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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

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

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

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

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

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

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

229164

registered interest
date	23/03/2015
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 assessment he has made of the effect of the abolition of the Patient Safety Agency and the transfer of its responsibility for the National Reporting and Learning System to NHS England on the number of patient safety alerts issued between June 2012 and December 2013.
tabling member constituency	Oldham East and Saddleworth
tabling member printed	Debbie Abrahams
uin	228685
answer	answer is ministerial correction date of answer 26/03/2015 answer text <p>Responsibility for issuing patient safety advice to the healthcare system in the form of patient safety alerts transferred from the National Patient Safety Agency to NHS England in June 2012. Between June 2012 – December 2013 one Patient Safety Alert (NHS/PSA/W/2013/001: ‘Placement devices for nasogastric tube insertion DO NOT replace initial position checks’) was issued on 5 December 2013. To date, all providers have reported this alert as either ‘complete’ or ‘action not required’.</p><p> </p><p> </p><p> </p><p>During the period in question NHS England maintained a constant review of patient safety incidents reported to the National Reporting and Learning System involving death and severe harm and, had an urgent patient safety issue needing alerting been identified, an alert would have been issued.</p><p> </p><p> </p><p> </p> answering member constituency Mid Norfolk answering member printed George Freeman question first answered 26/03/2015 14:20:27 answering member 4020 label Biography information for George Freeman
tabling member	4212 label Biography information for Debbie Abrahams

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

228161

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, with reference to his Department's recent report, Culture change in the NHS, Cm 9009, whether he plans to place responsibility for patient safety alerts within (a) NHS England or (b) an arms-length organisation.
tabling member constituency	Denton and Reddish
tabling member printed	Andrew Gwynne
uin	228119
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 228068 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