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926528

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

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

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

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

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

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

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

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

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

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