information on patient safety incidents is not held in the format requested.</p><p>Information on patient safety incidents, including those relating to ambulance services, is published by NHS England as part of the National Reporting and Learning System and is available at the following link: <a href="https://www.england.nhs.uk/patient-safety/national-patient-safety-incident-reports/" target="_blank">https://www.england.nhs.uk/patient-safety/national-patient-safety-incident-reports/</a></p> answering member constituency Colchester answering member printed Will Quince question first answered 01/02/2023 12:26:38 answering member 4423 label Biography information for Will Quince
	tabling member	4638 label Biography information for Mr Tanmanjeet Singh Dhesi

1468132

	registered interest
	date	07/06/2022
	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 impact of (a) staffing levels and (b) response times on patient safety in the most recent period for which data is available.
	tabling member constituency	Kingston upon Hull North
	tabling member printed	Dame Diana Johnson
	uin	13658
	answer	answer is ministerial correction date of answer 20/06/2022 answer text <p>No specific assessment has been made. Data on patient safety incidents is collected and reported through the National Reporting and Learning System (NRLS). However, the NRLS is a largely voluntary scheme for reporting patient safety incidents and does not provide the actual number of patient safety incidents occurring in the National Health Service.</p> answering member constituency Lewes answering member printed Maria Caulfield question first answered 20/06/2022 14:21:47 answering member 4492 label Biography information for Maria Caulfield
	tabling member	1533 label Biography information for Dame Diana Johnson

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

1692731

	registered interest
	date	29/02/2024
	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 her Department records instances of near misses for (a) surgical fires and (b) other patient safety incidences.
	tabling member constituency	Strangford
	tabling member printed	Jim Shannon
	uin	16354
	answer	answer is ministerial correction date of answer 08/03/2024 answer text <p>Any unexpected or unintended incident which could have or did lead to harm to one or more patients can be recorded on the Learn from Patient Safety Events (LFPSE) service, to support local and national learning. This can include surgical fires or burns. We are informed that NHS England does not define the severity of harm related to surgical fires or burns specifically. Grading the severity of harm related to a patient safety incident that is recorded on LFPSE, should be done using NHS England’s guidance on recording patient safety events and levels of harm, which asks that near miss events be graded as no harm. The guidance is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/long-read/policy-guidance-on-recording-patient-safety-events-and-levels-of-harm/" target="_blank">https://www.england.nhs.uk/long-read/policy-guidance-on-recording-patient-safety-events-and-levels-of-harm/</a></p><p> </p><p>If a surgical fire or burn is assessed locally and constitutes a patient safety event, it would fall under the scope of the Care Quality Commission’s (CQC) Regulations 16 or 18, and must be reported to the CQC. This means that the most serious surgical fires or burns which result in serious harm or the death of a service user, are subject to mandatory reporting. NHS trusts can comply with this requirement by recording patient safety events using the LFPSE service, and NHS England shares all such data with the CQC, who are responsible for regulating compliance with CQC regulations. CQC Regulations 16 and 18 are available respectively, at the following links:</p><p> </p><p><a href="https://www.cqc.org.uk/guidance-providers/regulations/regulation-16-notification-death-service-user" target="_blank">https://www.cqc.org.uk/guidance-providers/regulations/regulation-16-notification-death-service-user</a></p><p> </p><p><a href="https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-18-notification-other-incidents" target="_blank">https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-18-notification-other-incidents</a></p><p> </p><p>Although the recording of wider patient safety events onto LFPSE is a voluntary process, providers are encouraged to record all patient safety incidents, irrespective of the level of harm, to support local and national learning.</p><p> </p><p>The LFPSE service and its predecessor, the National Reporting and Learning System, do not have specific categories for surgical fires or burns. Determining how many patient safety events related to surgical fires or burns were recorded by National Health Service providers in each of the last five years would require a search of the free text of recorded patient safety events, using key words, and a subsequent expert clinical review of all potential records to determine relevance to the question. This could only be provided at disproportionate cost.</p> answering member constituency Lewes answering member printed Maria Caulfield grouped question UIN 16353 16355 question first answered 08/03/2024 14:06:43 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4131 label Biography information for Jim Shannon

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

1657261

	registered interest
	date	01/09/2023
	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 steps he is taking to ensure that the NHS responds to concerns raised by staff about potential harm to patients (a) appropriately and (b) swiftly.
	tabling member constituency	Solihull
	tabling member printed	Julian Knight
	uin	196896
	answer	answer is ministerial correction date of answer 25/09/2023 answer text <p>Last year, NHS England rolled out a strengthened Freedom to Speak Up policy, which covers the importance of listening to concerns and responding to concerns that are raised. All organisations providing services within the National Health Service are expected to adopt the updated national policy by 31 January 2024 at the latest. The National Guardian’s Office has also produced a training package aimed at all workers, including managers and senior leaders, which underlines the importance of responding to and acting on staff concerns.</p><p>There is also a network of Freedom to Speak Up Guardians, covering every trust, whose role includes ensuring the person who raises a concern is responded to and receives feedback on the actions taken.</p><p>Following the outcome of the trial of Lucy Letby, NHS England wrote to all NHS trusts to further emphasise the importance of NHS leaders listening to the concerns of patients, families and staff and following whistleblowing procedures.</p> answering member constituency Lewes answering member printed Maria Caulfield question first answered 25/09/2023 14:03:11 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4410 label Biography information for Julian Knight

1657271

	registered interest
	date	01/09/2023
	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, whether there are protocols in place for mandatory external reviews after internal concerns on patient safety are raised within the NHS.
	tabling member constituency	Solihull
	tabling member printed	Julian Knight
	uin	196906
	answer	answer is ministerial correction date of answer 14/09/2023 answer text <p>From 2015, the National Health Service has followed the Serious Incident Framework to guide its response to serious incidents in the NHS. Details of this framework are available at the following link:</p><p><a href="https://www.england.nhs.uk/patient-safety/serious-incident-framework/" target="_blank">https://www.england.nhs.uk/patient-safety/serious-incident-framework/</a></p><p> </p><p>In response to evidence that this framework was not leading to sufficient patient safety improvement, the new Patient Safety Incident Response Framework (PSIRF) was developed, tested, and is now being implemented across the NHS. All NHS organisations contracted under the NHS standard contract are expected to transition to PSIRF in autumn 2023. More information is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/incident-response-framework/" target="_blank">https://www.england.nhs.uk/patient-safety/incident-response-framework/</a></p><p> </p><p>PSIRF has guidance for oversight bodies, including integrated care boards and NHS England regional teams, describing when it may be appropriate for those bodies to consider commissioning an independent patient safety incident investigation. The guidance is available at the following link:</p><p><a href="https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-4.-Oversight-roles-and-responsibilities-specification-v1-FINAL.pdf" target="_blank">https://www.england.nhs.uk/wp-content/uploads/2022/08/B1465-4.-Oversight-roles-and-responsibilities-specification-v1-FINAL.pdf</a></p><p> </p><p>Providers can also commission invited reviews from Royal Colleges, including in response to patient safety concerns. These provide independent and objective advice to provider boards. The reviews support but do not replace the processes of healthcare regulatory bodies, including the Care Quality Commission and the General Medical Council, or the provider’s own procedures for addressing and managing patient safety.</p><p> </p><p>NHS England will refresh ‘Maintaining High Professional Standards in the Modern NHS’, in line with current best practice and learning from incidents and reviews.</p> answering member constituency Lewes answering member printed Maria Caulfield grouped question UIN 196902 question first answered 14/09/2023 14:44:23 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4410 label Biography information for Julian Knight

1657277

	registered interest
	date	01/09/2023
	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 guidance his Department provides hospitals on involving the police in investigations related to patient harm.
	tabling member constituency	Solihull
	tabling member printed	Julian Knight
	uin	196912
	answer	answer is ministerial correction date of answer 12/09/2023 answer text <p>NHS England’s Serious Incident Framework sets out the key principles of serious incident management and defines the roles and responsibilities of those involved in the management of serious incidents, including the police and those providing National Health Service healthcare services.</p><p>The Department’s ‘Memorandum of understanding: investigating patient safety incidents involving unexpected death or serious untoward harm’, published in 2006, also provides a source for reference where a serious incident occurs in a healthcare setting and an investigation is also required by the police, the Health and Safety Executive and/or the coroner. The NHS, the Association of Chief Police Officers (now the National Police Chiefs' Council) and the Health and Safety Executive are party to this agreement.</p> answering member constituency Lewes answering member printed Maria Caulfield question first answered 12/09/2023 10:06:51 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4410 label Biography information for Julian Knight

1471039

	registered interest
	date	16/06/2022
	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 progress he has made on the appointment of a new patient safety commissioner.
	tabling member constituency	Enfield North
	tabling member printed	Feryal Clark
	uin	19728
	answer	answer is ministerial correction date of answer 23/06/2022 answer text <p>On 20 June 2022, Henrietta Hughes was announced as the Government’s preferred candidate for the role of Patient Safety Commissioner. This role is subject to a pre-scrutiny appointment hearing by the Health and Social Care Committee on 5 July 2022.</p><p> </p> answering member constituency Lewes answering member printed Maria Caulfield question first answered 23/06/2022 11:53:50 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4822 label Biography information for Feryal Clark