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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

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

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

442684

	registered interest
	date	05/01/2016
	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 steps are being taken to ensure that all NHS trusts are (a) identifying patient safety incidents, (b) conducting full investigations to identify the causes of such incidents and (c) implementing measures to prevent recurring such incidents.
	tabling member constituency	Wolverhampton North East
	tabling member printed	Emma Reynolds
	uin	21014
	answer	answer is ministerial correction date of answer 11/01/2016 answer text <p>Currently, NHS England has a leadership role for patient safety in the National Health Service and supports providers to identify, understand and manage risks that might affect the safety of patients. The primary source for identifying risks is the National Reporting and Learning System (NRLS). The NRLS operates as a database and holds over 1.4 million locally reported patient safety incidents. These are reviewed to help address the identified issues or risks in the NHS. NHS England alerts NHS trusts of emerging patient safety risks via the National Patient Safety Alerting System – a three-stage alerting process which ensures the timely sharing of relevant safety information. The system also encourages information sharing between organisations so that examples of best practice can be widely adopted.</p><p>NHS trusts are expected to review their own patient safety incidents. The revised Serious Incident Framework published in March 2015 has sought to simplify the incident management process and ensure that serious incidents are identified correctly, investigated thoroughly and, most importantly, learned from to prevent the likelihood of similar incidents happening again.</p><p>The NHS standard contract also stipulates that providers must consider and respond to the recommendations arising from any audit, Serious Incident report or Patient Safety Incident report.</p> answering member constituency Ipswich answering member printed Ben Gummer question first answered 11/01/2016 09:46:58 answering member 3988 label Biography information for Ben Gummer
	tabling member	4077 label Biography information for Emma Reynolds

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

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

984845

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