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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

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

178543

	registered interest
	date	09/02/2015
	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, with reference to Patient Safety Alert: Improving medication error incident reporting and learning, published by NHS England on 20 March 2014, what progress he has made in developing the National Medication Safety Network; and what channels are available for patient groups to make representations to the National Medication Safety Network.
	tabling member constituency	Newcastle upon Tyne North
	tabling member printed	Catherine McKinnell
	uin	223771
	answer	answer is ministerial correction date of answer 24/02/2015 answer text <p>NHS England, in collaboration with the Medicines and Healthcare products Regulatory Agency (MHRA), has carried out the following activities in relation to developing the National Medication Safety Network:</p><p> </p><p> </p><p> </p><p>- Undertaken nine web events with presentations and recordings posted to the <a href="http://www.patientsafetyfirst.nhs.uk/" target="_blank">www.patientsafetyfirst.nhs.uk</a> web forum accessed by Medication Safety Officers (MSOs). A total of 699 MSOs have participated in these formal web meetings.</p><p> </p><p>- Run a conference for MSOs on 19 January 2015 with keynote speakers from NHS England, MHRA and the National Reporting and Learning System with 150 MSOs in attendance.</p><p> </p><p>- Run dedicated web events for the 18 Community Pharmacy MSOs.</p><p> </p><p>- Are arranging one-day regional meetings on 10 March 2015 (London), 15 July 2015 (Midlands) 12 May (South), 14 October (North) inviting 70-100 MSOs. A key aim of these events is to provide the opportunity for MSOs to feedback in person to NHS England and the MHRA on development of the MSO role.</p><p> </p><p>- We have dedicated (0.4 full-time equivalent) support for development of the MSO role from the Specialist Pharmacy Service. The remit includes monitoring of engagement by MSOs in the network.</p><p> </p><p> </p><p> </p><p>Although the NHS England Medication Safety team have not yet received any formal representations from national patient groups, MSOs have been encouraged to liaise with their local organisation ‘patient and public voice’ leads to help recruit patients onto their medication safety committees.</p><p> </p><p> </p><p> </p><p>Members of the public and patient groups can also make enquiries directly to NHS England.</p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter question first answered 24/02/2015 14:08:53 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	4125 label Biography information for Catherine McKinnell

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

228187

	registered interest
	date	18/03/2015
	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 NHS trusts and foundation trusts have had action taken against them for not implementing guidance from patient safety alerts since May 2010; and what action was taken in each such case.
	tabling member constituency	Denton and Reddish
	tabling member printed	Andrew Gwynne
	uin	228067
	answer	answer is ministerial correction date of answer 23/03/2015 answer text <p>Healthcare providers are expected to implement all the actions contained in a patient safety alert that are relevant to them and ensure that all relevant parts of their organisation and staff are aware of the information and/or the required changes. Providers should be scrutinising the implementation of their alerts and satisfying themselves that the alerts are complete by the designated deadline.</p><p> </p><p> </p><p> </p><p>NHS England publishes monthly data about any trusts who have failed to declare compliance with stage one, two, or three of the National Patient Safety Alerting System’s (NaPSAS) alerts by their set due date. Provider compliance should also be an integral part of the commissioners’ responsibilities for improving quality.</p><p> </p><p> </p><p> </p><p>As part of its inspections, the Care Quality Commission (CQC) looks at how providers respond to patient safety alerts as evidence of how effectively they manage and address safety concerns, and how they use this as learning to improve their safety systems and processes. CQC is continuing to develop and embed its approach to the use of data and intelligence across all the sectors it regulates as an integral part of its new approach to inspections, and has given greater prominence to safety alerts in its revised surveillance model. CQC’s Intelligent Monitoring system for the Acute Sector includes a composite indicator around completion of safety alerts and CQC is currently considering whether this can be implemented for the other sectors it regulates. This contributes to providers’ overall risk scores, which inform both the scheduling and prioritisation of inspections and the identification of focus areas for inspections.</p><p> </p><p> </p><p> </p><p>Monitor is responsible for ensuring NHS foundation trusts are well-led so that they can provide quality care on a sustainable basis and would expect to be alerted by their providers of anything that might have a bearing on compliance with their licence including where there are significant issues regarding compliance with patient safety alerts. The NHS Trust Development Authority (TDA), as part of its oversight and escalation process, uses quality surveillance monitoring which it reviews on a monthly basis and which it uses to hold trusts to account for the timely compliance with alerts. This is undertaken via the TDA’s regular integrated delivery meetings with the trusts.</p><p> </p><p> </p><p> </p><p>The Government has agreed to consider with relevant organisations the options for transferring NHS England’s responsibilities for safety to a single national body and this will include responsibility for patent safety alerts. No decision has yet been taken about the specific functions to be transferred and until such time, NHS England will continue to be responsible for these functions.</p><p> </p><p> </p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter grouped question UIN 228068 228119 question first answered 23/03/2015 17:55:34 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	1506 label Biography information for Andrew Gwynne

228188

	registered interest
	date	18/03/2015
	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, what plans (a) his Department, (b) NHS England and (c) the Care Quality Commission have to ensure that patient safety alert guidance is implemented; and how his Department plans to monitor compliance with that guidance.
	tabling member constituency	Denton and Reddish
	tabling member printed	Andrew Gwynne
	uin	228068
	answer	answer is ministerial correction date of answer 23/03/2015 answer text <p>Healthcare providers are expected to implement all the actions contained in a patient safety alert that are relevant to them and ensure that all relevant parts of their organisation and staff are aware of the information and/or the required changes. Providers should be scrutinising the implementation of their alerts and satisfying themselves that the alerts are complete by the designated deadline.</p><p> </p><p> </p><p> </p><p>NHS England publishes monthly data about any trusts who have failed to declare compliance with stage one, two, or three of the National Patient Safety Alerting System’s (NaPSAS) alerts by their set due date. Provider compliance should also be an integral part of the commissioners’ responsibilities for improving quality.</p><p> </p><p> </p><p> </p><p>As part of its inspections, the Care Quality Commission (CQC) looks at how providers respond to patient safety alerts as evidence of how effectively they manage and address safety concerns, and how they use this as learning to improve their safety systems and processes. CQC is continuing to develop and embed its approach to the use of data and intelligence across all the sectors it regulates as an integral part of its new approach to inspections, and has given greater prominence to safety alerts in its revised surveillance model. CQC’s Intelligent Monitoring system for the Acute Sector includes a composite indicator around completion of safety alerts and CQC is currently considering whether this can be implemented for the other sectors it regulates. This contributes to providers’ overall risk scores, which inform both the scheduling and prioritisation of inspections and the identification of focus areas for inspections.</p><p> </p><p> </p><p> </p><p>Monitor is responsible for ensuring NHS foundation trusts are well-led so that they can provide quality care on a sustainable basis and would expect to be alerted by their providers of anything that might have a bearing on compliance with their licence including where there are significant issues regarding compliance with patient safety alerts. The NHS Trust Development Authority (TDA), as part of its oversight and escalation process, uses quality surveillance monitoring which it reviews on a monthly basis and which it uses to hold trusts to account for the timely compliance with alerts. This is undertaken via the TDA’s regular integrated delivery meetings with the trusts.</p><p> </p><p> </p><p> </p><p>The Government has agreed to consider with relevant organisations the options for transferring NHS England’s responsibilities for safety to a single national body and this will include responsibility for patent safety alerts. No decision has yet been taken about the specific functions to be transferred and until such time, NHS England will continue to be responsible for these functions.</p><p> </p><p> </p><p> </p> answering member constituency Central Suffolk and North Ipswich answering member printed Dr Daniel Poulter grouped question UIN 228067 228119 question first answered 23/03/2015 17:55:34 answering member 3932 label Biography information for Dr Dan Poulter
	tabling member	1506 label Biography information for Andrew Gwynne