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1663502

	registered interest
	date	13/10/2023
	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 he has made of the level of public awareness of the National Reporting and Learning System; and whether he is taking steps to raise awareness of the system.
	tabling member constituency	Lewisham, Deptford
	tabling member printed	Vicky Foxcroft
	uin	201356
	answer	answer is ministerial correction date of answer 23/10/2023 answer text <p>The National Reporting and Learning System (NRLS) has been in operation since 2003 and supports NHS England to fulfil statutory duties relating to the collation of and learning from patient safety incident reports.</p><p> </p><p>NRLS is principally a secondary use service and collects patient safety incident records that are recorded on healthcare providers’ Local Risk Management Systems (LRMS). The primary use of patient safety incident records is by the provider organisation that collects the data on its own LRMS and uses the information to support local safety improvement efforts. NRLS was created to support the national collation of patient safety incident records from LRMS and some of the existing LRMS predate the introduction of the NRLS.</p><p> </p><p>Given its age, NRLS is being replaced with the new Learn From Patient Safety Events (LFPSE) service. More information is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/" target="_blank">https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/</a></p><p> </p><p>NRLS, and its replacement LFPSE, support the collation of patient safety incident records from members of the public as well as from LRMS. NRLS does this through the Patient and Public eForm, which is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/report-patient-safety-incident/#public" target="_blank">https://www.england.nhs.uk/patient-safety/report-patient-safety-incident/#public</a></p><p> </p><p>As part of the development of the LFPSE service, work is underway to determine how best to support the future collection of patient safety incidents information from patients and the public. A report on the first stage of this work, published in October 2023, is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/publication/the-learn-from-patient-safety-events-lfpse-service-patient-and-family-discovery-report/" target="_blank">https://www.england.nhs.uk/publication/the-learn-from-patient-safety-events-lfpse-service-patient-and-family-discovery-report/</a></p><p> </p><p>Information on how patient safety incident records are collated and used by NHS England is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/" target="_blank">https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/</a></p><p> </p><p>No data is held on patient safety incident recording prior to the introduction of the NRLS in 2003. Data on the number of patient safety incidents collected by NRLS is available at the following link:</p><p> </p><p><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 Lewes answering member printed Maria Caulfield grouped question UIN 201357 201358 question first answered 23/10/2023 11:52:59 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4491 label Biography information for Vicky Foxcroft

1663503

	registered interest
	date	13/10/2023
	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 the National Reporting and Learning System works alongside independent reports to individual (a) clinics, (b) hospitals, (c) Patient Advice and Liaison Services and (d) Clinical Commissioning Groups which are dealt with in-house.
	tabling member constituency	Lewisham, Deptford
	tabling member printed	Vicky Foxcroft
	uin	201357
	answer	answer is ministerial correction date of answer 23/10/2023 answer text <p>The National Reporting and Learning System (NRLS) has been in operation since 2003 and supports NHS England to fulfil statutory duties relating to the collation of and learning from patient safety incident reports.</p><p> </p><p>NRLS is principally a secondary use service and collects patient safety incident records that are recorded on healthcare providers’ Local Risk Management Systems (LRMS). The primary use of patient safety incident records is by the provider organisation that collects the data on its own LRMS and uses the information to support local safety improvement efforts. NRLS was created to support the national collation of patient safety incident records from LRMS and some of the existing LRMS predate the introduction of the NRLS.</p><p> </p><p>Given its age, NRLS is being replaced with the new Learn From Patient Safety Events (LFPSE) service. More information is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/" target="_blank">https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/</a></p><p> </p><p>NRLS, and its replacement LFPSE, support the collation of patient safety incident records from members of the public as well as from LRMS. NRLS does this through the Patient and Public eForm, which is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/report-patient-safety-incident/#public" target="_blank">https://www.england.nhs.uk/patient-safety/report-patient-safety-incident/#public</a></p><p> </p><p>As part of the development of the LFPSE service, work is underway to determine how best to support the future collection of patient safety incidents information from patients and the public. A report on the first stage of this work, published in October 2023, is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/publication/the-learn-from-patient-safety-events-lfpse-service-patient-and-family-discovery-report/" target="_blank">https://www.england.nhs.uk/publication/the-learn-from-patient-safety-events-lfpse-service-patient-and-family-discovery-report/</a></p><p> </p><p>Information on how patient safety incident records are collated and used by NHS England is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/" target="_blank">https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/</a></p><p> </p><p>No data is held on patient safety incident recording prior to the introduction of the NRLS in 2003. Data on the number of patient safety incidents collected by NRLS is available at the following link:</p><p> </p><p><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 Lewes answering member printed Maria Caulfield grouped question UIN 201356 201358 question first answered 23/10/2023 11:52:59 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4491 label Biography information for Vicky Foxcroft

1663504

	registered interest
	date	13/10/2023
	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 patient safety incidents were reported before the introduction of the National Reporting and Learning System (NRLS); and what data he holds on the number of such incidents recorded in (a) each of the five years (i) before and (ii) after the introduction of the NRLS and (b) in each of the last five years.
	tabling member constituency	Lewisham, Deptford
	tabling member printed	Vicky Foxcroft
	uin	201358
	answer	answer is ministerial correction date of answer 23/10/2023 answer text <p>The National Reporting and Learning System (NRLS) has been in operation since 2003 and supports NHS England to fulfil statutory duties relating to the collation of and learning from patient safety incident reports.</p><p> </p><p>NRLS is principally a secondary use service and collects patient safety incident records that are recorded on healthcare providers’ Local Risk Management Systems (LRMS). The primary use of patient safety incident records is by the provider organisation that collects the data on its own LRMS and uses the information to support local safety improvement efforts. NRLS was created to support the national collation of patient safety incident records from LRMS and some of the existing LRMS predate the introduction of the NRLS.</p><p> </p><p>Given its age, NRLS is being replaced with the new Learn From Patient Safety Events (LFPSE) service. More information is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/" target="_blank">https://www.england.nhs.uk/patient-safety/learn-from-patient-safety-events-service/</a></p><p> </p><p>NRLS, and its replacement LFPSE, support the collation of patient safety incident records from members of the public as well as from LRMS. NRLS does this through the Patient and Public eForm, which is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/report-patient-safety-incident/#public" target="_blank">https://www.england.nhs.uk/patient-safety/report-patient-safety-incident/#public</a></p><p> </p><p>As part of the development of the LFPSE service, work is underway to determine how best to support the future collection of patient safety incidents information from patients and the public. A report on the first stage of this work, published in October 2023, is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/publication/the-learn-from-patient-safety-events-lfpse-service-patient-and-family-discovery-report/" target="_blank">https://www.england.nhs.uk/publication/the-learn-from-patient-safety-events-lfpse-service-patient-and-family-discovery-report/</a></p><p> </p><p>Information on how patient safety incident records are collated and used by NHS England is available at the following link:</p><p> </p><p><a href="https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/" target="_blank">https://www.england.nhs.uk/patient-safety/using-patient-safety-events-data-to-keep-patients-safe/</a></p><p> </p><p>No data is held on patient safety incident recording prior to the introduction of the NRLS in 2003. Data on the number of patient safety incidents collected by NRLS is available at the following link:</p><p> </p><p><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 Lewes answering member printed Maria Caulfield grouped question UIN 201356 201357 question first answered 23/10/2023 11:52:59 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4491 label Biography information for Vicky Foxcroft

519221

	registered interest
	date	18/05/2016
	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 never events have been recorded in (a) Furness General Hospital and (b) Westmorland General Hospital in the last five years.
	tabling member constituency	Westmorland and Lonsdale
	tabling member printed	Tim Farron
	uin	37216
	answer	answer is ministerial correction date of answer 23/05/2016 answer text <p>The information is not available in the format requested. In addition, data are not available at hospital level. The 2012-13 publication does not have trust level data.</p><p> </p><p>Published data on never events from 2012-13 to 2015-16 are available on the NHS England website at:</p><p> </p><p><a href="https://www.england.nhs.uk/patientsafety/never-events/ne-data/" target="_blank">https://www.england.nhs.uk/patientsafety/never-events/ne-data/</a></p><p> </p><p>The following table shows the reported never events at the University Hospitals of Morecambe Bay NHS Foundation Trust for 2013-14 and 2015-16. No never events were reported at this Trust in 2014-15. Cumbria Partnership NHS Foundation Trust, which also provides services from the Furness General Hospital and the Westmorland General Hospital, has no reported never events in the published data.</p><p> </p><p> </p><table><tbody><tr><td colspan="6"><p>University Hospitals of Morecambe Bay NHS Foundation Trust</p></td></tr><tr><td colspan="6"><p>2015-16 (monthly provisional)</p></td></tr><tr><td><p>Month</p></td><td><p>Retained foreign object post procedure</p></td><td><p>Wrong implant/ prosthesis</p></td><td><p>Wrong site surgery</p></td><td><p>Other NE (types 4-25)</p></td><td><p>Sub-total Serious Incidents reported as Never Events that can be matched to Never Event list type 1-25</p></td></tr><tr><td><p>July</p></td><td><p> </p></td><td><p> </p></td><td><p>1</p></td><td><p> </p></td><td><p>1</p></td></tr><tr><td><p>May</p></td><td><p> </p></td><td><p> </p></td><td><p>1</p></td><td><p> </p></td><td><p>1</p></td></tr><tr><td><p> </p></td><td><p> </p></td><td><p> </p></td><td><p> </p></td><td><p> </p></td><td><p> </p></td></tr><tr><td colspan="6"><p>2013-14</p></td></tr><tr><td><p>Annual</p></td><td><p> </p></td><td><p>2</p></td><td><p>1</p></td><td><p> </p></td><td><p>3</p></td></tr></tbody></table><p> </p><p><em>Source:</em> NHS England <a href="https://www.england.nhs.uk/patientsafety/never-events/ne-data/" target="_blank">https://www.england.nhs.uk/patientsafety/never-events/ne-data/</a></p><p> </p><p><em>Notes: </em></p><p> </p><ol><li>From April 2014, NHS England published provisional never events data as monthly updates throughout each financial year. Each report updates the previous month’s data as information on never events is reported or amended.</li><li>The provisional monthly never events data summaries for 2015/16 have been drawn from the STEIS system. Each report includes all Serious Incidents reported as occurring within the indicated timeframe, where they are designated by their reporters as never events at the date the data was extracted. Please note these reports are provisional data and subject to change.</li><li>As of 1 April 2016, patient safety is now part of NHS Improvement. Never events data publications for 2016/17 financial year and onwards will be published by NHS Improvement.</li></ol><p> </p> answering member constituency Ipswich answering member printed Ben Gummer question first answered 23/05/2016 14:31:01 answering member 3988 label Biography information for Ben Gummer
	tabling member	1591 label Biography information for Tim Farron

522595

	registered interest
	date	03/06/2016
	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 never events have been recorded in hospitals in England in the last five years.
	tabling member constituency	Westmorland and Lonsdale
	tabling member printed	Tim Farron
	uin	38974
	answer	answer is ministerial correction date of answer 08/06/2016 answer text <p>In the last five years there have been a total of 1,881 Never Events recorded in hospitals in England. The table below provides the specific annual figures of this total.</p><p> </p><table><tbody><tr><td><p>Year</p></td><td><p>Data source</p></td><td><p>Total</p></td></tr><tr><td><p>2011/12</p></td><td><p>National Reporting and Learning System</p></td><td><p>326</p></td></tr><tr><td rowspan="2"><p>2012/13</p></td><td><p>National Reporting and Learning System</p></td><td><p>237</p></td></tr><tr><td><p>Strategic Executive Information System</p></td><td><p>329</p></td></tr><tr><td><p>2013/14</p></td><td><p>Strategic Executive Information System</p></td><td><p>338</p></td></tr><tr><td><p>2014/15</p></td><td><p>Strategic Executive Information System</p></td><td><p>306</p></td></tr><tr><td><p>2015/16 (provisional)</p></td><td><p>Strategic Executive Information System</p></td><td><p>345</p></td></tr></tbody></table><p> </p><p>Never Events cannot be compared year on year as the number of Never Events contained within the Never Events list and definitions of the individual Never Events have been modified each year, so direct comparison is not appropriate.</p><p> </p><p>Data for 2015/16 is still provisional and is yet to be confirmed in the annual data summary.</p> answering member constituency Ipswich answering member printed Ben Gummer question first answered 08/06/2016 13:54:45 answering member 3988 label Biography information for Ben Gummer
	tabling member	1591 label Biography information for Tim Farron

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

143393

	registered interest
	date	07/11/2014
	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, what steps he is taking to promote the Sign up to Safety campaign; and if he will make a statement.
	tabling member constituency	Bromley and Chislehurst
	tabling member printed	Robert Neill
	uin	213871
	answer	answer is ministerial correction date of answer 19/11/2014 answer text <p>The Sign up to Safety campaign was launched on 24 June 2014. Each organisation that has joined the campaign has committed to improving patient safety through the implementation of a Safety Improvement Plan. The Safety Improvement Plan builds on the pledges the organisation set out when joining. The pledges are expanded in more detail in the plan, which sets out what the organisation wants to achieve and by when. Each organisation is expected to demonstrate how they will measure the local impact of their aims over the next three years via a measurement section within their plans. They will then implement their aims over the next three years.</p><p> </p><p> </p><p> </p><p>The Sign up to Safety campaign is being promoted by means of:</p><p> </p><p>- a national campaign website;</p><p> </p><p>- regional and national presentations at events across the country delivered by the Campaign Director, the Secretary of State and others;</p><p> </p><p>- Twitter with over 1,500 followers;</p><p> </p><p>- a blog by the Campaign Director;</p><p> </p><p>- an online seminar programme (webinars);</p><p> </p><p>- through partner organisations including NHS England, Care Quality Commission, Monitor, NHS Trust Development Authority, NHS Litigation Authority, Health Education England, and NHS Improving Quality;</p><p> </p><p>- mini poster campaigns, such as the Safe Care Costs Less, and individual events, such as the launch of the Patient Briefing Video; and</p><p> </p><p>- through participant websites and local events.</p><p> </p><p> </p><p> </p><p>As at the end of October 2014, a total number of 136 organisations have agreed to participate in the Sign up to Safety campaign. Each participant organisation is expected to set out how they will contribute to the campaign’s three year objective via their Safety Improvement Plan – they are expected to quantify the expected impact of their actions on a reduction of avoidable harm and saving lives. The measurement and evaluation of the impact at a regional and national level will be led by NHS England working with NHS Improving Quality as part of the integrated measurement strategy for both the campaign and the Patient Safety Collaborative programme. This will include the National Reporting and Learning System, harms via the Safety Thermometer and mortality rates, case studies of individual organisations and patient record reviews.</p><p> </p><p> </p><p> </p><p><strong> </strong></p><p> </p><p><strong> </strong></p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter grouped question UIN 213870 213872 question first answered 19/11/2014 15:47:48 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	1601 label Biography information for Sir Robert Neill

143394

	registered interest
	date	07/11/2014
	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, whether the Sign up to Safety campaign is on course to achieve its three-year objective to (a) reduce avoidable harm by 50 per cent and (b) save 6,000 lives.
	tabling member constituency	Bromley and Chislehurst
	tabling member printed	Robert Neill
	uin	213872
	answer	answer is ministerial correction date of answer 19/11/2014 answer text <p>The Sign up to Safety campaign was launched on 24 June 2014. Each organisation that has joined the campaign has committed to improving patient safety through the implementation of a Safety Improvement Plan. The Safety Improvement Plan builds on the pledges the organisation set out when joining. The pledges are expanded in more detail in the plan, which sets out what the organisation wants to achieve and by when. Each organisation is expected to demonstrate how they will measure the local impact of their aims over the next three years via a measurement section within their plans. They will then implement their aims over the next three years.</p><p> </p><p> </p><p> </p><p>The Sign up to Safety campaign is being promoted by means of:</p><p> </p><p>- a national campaign website;</p><p> </p><p>- regional and national presentations at events across the country delivered by the Campaign Director, the Secretary of State and others;</p><p> </p><p>- Twitter with over 1,500 followers;</p><p> </p><p>- a blog by the Campaign Director;</p><p> </p><p>- an online seminar programme (webinars);</p><p> </p><p>- through partner organisations including NHS England, Care Quality Commission, Monitor, NHS Trust Development Authority, NHS Litigation Authority, Health Education England, and NHS Improving Quality;</p><p> </p><p>- mini poster campaigns, such as the Safe Care Costs Less, and individual events, such as the launch of the Patient Briefing Video; and</p><p> </p><p>- through participant websites and local events.</p><p> </p><p> </p><p> </p><p>As at the end of October 2014, a total number of 136 organisations have agreed to participate in the Sign up to Safety campaign. Each participant organisation is expected to set out how they will contribute to the campaign’s three year objective via their Safety Improvement Plan – they are expected to quantify the expected impact of their actions on a reduction of avoidable harm and saving lives. The measurement and evaluation of the impact at a regional and national level will be led by NHS England working with NHS Improving Quality as part of the integrated measurement strategy for both the campaign and the Patient Safety Collaborative programme. This will include the National Reporting and Learning System, harms via the Safety Thermometer and mortality rates, case studies of individual organisations and patient record reviews.</p><p> </p><p> </p><p> </p><p><strong> </strong></p><p> </p><p><strong> </strong></p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter grouped question UIN 213870 213871 question first answered 19/11/2014 15:47:48 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	1601 label Biography information for Sir Robert Neill

143397

	registered interest
	date	07/11/2014
	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, what progress organisations which have participated in the Sign up to Safety campaign have made on fulfilling the pledges in that campaign; and if he will make a statement.
	tabling member constituency	Bromley and Chislehurst
	tabling member printed	Robert Neill
	uin	213870
	answer	answer is ministerial correction date of answer 19/11/2014 answer text <p>The Sign up to Safety campaign was launched on 24 June 2014. Each organisation that has joined the campaign has committed to improving patient safety through the implementation of a Safety Improvement Plan. The Safety Improvement Plan builds on the pledges the organisation set out when joining. The pledges are expanded in more detail in the plan, which sets out what the organisation wants to achieve and by when. Each organisation is expected to demonstrate how they will measure the local impact of their aims over the next three years via a measurement section within their plans. They will then implement their aims over the next three years.</p><p> </p><p> </p><p> </p><p>The Sign up to Safety campaign is being promoted by means of:</p><p> </p><p>- a national campaign website;</p><p> </p><p>- regional and national presentations at events across the country delivered by the Campaign Director, the Secretary of State and others;</p><p> </p><p>- Twitter with over 1,500 followers;</p><p> </p><p>- a blog by the Campaign Director;</p><p> </p><p>- an online seminar programme (webinars);</p><p> </p><p>- through partner organisations including NHS England, Care Quality Commission, Monitor, NHS Trust Development Authority, NHS Litigation Authority, Health Education England, and NHS Improving Quality;</p><p> </p><p>- mini poster campaigns, such as the Safe Care Costs Less, and individual events, such as the launch of the Patient Briefing Video; and</p><p> </p><p>- through participant websites and local events.</p><p> </p><p> </p><p> </p><p>As at the end of October 2014, a total number of 136 organisations have agreed to participate in the Sign up to Safety campaign. Each participant organisation is expected to set out how they will contribute to the campaign’s three year objective via their Safety Improvement Plan – they are expected to quantify the expected impact of their actions on a reduction of avoidable harm and saving lives. The measurement and evaluation of the impact at a regional and national level will be led by NHS England working with NHS Improving Quality as part of the integrated measurement strategy for both the campaign and the Patient Safety Collaborative programme. This will include the National Reporting and Learning System, harms via the Safety Thermometer and mortality rates, case studies of individual organisations and patient record reviews.</p><p> </p><p> </p><p> </p><p><strong> </strong></p><p> </p><p><strong> </strong></p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter grouped question UIN 213871 213872 question first answered 19/11/2014 15:47:48 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	1601 label Biography information for Sir Robert Neill

1701431

	registered interest
	date	16/04/2024
	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, what assessment she has made of the effectiveness of NHS speak up guardians in (a) primary and (b) secondary care settings.
	tabling member constituency	York Central
	tabling member printed	Rachael Maskell
	uin	22064
	answer	answer is ministerial correction date of answer 22/04/2024 answer text <p>Freedom to Speak Up Guardians are a valued channel through which concerns can be raised, and have handled over 100,000 cases since the National Guardian’s Office first started collecting data in 2017. This represents over 100,000 opportunities for learning and improvement. In 2022/23 alone over 25,000 cases were raised with Freedom to Speak Up Guardians and over four-fifths, or 82.2% of those who gave feedback to their Freedom to Speak Up Guardian, said they would speak up again.</p> answering member constituency Pendle answering member printed Andrew Stephenson question first answered 22/04/2024 10:55:12 answering member 4044 label Biography information for Andrew Stephenson
	tabling member	4471 label Biography information for Rachael Maskell

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

142222

	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, what recent assessment he has made of the uptake of the Sign up to Safety campaign in each (a) region and (b) clinical commissioning group area.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	213774
	answer	answer is ministerial correction date of answer 18/11/2014 answer text <p>As at the end of October 2014, a total number of 136 organisations have agreed to participate in the Sign up to Safety campaign. A breakdown by Academic Health Science Network (AHSN) is as follows:</p><p> </p><table><tbody><tr><td><p><strong> </strong></p><p>By AHSN region</p></td><td> </td></tr><tr><td><p>Yorkshire and Humber</p></td><td><p>9</p></td></tr><tr><td><p>West of England</p></td><td><p>7</p></td></tr><tr><td><p>West Midlands</p></td><td><p>8</p></td></tr><tr><td><p>Wessex</p></td><td><p>4</p></td></tr><tr><td><p>London</p></td><td><p>24</p></td></tr><tr><td><p>South West Peninsula</p></td><td><p>5</p></td></tr><tr><td><p>Oxford</p></td><td><p>4</p></td></tr><tr><td><p>North West Coast</p></td><td><p>15</p></td></tr><tr><td><p>North East and North Cumbria</p></td><td><p>8</p></td></tr><tr><td><p>Kent, Surrey and Sussex</p></td><td><p>13</p></td></tr><tr><td><p>Greater Manchester</p></td><td><p>9</p></td></tr><tr><td><p>Eastern</p></td><td><p>11</p></td></tr><tr><td><p>East Midlands</p></td><td><p>16</p></td></tr><tr><td><p>Other</p></td><td><p>3</p></td></tr><tr><td> </td><td><p>136</p></td></tr></tbody></table><p> </p><p> </p><p> </p><p>The information has not been split by clinical commissioning group. However 16 clinical commissioning groups have signed up to the campaign to date.</p><p> </p><p> </p><p> </p><p><strong> </strong></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 15:40:10 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4078 label Biography information for Paul Uppal

142224

	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 occurred in England in each year since 2000.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	213775
	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 213780 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

164366

	registered interest
	date	24/11/2014
	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, what progress he has made on implementing the recommendations of the Berwick report into Improving the Safety of Patients in England, published in August 2013.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	215725
	answer	answer is ministerial correction date of answer 01/12/2014 answer text <p>The Government has put in place a number of measures to support National Health Service orgnisations to respond positively to the Berwick Report ‘<em>Improving the Safety of Patients in England</em>’’ including greater transparency, openness and candour; ensuring safe staffing levels; creating a culture of learning and development with the establishment of 15 Patient Safety Collaboratives; and making patient safety a primary goal with a new ambition to halve avoidable harm and save 6,000 lives over the next three years, underpinned by the Sign up to Safety campaign.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 01/12/2014 17:23:17 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4078 label Biography information for Paul Uppal

164380

	registered interest
	date	24/11/2014
	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, what the rates of (a) pulmonary embolism, (b) blood-stream infection and (c) foreign body left in after procedure has been in England in each year since 2000.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	215682
	answer	answer is ministerial correction date of answer 01/12/2014 answer text <p><strong> </strong></p><p> </p><p>The Health and Social Care Information Centre (HSCIC) has provided data on (a) a count of finished admission episodes (FAEs) where there was a primary diagnosis of pulmonary embolism and the number of FAEs as a rate per 100,000 of the total number of FAEs and (b) a count of finished consultant episodes (FCEs) with a primary or secondary diagnosis of pulmonary embolism and the number of FCEs as a rate per 100,000 of the total number FCEs, for the years 2000-01 to 2012-13.</p><p> </p><p>This is summarised in the following table:</p><p> </p><table><tbody><tr><td><p>Year</p></td><td><p>FAEs with primary diagnosis of &quot;pulmonary embolism&quot;</p></td><td><p>Rate per 100,000 of total FAEs</p></td><td><p>FCEs with primary or secondary diagnosis of &quot;pulmonary embolism&quot;</p></td><td><p>Rate per 100,000 of total FCEs</p></td></tr><tr><td><p>2000-01</p></td><td><p>15,179</p></td><td><p>136.5</p></td><td><p>32,937</p></td><td><p>268.6</p></td></tr><tr><td><p>2001-02</p></td><td><p>14,735</p></td><td><p>133.0</p></td><td><p>33,537</p></td><td><p>271.8</p></td></tr><tr><td><p>2002-03</p></td><td><p>15,536</p></td><td><p>136.6</p></td><td><p>37,093</p></td><td><p>291.8</p></td></tr><tr><td><p>2003-04</p></td><td><p>16,095</p></td><td><p>136.3</p></td><td><p>39,196</p></td><td><p>294.8</p></td></tr><tr><td><p>2004-05</p></td><td><p>15,621</p></td><td><p>129.1</p></td><td><p>40,059</p></td><td><p>292.3</p></td></tr><tr><td><p>2005-06</p></td><td><p>16,347</p></td><td><p>128.9</p></td><td><p>43,360</p></td><td><p>300.6</p></td></tr><tr><td><p>2006-07</p></td><td><p>16,629</p></td><td><p>128.1</p></td><td><p>46,685</p></td><td><p>315.8</p></td></tr><tr><td><p>2007-08</p></td><td><p>16,948</p></td><td><p>125.7</p></td><td><p>49,114</p></td><td><p>319.8</p></td></tr><tr><td><p>2008-09</p></td><td><p>18,214</p></td><td><p>128.7</p></td><td><p>56,029</p></td><td><p>345.2</p></td></tr><tr><td><p>2009-10</p></td><td><p>19,763</p></td><td><p>135.9</p></td><td><p>62,367</p></td><td><p>371.1</p></td></tr><tr><td><p>2010-11</p></td><td><p>20,908</p></td><td><p>140.4</p></td><td><p>67,477</p></td><td><p>390.7</p></td></tr><tr><td><p>2011-12</p></td><td><p>21,525</p></td><td><p>143.3</p></td><td><p>70,466</p></td><td><p>403.5</p></td></tr><tr><td><p>2012-13</p></td><td><p>23,578</p></td><td><p>155.7</p></td><td><p>79,058</p></td><td><p>446.3</p></td></tr></tbody></table><p> </p><p> </p><p> </p><p> </p><p> </p><p>Public Health England (PHE) collects data on blood stream infections caused by bacteria (bacteraemia) relating to specific organisms as part of its mandatory Healthcare Associated Infection surveillance programmes.</p><p> </p><p>Microbiology laboratories in England, Wales and Northern Ireland also voluntarily submit data to PHE relating to episodes of bacteraemia and blood stream infections caused by fungi (fungaemia).</p><p> </p><p>The data summarised in Tables 1-3, taken from PHE’s mandatory surveillance programmes, represent bacteraemia cases reported in England resulting from: Methicillin-resistant Staphylococcus aureus (MRSA); Methicillin-susceptible Staphylococcus aureus (MSSA) and E.coli where comparable data is available. Rates of all reported cases per 100,000 population are included, where available.</p><p> </p><table><tbody><tr><td colspan="8"><p>Table 1a: All reported cases of MRSA bacteraemia (April 2007-March 2014)</p><p> </p></td></tr><tr><td><p>Financial year</p></td><td><p>April 2007 to March 2008</p></td><td><p>April 2008 to March 2009</p></td><td><p>April 2009 to March 2010</p></td><td><p>April 2010 to March 2011</p></td><td><p>April 2011 to March 2012</p></td><td><p>April 2012 to March 2013</p></td><td><p>April 2013 to March 2014</p></td></tr><tr><td><p>Count</p></td><td><p>4,451</p></td><td><p>2,935</p></td><td><p>1,898</p></td><td><p>1,481</p></td><td><p>1,116</p></td><td><p>924</p></td><td><p>862</p></td></tr><tr><td><p>Rate per 100,000 population</p></td><td><p> </p></td><td><p> </p></td><td><p>3.6</p></td><td><p>2.8</p></td><td><p>2.1</p></td><td><p>1.7</p></td><td><p>1.6</p></td></tr></tbody></table><p> </p><p><em>Note: </em>Data is available at: <a href="https://www.gov.uk/government/statistics/mrsa-bacteraemia-annual-data" target="_blank">https://www.gov.uk/government/statistics/mrsa-bacteraemia-annual-data</a></p><p> </p><p> </p><p> </p><table><tbody><tr><td colspan="4"><p>Table 2: All reported cases of MSSA bacteraemia (April 2011 - March 2014)</p><p> </p></td></tr><tr><td><p>Financial year</p></td><td><p>April 2011 to March 2012</p></td><td><p>April 2012 to March 2013</p></td><td><p>April 2013 to March 2014</p></td></tr><tr><td><p>Count</p></td><td><p>8,767</p></td><td><p>8,812</p></td><td><p>9,290</p></td></tr><tr><td><p>Rate per 100,000 population</p></td><td><p>16.5</p></td><td><p>16.5</p></td><td><p>17.4</p></td></tr></tbody></table><p> </p><p><em>Note: </em>Data is available at: <a href="https://www.gov.uk/government/statistics/mssa-bacteraemia-annual-data" target="_blank">https://www.gov.uk/government/statistics/mssa-bacteraemia-annual-data</a></p><p> </p><p> </p><p> </p><table><tbody><tr><td colspan="3"><p>Table 3: All reported cases of <em>E. coli </em>bacteraemia (April 2012-March 2014)</p><p> </p></td></tr><tr><td><p>Financial year</p></td><td><p>April 2012 to March 2013</p></td><td><p>April 2013 to March 2014</p></td></tr><tr><td><p>Count</p></td><td><p>32,309</p></td><td><p>34,275</p></td></tr><tr><td><p>Rate per 100,000 population</p></td><td><p>60.4</p></td><td><p>64.1</p></td></tr></tbody></table><p> </p><p><em>Note: </em>Data is available at: <a href="https://www.gov.uk/government/statistics/escherichia-coli-e-coli-bacteraemia-annual-data" target="_blank">https://www.gov.uk/government/statistics/escherichia-coli-e-coli-bacteraemia-annual-data</a></p><p> </p><p>The data summarised in Table 4, taken from PHE’s voluntary surveillance database, represents all voluntarily reported patient episodes involving either bacteraemia and/or fungaemia for the period of January 2008 to December 2012 in England, Wales and Northern Ireland.</p><p> </p><table><tbody><tr><td colspan="6"><p>Table 4: Patient episodes involving either bacteraemia and/or fungaemia 2008-2012, England, Wales and Northern Ireland</p><p> </p></td></tr><tr><td><p>Calendar Year</p></td><td><p>2008</p></td><td><p>2009</p></td><td><p>2010</p></td><td><p>2011</p></td><td><p>2012</p></td></tr><tr><td><p>Count</p></td><td><p>95,931</p></td><td><p>94,190</p></td><td><p>92,867</p></td><td><p>94,166</p></td><td><p>95,647</p></td></tr></tbody></table><p> </p><p><em>Note: </em>Data extracted from the Public Health England (PHE) voluntary surveillance database, LabBase2, on 3 December 2013.</p><p> </p><p> </p><p> </p><p>Before 2009, information was not collated on foreign bodies retained after procedures (which is classed as a ‘never event’) and so we are unable to provide data for the period prior to 2009.</p><p> </p><p> </p><p> </p><p>In 2009-10, there were nine retained foreign objects post procedure reported during this period.</p><p> </p><p>In 2010-11, there were 67 retained foreign object never events reported to Strategic Executive Information System (STEIS) and 22 reported to the National Reporting and Learning Service (NRLS).</p><p> </p><p>In 2011-12, there were 161 retained foreign object never events reported to STEIS and 86 reported to the NRLS in 2011-12.</p><p> </p><p>In 2012-13, there were 130 retained foreign object never events reported to STEIS and 124 reported to the NRLS in 2012-13 (please note incidents are potentially reported to both systems but the exact degree of overlap of reported incidents during the period 2010-11 and 2011-12 is unclear).</p><p> </p><p> </p><p> </p><p>Since April 2013 reports made to the NRLS and STEIS have been directly reconciled to provide a single total and provisional data published by NHS England shows 123 retained object never events were reported in 2013-14 and 44 in the six months to September 2014:</p><p> </p><p> </p><p> </p><p><a href="http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/" target="_blank">http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/</a></p><p> </p><p> </p><p> </p><p>Methods for identifying and collating the data from two systems (NRLS and STEIS) have changed over the years, with specific reporting fields for Never events replacing keyword searches, and year-end attempts to reconcile events reported in both systems replaced with direct communication as and when incidents were reported. This is a further reason why events from the earlier years are not directly comparable. The numbers of Never Events reported for 2010-11 and 2011-12 were reported in Annex A of the ‘<em>The never events policy framework: An update to the never events policy</em>’</p><p> </p><p> </p><p> </p><p><a href="https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213046/never-events-policy-framework-update-to-policy.pdf" target="_blank">https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/213046/never-events-policy-framework-update-to-policy.pdf</a></p><p> </p><p> </p><p> </p><p>It should be noted that the updated policy expanded the list of never events from 8 to 25 in 2012 and the detail of definitions of retained foreign objects was also clarified in The never events list; 2013/14 update:</p><p> </p><p> </p><p> </p><p><a href="http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf" target="_blank">http://www.england.nhs.uk/wp-content/uploads/2013/12/nev-ev-list-1314-clar.pdf</a>.</p><p> </p><p> </p><p> </p><p>Note numbers in different years are not directly comparable due to these definitional changes.</p><p> </p><p> </p><p> </p><p><strong> </strong></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 01/12/2014 17:19:54 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4078 label Biography information for Paul Uppal

164381

	registered interest
	date	24/11/2014
	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 hospitals have been rated poor with regards to open and honest reporting of patient safety incidents in each month since May 2010.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	215683
	answer	answer is ministerial correction date of answer 01/12/2014 answer text <p>As at 28 November 2014, 91 trusts were recorded as poor (red) against the open and honest reporting indicator. Data prior to June 2014 is not available in this form.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 01/12/2014 17:30:33 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4078 label Biography information for Paul Uppal

166013

	registered interest
	date	25/11/2014
	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 the findings of the friends and family test are being used to improve patient safety in the NHS.
	tabling member constituency	Wolverhampton South West
	tabling member printed	Paul Uppal
	uin	215852
	answer	answer is ministerial correction date of answer 02/12/2014 answer text <p>The Friends and Family Test (FFT) was implemented as a mechanism to provide near real-time feedback to identify both good and poor quality patient experience. Whilst the FFT aims to capture overall patient experience, part of the experience that patients may choose to comment on is whether they felt their care was safe. This information can then be used by providers to consider what they do well and make improvements where feedback is less positive. Commissioners and regulators monitor the results of the FFT and the Care Quality Commission (CQC) uses the data - together with other data such as mortality rates and ‘never events’ - as part of its new ‘Hospital Intelligence Monitoring’. The monitoring service gives the CQC an understanding of areas of care that need to be further investigated by inspectors:</p><p> </p><p> </p><p> </p><p><a href="http://www.cqc.org.uk/public/hospital-intelligent-monitoring" target="_blank">http://www.cqc.org.uk/public/hospital-intelligent-monitoring</a></p><p> </p><p> </p><p> </p><p>In April 2014, the Staff FFT was introduced to allow staff feedback on NHS Services based on recent experience. The Staff FFT asks staff to rate and comment on where they work as a place to work and as a place of care. This information can then be used by employers to consider what they do well and make improvements where feedback is less positive.</p><p> </p><p> </p><p> </p><p>Commissioners and regulators also monitor the results of the Staff FFT, and the CQC uses this data as part of their Intelligent Monitoring system. The response to this question is also displayed as a key patient safety indicator on NHS Choices:</p><p> </p><p> </p><p> </p><p><a href="http://www.nhs.uk/NHSEngland/thenhs/patient-safety/Pages/patient-safety-indicators.aspx" target="_blank">http://www.nhs.uk/NHSEngland/thenhs/patient-safety/Pages/patient-safety-indicators.aspx</a></p><p> </p><p> </p><p> </p><p>In addition, hospital boards and other providers and commissioners of services can consider the results of the FFT to consider the implications for quality and safety. A NHS England review of the FFT found that it is performing well as a service improvement tool, with 85% of trusts reporting that it is being used to improve patient experience, and 78% saying that FFT has increased the emphasis placed on patient experience in their trusts.</p><p> </p><p> </p><p> </p><p> </p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 02/12/2014 17:04:04 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4078 label Biography information for Paul Uppal

1144629

	registered interest
	date	04/09/2019
	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 the Government is taking to ensure that patient safety will be protected in the event that the UK leaves the EU without a deal.
	tabling member constituency	Newcastle-under-Lyme
	tabling member printed	Paul Farrelly
	uin	286668
	answer	answer is ministerial correction date of answer 09/09/2019 answer text <p>The Department is working with its partners across Government, the National Health Service, arm’s length bodies, local authorities, industry and the wider health and care system to ensure that all relevant parties are prepared for exiting the European Union.</p><p>The quality and safety of patient care is paramount in our preparedness plans.</p><p>The work being undertaken includes securing continued supplies of medicines, medical devices and clinical products, and ensuring that the NHS continues to have sufficient staff to maintain quality of care and the safety of patients.</p> answering member constituency Kingswood answering member printed Chris Skidmore question first answered 09/09/2019 18:55:01 answering member 4021 label Biography information for Chris Skidmore
	tabling member	1436 label Biography information for Paul Farrelly

1700337

	registered interest
	date	12/04/2024
	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 many never events occurred within NHS England in each year since 2019; and how many and what proportion of these incidents involved Physician Associates in each year.
	tabling member constituency	South Shields
	tabling member printed	Mrs Emma Lewell-Buck
	uin	21054
	answer	answer is ministerial correction date of answer 17/04/2024 answer text <p>Information on Never Events is published by NHS England, and all available data on Never Events is available at the following link:</p><p><a href="https://eur03.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.england.nhs.uk%2Fpatient-safety%2Fnever-events-data%2F&amp;data=05%7C02%7Cjonathan.stones%40dhsc.gov.uk%7C01ce069ba0534a13ed8d08dc5d394868%7C61278c3091a84c318c1fef4de8973a1c%7C1%7C0%7C638487747817797496%7CUnknown%7CTWFpbGZsb3d8eyJWIjoiMC4wLjAwMDAiLCJQIjoiV2luMzIiLCJBTiI6Ik1haWwiLCJXVCI6Mn0%3D%7C0%7C%7C%7C&amp;sdata=OXO3AEoXR3j0kiT5wETru35oEd3BrgsFWwvxdso0HI4%3D&amp;reserved=0" target="_blank">https://www.england.nhs.uk/patient-safety/never-events-data/</a></p><p>NHS England does not collect specific data relating to Physician Associate involvement in Never Events, and as such the information is not held.</p> answering member constituency Lewes answering member printed Maria Caulfield question first answered 17/04/2024 08:58:36 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4277 label Biography information for Mrs Emma Lewell-Buck

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

1167456

	registered interest
	date	30/10/2019
	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 his Department is taking to ensure that patients play an active role in promoting their own safety.
	tabling member constituency	South West Surrey
	tabling member printed	Mr Jeremy Hunt
	uin	7681
	answer	answer is ministerial correction date of answer 04/11/2019 answer text <p>The NHS Patient Safety Strategy, published in July 2019, sets out plans to create patient safety partners – patients, carers, families and lay people involved at all levels in National Health Service organisations - to improve safety. This work includes empowering patients to become active partners in their own safety.</p><p>The National Patient Safety team is working with patient and public voice representatives and wider NHS stakeholders on a framework for involving Patient Safety Partners. This is expected to be published in 2019/20.</p><p> </p><p> </p><p> </p><p><strong> </strong></p><p><strong> </strong></p> answering member constituency Mid Bedfordshire answering member printed Ms Nadine Dorries question first answered 04/11/2019 16:09:56 answering member 1481 label Biography information for Ms Nadine Dorries
	tabling member	1572 label Biography information for Jeremy Hunt

164370

	registered interest
	date	24/11/2014
	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, what plans he has to increase the use of patient experience surveys in the NHS to inform patient safety initiatives; and if he will make a statement.
	tabling member constituency	Copeland
	tabling member printed	Mr Jamie Reed
	uin	215718
	answer	answer is ministerial correction date of answer 27/11/2014 answer text <p>Patient experience surveys are a valuable source of evidence and the results are used in a range of ways, including the assessment of National Health Service performance as well as in regulatory activities such as registration, monitoring ongoing compliance and reviews. The Care Quality Commission has developed a new Intelligent Monitoring tool to give inspectors a clear picture of the areas of care that need to be followed up within an NHS acute trust or a specialist NHS trust. The system is built on a set of indicators that look at a range of information including patient experience, staff experience and performance.</p><p> </p><p> </p><p> </p><p>In addition to the patient experience surveys hospital boards and other providers and commissioners of services can also consider the results of the Friends and Family Test (FFT) to consider the implications for quality and safety. While not a traditional survey, the FFT provides near real-time feedback to identify both good and poor quality patient experience. A NHS England review of the FFT found that it is performing well as a service improvement tool, with 85% of trusts reporting that it is being used to improve patient experience, and 78% saying that FFT has increased the emphasis placed on patient experience in their trusts.</p><p> </p><p> </p><p> </p> answering member constituency Mid Norfolk answering member printed George Freeman question first answered 27/11/2014 17:09:16 answering member 4020 label Biography information for George Freeman
	tabling member	1503 label Biography information for Mr Jamie Reed

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

177532

	registered interest
	date	03/02/2015
	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 Strategic Executive Information System reports dating from before the Health and Social Care Act 2012 are waiting conclusion.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	223214
	answer	answer is ministerial correction date of answer 10/02/2015 answer text <p>Data and information safeguarding was strengthened under the Health and Social Care Act 2012. When data was extracted on 4 February the Strategic Executive Information System (STEIS) held reports of 1,255 Serious Incidents whose status was not classified as ‘closed’. It is not possible to determine from the database which of these incidents had been resolved locally.</p><p> </p><p> </p><p> </p><p>The principles for responding to Serious Incidents are set out in the current Serious Incident Framework, published in March 2013, and this includes the roles and responsibilities of providers and commissioners including effective governance and learning from a serious incident.</p><p> </p><p> </p><p> </p><p>NHS England is currently refreshing the Serious Incident Framework to take account of supporting all the guidance produced since March 2013 over 2013-14 and to reflect operational feedback on the implementation of the 2013 Framework.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 10/02/2015 18:02:58 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4036 label Biography information for Luciana Berger

225215

	registered interest
	date	04/03/2015
	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 and what proportion of NHS staff have signed up to the five NHS Sign up to Safety pledges.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	226441
	answer	answer is ministerial correction date of answer 09/03/2015 answer text <p>To date 236 organisations from across the National Health Service in England have signed up to the campaign and made their five pledges on behalf of all of their members of staff. This includes 86% of acute, 68% of community and 54% of mental health providers and 50% of ambulance trusts plus a range of other health related organisations at frontline regional and national level<strong>*</strong>.</p><p> </p><p> </p><p> </p><p>Individuals everywhere are also able to sign up to the campaign and make their own pledges online. Currently we have around 250 individuals who have done this so far from a wide variety of organisation types. The campaign has focused in its first year on engaging organisations and in its second year will focus on individual involvement.</p><p> </p><p> </p><p> </p><p>Organisations who have joined the Sign up to Safety community commit to turning their five pledges into a personalised Safety Improvement Plan. These plans are derived from working with their staff on what matters to them and sets out their ambition and focus for the next three years for how their staff will take action to support the NHS shared goal of halving avoidable harm and saving lives.</p><p> </p><p> </p><p> </p><p><strong>*</strong>Percentage figures derive from publicly available numbers from 2013, accessible on the NHS Confederation’s website.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 09/03/2015 15:59:39 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4036 label Biography information for Luciana Berger

227871

	registered interest
	date	17/03/2015
	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 Never events were investigated by NHS England in each year since 2012; how many and what proportion of those events related to mental health patients; what criteria NHS England uses to investigate incidents reported to the Strategic Executive Information System; and what mechanisms exist to ensure that actions and recommendations relating to the investigation of such incidents are implemented locally.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	227903
	answer	answer is ministerial correction date of answer 23/03/2015 answer text <p>NHS England does not investigate individual ‘never events’ since this is the responsibility of the provider of care within which the serious incident occurred.</p><p> </p><p> </p><p> </p><p>Never events are types of Serious Incidents as defined by the Serious Incident Framework (available online at: <a href="http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf" target="_blank">http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf</a>) and must be reported to the Strategic Executive Information System (STEIS) and investigated in accordance with this Framework. There are 25 never events categories defined in the current list within the companion Never Events Policy Framework which is available online at:</p><p> </p><p> </p><p> </p><p><a href="https://www.gov.uk/government/publications/healthcare-never-events-policy-framework-update" target="_blank">https://www.gov.uk/government/publications/healthcare-never-events-policy-framework-update</a></p><p> </p><p> </p><p> </p><p>The number of never events reported is published monthly by category on NHS England’s website:</p><p> </p><p> </p><p> </p><p><a href="http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/" target="_blank">http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/</a></p><p> </p><p> </p><p> </p><p>Although there are two never event categories directly relevant to mental health (13. ‘Suicide using non-collapsible rails’ and 14. ‘Escape of a transferred prisoner’), never event reports are not classified by care setting.</p><p> </p><p> </p><p> </p><p>There were 338 never events reported to the STEIS in financial year 2013/14, one of which involved the escape of a transferred patient from a mental health facility. In 2012/13 290 never events were reported to STEIS, one of which again involved the escape of a transferred patient from a mental health facility. There were no reports in either year associated with the category ‘suicide using a collapsible rail’. Mental health patients may have experienced never events in other categories.</p><p> </p><p> </p><p> </p><p>As described within the Serious Incident Framework, it is the provider of the care, within which the serious incident occurred, that is responsible for reporting, investigating and responding to the serious incident. Commissioners are accountable for quality-assuring the robustness of their providers’ investigations and the development and implementation of effective actions by the provider, to prevent recurrence of similar incidents. Serious incident investigations should be closed by the relevant commissioner when they are satisfied that the investigation report and action plan meet the required standard. Providers and commissioners are expected to establish mechanisms for monitoring on-going or long-term actions to ensure they are fully implemented.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 23/03/2015 17:53:29 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4036 label Biography information for Luciana Berger

227872

	registered interest
	date	17/03/2015
	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 categories of a Never ever event there are which must be reported to the Strategic Executive Information System; and how many and what proportion of those categories are relevant to mental health.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	227904
	answer	answer is ministerial correction date of answer 23/03/2015 answer text <p>There are 25 serious incident categories classified as ‘never events’. All of these incidents must be reported to the Strategic Executive Information System. A never event is a serious, largely preventable patient safety incident that should not occur if the available preventative measures are implemented. Although there are two never event categories which are directly relevant to mental health (<em>13.</em> <em>Suicide using non-collapsible rails</em> and <em>14.</em> <em>Escape of a transferred prisoner</em>) never event reports are not classified by care setting.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 23/03/2015 17:54:24 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4036 label Biography information for Luciana Berger

228872

	registered interest
	date	20/03/2015
	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 face-down physical restraint is included in the list of never ever events that must be reported to the Strategic Executive Information System.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	228605
	answer	answer is ministerial correction date of answer 25/03/2015 answer text <p>Face-down physical restraint is not included in the list of Never Events contained within the Never Events Framework that must be reported to the Strategic Executive Information System.</p><p> </p><p> </p><p> </p><p>Use of face-down restraint is, however, a patient safety incident that should be reported and submitted to the National Reporting and Learning System. Any serious harm resulting from the use of face-down restraint would be reportable to the Strategic Executive Information System as a Serious Incident.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 25/03/2015 12:42:02 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4036 label Biography information for Luciana Berger

446815

	registered interest
	date	21/01/2016
	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, what guidance his Department issues on safeguards in hospitals for patients who are heavily medicated while they eat.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	23650
	answer	answer is ministerial correction date of answer 28/01/2016 answer text <p>It is for health and social care providers to develop local nutrition and hydration policies and there are a number of best practice resources and guidelines available to help providers do this.</p><br /><p>Nursing staff understand the importance of proper nutrition and will follow guidelines in assessing patients for their ability to swallow safely. From this they can make judgements about a patient’s capability to eat and drink safely and adequately, which will include taking into account whether they are heavily medicated or not.</p><br /><p>The National Patient Safety Agency and the Royal College of Nursing published a series of factsheets in 2009, setting out the key characteristics of good nutritional care in healthcare environments.</p><br /><p><a href="http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865" target="_blank">http://www.nrls.npsa.nhs.uk/resources/?entryid45=59865</a></p><br /><p>It includes the Council of Europe 10 key characteristics of good nutritional care in hospitals, which recommends that all patients are screened on admission to identify the patients who are malnourished or at risk of becoming malnourished; all patients are re-screened weekly; and all patients have a care plan which identifies their nutritional care needs and how they are to be met.</p><br /><p>The National Institute for Health and Care Excellence (NICE<em>) Quality standard for nutrition support in adults</em></p><br /><p><a href="http://www.nice.org.uk/Guidance/QS24" target="_blank">www.nice.org.uk/Guidance/QS24</a></p><br /><p>defines clinical best practice for adults in hospital and the community who are at risk of malnutrition. And NICE <em>Nutrition support in adults: Oral nutrition support, enteral tube feeding and parenteral nutrition</em></p><br /><p><a href="http://www.nice.org.uk/guidance/cg32" target="_blank">www.nice.org.uk/guidance/cg32</a></p><br /><p>offers best practice advice to help healthcare professionals correctly identify people in hospital and the community who need nutrition support, and enable them to choose and deliver the most appropriate nutrition support at the most appropriate time.</p><p><br> <br></p> answering member constituency Ipswich answering member printed Ben Gummer question first answered 28/01/2016 16:34:29 answering member 3988 label Biography information for Ben Gummer
	tabling member	4036 label Biography information for Luciana Berger

795959

	registered interest
	date	28/11/2017
	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, what steps he is taking to reduce the number of never events in NHS trusts.
	tabling member constituency	Liverpool, Wavertree
	tabling member printed	Luciana Berger
	uin	116273
	answer	answer is ministerial correction date of answer 01/12/2017 answer text <p>My Rt. hon. Friend the Secretary of State has commissioned the Care Quality Commission to carry out a Thematic Review into Never Events and this work will be supported by NHS Improvement.</p><p> </p><p>The thematic review will examine what can be done to reduce Never Events, and explore what further support and guidance the National Health Service needs to overcome the barriers that prevent the correct implementation of existing guidance. The review will also identify good practice happening throughout the NHS around Never Events and look to embed this throughout the NHS.</p> answering member constituency Ludlow answering member printed Mr Philip Dunne question first answered 01/12/2017 12:44:37 answering member 1542 label Biography information for Philip Dunne
	tabling member	4036 label Biography information for Luciana Berger

421242

	registered interest
	date	14/10/2015
	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	2
	legislature	25277 pref label House of Lords
	question text	To ask Her Majesty’s Government what research is being undertaken to establish the impact of the safeguarding policy for patients on the behaviour of nurses in attending to the needs of patients.
	tabling member printed	Lord Mawson
	uin	HL2613
	answer	answer is ministerial correction date of answer 28/10/2015 answer text <p>No central research has been commissioned to assess the impact of safeguarding policies for patients on the behaviour of nurses in attending to the needs of patients. Research may have been commissioned at a local level; however, this data is not collected centrally.</p><br /><p>The Care Act 2014, which placed adult safeguarding on a statutory footing for the first time, made clear the responsibilities of agencies in relation to adult safeguarding with a greater focus on the prevention of abuse and neglect.</p><br /><p>The Department is clear in statutory guidance supporting the Care Act that workers across a wide range of organisations, and not just those in frontline health and social care roles, need to be vigilant on behalf of those unable to protect themselves.</p><br /><p>Commissioners and providers will have clear policies and procedures that set out the roles of nurses and all other staff in relation to safeguarding and the training and support that is required in order for them to fulfil those roles.</p><br /><p>The Department and NHS England’s Compassion in Practice nursing strategy was published in December 2012 and is based around six core values: Care, Compassion, Competence, Communication, Courage, and Commitment. The vision aims to embed these values, known as the 6C’s, in all nursing, midwifery and care-giving settings throughout the NHS and social care to improve care for patients. A copy of the strategy is attached and can be found at:</p><br /><p><a href="http://www.england.nhs.uk/nursingvision/" target="_blank">http://www.england.nhs.uk/nursingvision/</a></p> answering member printed Lord Prior of Brampton question first answered 28/10/2015 12:21:43 answering member 127 label Biography information for Lord Prior of Brampton attachment 1 file name compassion-in-practice.pdf title Compassion in Practice
	tabling member	3830 label Biography information for Lord Mawson

773000

	registered interest
	date	18/10/2017
	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	2
	legislature	25277 pref label House of Lords
	question text	To ask Her Majesty's Government when they expect to bring forward the Patient Safety Bill announced in the Queen's Speech in June.
	tabling member printed	Lord Hunt of Kings Heath
	uin	HL2201
	answer	answer is ministerial correction date of answer 31/10/2017 answer text <p>Patient safety has been a key priority for this Government and we have made huge strides to ensure patients have access to high quality healthcare.</p><p> </p><p>Following the Queen’s Speech in June, the Government committed to publishing a bill to establish a new independent body to investigate serious patient safety incidents in the National Health Service, with a focus on learning.</p><p> </p><p>The Health Service Safety Investigations Bill was laid in draft in Parliament on 14 September 2017 and will undergo a period of pre-legislative scrutiny. Following pre-legislative scrutiny, introduction of the Bill will depend on parliamentary time being available.</p> answering member printed Lord O'Shaughnessy question first answered 31/10/2017 15:05:55 answering member 4545 label Biography information for Lord O'Shaughnessy
	tabling member	2024 label Biography information for Lord Hunt of Kings Heath

1690168

	registered interest
	date	19/02/2024
	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	2
	legislature	25277 pref label House of Lords
	question text	To ask His Majesty's Government what assessment they have made of the comments by the Royal College of Nursing that the fall in each of the past three years in applications to university nursing courses is a direct threat to patient safety, and what actions they are taking to improve patient safety in England.
	tabling member printed	Lord Allen of Kensington
	uin	HL2513
	answer	answer is ministerial correction date of answer 29/02/2024 answer text <p>The number of applicants continues to outstrip the places on offer. Nursing training places are competitive, and lead to an attractive and important career in the National Health Service.</p><p>Record numbers of nurses are now working in the NHS, and the first ever NHS Long Term Workforce Plan, backed by over £2.4 billion of funding, will add 24,000 more nurse and midwifery training places by 2031.</p><p>Over the last decade, the Government and system partners have delivered major initiatives to advance patient safety in the NHS. This includes implementing the first NHS Patient Safety Strategy, establishing the independent Health Services Safety Investigations Body to address the most serious patient safety incidents, and appointing the first Patient Safety Commissioner to champion the patient voice in relation to the safety of medicines and medical devices.</p> answering member printed Lord Markham question first answered 29/02/2024 16:15:39 answering member 4948 label Biography information for Lord Markham
	tabling member	4304 label Biography information for Lord Allen of Kensington

758760

	registered interest
	date	07/09/2017
	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 never events have occurred involving (a) audiologists, (b) cardiac physiologists, (c) gastro-intestinal physiologists, (d) neurophysiologists, (e) respiratory physiologists and (f) sleep physiologists in the last five years.
	tabling member constituency	Ellesmere Port and Neston
	tabling member printed	Justin Madders
	uin	9435
	answer	answer is ministerial correction date of answer 15/09/2017 answer text <p>This data is not collected centrally. Never events are reported through a tool called the Strategic Executive Information System which does not routinely collect information on the specialty of staff involved in never events.</p> answering member constituency Ludlow answering member printed Mr Philip Dunne question first answered 15/09/2017 12:10:34 answering member 1542 label Biography information for Philip Dunne
	tabling member	4418 label Biography information for Justin Madders

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

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

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

1046792

	registered interest
	date	23/01/2019
	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 incidents recorded in the National Patient Safety Agency's National Reporting and Learning System were classified as never events in each year since 2008.
	tabling member constituency	Leicester South
	tabling member printed	Jonathan Ashworth
	uin	211764
	answer	answer is ministerial correction date of answer 31/01/2019 answer text <p>The following table shows data collected on Never Events from 2010/11, the first year when data was available. Never Events are serious incidents or errors that should never occur if proper safety procedures are followed.</p><p><em> </em></p><p>Never Events Data was collected by the National Reporting and Learning System (NRLS) and the Strategic Executive Information System (StEIS) until 2013. Since April 2013 data has been collected from StEIS only. The data from these two systems are not directly comparable due to differences in the way incidents are identified and reported. The number of events, and definitions of events contained in the Never Event List, are modified regularly, so direct year-on-year comparisons are not appropriate.</p><p> </p><p>The data for 2017/18 is provisional and still to be confirmed in the annual data summary.</p><p> </p><p>Number of Never Events</p><table><tbody><tr><td><p>Year</p></td><td><p>Data Source</p></td><td><p>Total</p></td></tr><tr><td rowspan="2"><p>2010/11</p></td><td><p>NRLS</p></td><td><p>56</p></td></tr><tr><td><p>StEIS</p></td><td><p>166</p></td></tr><tr><td rowspan="2"><p>2011/12</p></td><td><p>NRLS</p></td><td><p>163</p></td></tr><tr><td><p>StEIS</p></td><td><p>326</p></td></tr><tr><td rowspan="2"><p>2012/13</p></td><td><p>NRLS</p></td><td><p>237</p></td></tr><tr><td><p>StEIS</p></td><td><p>329</p></td></tr><tr><td><p>2013/14</p></td><td><p>StEIS</p></td><td><p>338</p></td></tr><tr><td><p>2014/15</p></td><td><p>StEIS</p></td><td><p>306</p></td></tr><tr><td><p>2015/16</p></td><td><p>StEIS</p></td><td><p>345</p></td></tr><tr><td><p>2016/17</p></td><td><p>StEIS</p></td><td><p>445</p></td></tr><tr><td><p>2017/18 (provisional)</p></td><td><p>StEIS</p></td><td><p>393 (April 2017-January 2018) 76 (February-March 2018)*</p></td></tr></tbody></table><p> </p><p>Note:</p><p>*Revised framework and list of Never Events from 1 February 2018</p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 31/01/2019 17:20:06 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	4244 label Biography information for Jonathan Ashworth

1173522

	registered interest
	date	27/01/2020
	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 effect on patient safety of the implementation of the Health and Care (Staffing) (Scotland) Act 2019; and if he will make a statement.
	tabling member constituency	Leicester South
	tabling member printed	Jonathan Ashworth
	uin	8301
	answer	answer is ministerial correction date of answer 04/02/2020 answer text <p>It is a matter for the devolved Government for Scotland to make any assessment of the effects on patient safety of the implementation of their legislation.</p><p>When any such assessment is made available we will review it as we review a range of evidence on the provision of healthcare.</p><p> </p><p> </p><p> </p><p> </p> answering member constituency Mid Bedfordshire answering member printed Ms Nadine Dorries question first answered 04/02/2020 15:25:31 answering member 1481 label Biography information for Ms Nadine Dorries
	tabling member	4244 label Biography information for Jonathan Ashworth

1668521

	registered interest
	date	08/11/2023
	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 accountability mechanisms are included in the NHS England Learn from Patient Safety Events system to hold (a) commissioners and (b) providers to account on patient safety (i) records and (ii) incidences.
	tabling member constituency	Strangford
	tabling member printed	Jim Shannon
	uin	805
	answer	answer is ministerial correction date of answer 15/11/2023 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 would include incidents caused by surgical fires or burns.</p><p>Providers are encouraged to foster a positive safety culture among their staff, and ensure an appropriate local focus on incident recognition, recording, and response.</p><p>Recording onto LFPSE is a voluntary process, except where reporting to NHS England fulfils duties for other statutory mandatory requirements, such as reporting notifiable incidents to the Care Quality Commission (CQC). NHS England shares all such data with the CQC. Notifiable incidents include events resulting in “serious harm” or the death of a service user, and therefore the most serious surgical fires or burns are subject to mandatory reporting. However, providers are encouraged to record all patient safety incidents, irrespective of the level of harm, to support local and national learning.</p><p>Published National Safety Standards for Invasive Procedures include a requirement for a risk assessment and management plan to minimise the risk of surgical fires in the perioperative environment. They require that multidisciplinary team training should involve rehearsal and analysis of typical and emergency scenarios, such as a surgical fire, and that prior to surgery, any fire risk and the management plan are discussed and confirmed.</p><p>LFPSE is not designed for performance management. However, it supports certain oversight functions within providers, including the ability to review all records submitted by staff, and to mark them as either meeting certain other requirements, such as notification to the CQC, or not. This supports good governance within the provider, encouraging scrutiny of recorded events, and the fulfilment of other statutory or national policy reporting requirements. LFPSE data is being made available to integrated care boards and regional teams to facilitate their roles in safety oversight and provider improvement support.</p><p>NHS England does not hold or collect information on the number of surgical fires which occur. Although incidents where serious harm and death are captured within LFPSE, and trusts may choose to record lower levels of harm, there is no category for surgical fires within the existing reporting system with which they could be counted and therefore any count would not be definitive.</p> answering member constituency Lewes answering member printed Maria Caulfield grouped question UIN 804 806 807 808 question first answered 15/11/2023 17:25:08 answering member 4492 label Biography information for Maria Caulfield
	tabling member	4131 label Biography information for Jim Shannon

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

1132763

	registered interest
	date	18/06/2019
	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	What steps he is taking to ensure NHS patient safety.
	tabling member constituency	Stafford
	tabling member printed	Jeremy Lefroy
	uin	911420
	answer	answer is ministerial correction date of answer 18/06/2019 answer text <p>Patient safety remains a key priority for the National Health Service. NHS Improvement and NHS England are developing a new National Patient Safety Strategy that will sit alongside the NHS Long Term Plan.</p><p>The strategy will be published this summer and will build on existing work to provide a coherent framework that the whole NHS can recognise and support</p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 18/06/2019 15:03:47 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	4109 label Biography information for Jeremy Lefroy

1352440

	registered interest
	date	03/09/2021
	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, who is responsible for monitoring the implementation of the (a) national patient safety recommendations and (b) maternity safety recommendations made by the Healthcare Safety Investigation Branch.
	tabling member constituency	South West Surrey
	tabling member printed	Jeremy Hunt
	uin	41766
	answer	answer is ministerial correction date of answer 16/11/2021 answer text <p>Responsibility for monitoring the implementation of the Healthcare Safety Investigation Branch’s (HSIB) national patient safety recommendations rest with the recipient organisations. The National Patient Safety Committee, coordinated by NHS England and NHS Improvement, has established a pilot to examine how the implementation of all the HSIB’s national recommendations could be monitored, the potential resources required and information that may aid future evaluation. The National Patient Safety Committee’s draft report on the pilot is currently undergoing review and is expected to be finalised this year.</p><p>Responsibility for monitoring the implementation of the maternity safety recommendations made by the HSIB rests with individual National Health Service trusts. The HSIB works closely with trusts on addressing emerging themes from the investigations and has quarterly review meetings where trusts provide feedback on the actions being taken to implement the recommendations. The HSIB will raise any immediate concerns to the Department and NHS England and NHS Improvement via governance and assurance meetings.</p> answering member constituency Lewes answering member printed Maria Caulfield grouped question UIN 41767 41768 question first answered 16/11/2021 12:36:30 answering member 4492 label Biography information for Maria Caulfield previous answer version 19499 answering member constituency Mid Bedfordshire answering member printed Ms Nadine Dorries answering member 1481 label Biography information for Ms Nadine Dorries
	tabling member	1572 label Biography information for Jeremy Hunt

1352441

	registered interest
	date	03/09/2021
	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 of the 39 national patient safety recommendations made by the Healthcare Safety Investigation Branch in 2020-21 his Department has assessed as having been implemented in full.
	tabling member constituency	South West Surrey
	tabling member printed	Jeremy Hunt
	uin	41767
	answer	answer is ministerial correction date of answer 16/11/2021 answer text <p>Responsibility for monitoring the implementation of the Healthcare Safety Investigation Branch’s (HSIB) national patient safety recommendations rest with the recipient organisations. The National Patient Safety Committee, coordinated by NHS England and NHS Improvement, has established a pilot to examine how the implementation of all the HSIB’s national recommendations could be monitored, the potential resources required and information that may aid future evaluation. The National Patient Safety Committee’s draft report on the pilot is currently undergoing review and is expected to be finalised this year.</p><p>Responsibility for monitoring the implementation of the maternity safety recommendations made by the HSIB rests with individual National Health Service trusts. The HSIB works closely with trusts on addressing emerging themes from the investigations and has quarterly review meetings where trusts provide feedback on the actions being taken to implement the recommendations. The HSIB will raise any immediate concerns to the Department and NHS England and NHS Improvement via governance and assurance meetings.</p> answering member constituency Lewes answering member printed Maria Caulfield grouped question UIN 41766 41768 question first answered 16/11/2021 12:36:30 answering member 4492 label Biography information for Maria Caulfield previous answer version 19481 answering member constituency Bury St Edmunds answering member printed Jo Churchill answering member 4380
	tabling member	1572 label Biography information for Jeremy Hunt

1131259

	registered interest
	date	11/06/2019
	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 support global patient safety.
	tabling member constituency	North Antrim
	tabling member printed	Ian Paisley
	uin	263152
	answer	answer is ministerial correction date of answer 19/06/2019 answer text <p>Patient safety in the National Health Service is a key priority for the Government. We also remain committed to building on the momentum we have established to address patient safety challenges globally.</p><p>The United Kingdom-led World Health Assembly Resolution, ‘Global Action on Patient Safety’, was adopted on 28 May 2019. It urges all countries to prioritise safety in the delivery of universal health coverage and establishes an annual World Patient Safety Day on 17 September.</p><p>The Government is committed to maintaining its leadership role on global patient safety.</p> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 19/06/2019 16:18:53 answering member 4008 label Biography information for Dame Caroline Dinenage
	tabling member	4129 label Biography information for Ian Paisley

427713

	registered interest
	date	10/11/2015
	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, what steps he is taking to ensure that NHS staff can report patient safety incidents quickly and efficiently.
	tabling member constituency	Halifax
	tabling member printed	Holly Lynch
	uin	15911
	answer	answer is ministerial correction date of answer 18/11/2015 answer text <p>NHS England is responsible for the National Reporting and Learning System which collates information on patient safety incidents reported by staff working in NHS funded care.</p><p>There are plans to develop a new patient safety incident management system and one of the aims will be to make it quicker and easier for staff to report.</p> answering member constituency Ipswich answering member printed Ben Gummer question first answered 18/11/2015 10:39:40 answering member 3988 label Biography information for Ben Gummer
	tabling member	4472 label Biography information for Holly Lynch

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