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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

922422

registered interest
date	12/06/2018
answering body	Department of Health and Social Care
answering dept id	17
answering dept short name	Health and Social Care
answering dept sort name	Health and Social Care
hansard heading	Patients: Safety
house id	1
legislature	25259 pref label House of Commons
question text	To ask the Secretary of State for Health and Social Care, how many never events were recorded by NHS trusts in each of the last five years.
tabling member constituency	Ellesmere Port and Neston
tabling member printed	Justin Madders
uin	152793
answer	answer is ministerial correction date of answer 19/06/2018 answer text <p>Never Events are serious incidents that are entirely preventable because guidance or safety recommendations providing strong systemic protective barriers are available at a national level, and should have been implemented by all healthcare providers.</p><p> </p><p>National Health Service providers are encouraged to report all Never Events through the National Reporting and Learning System. The Care Quality Commission views failure to report a Never Event as a breach of a provider’s registration requirement and which may attract sanctions.</p><p> </p><p>Below are the total numbers of Never Events for the last five years which are published online by NHS Improvement and can be accessed at the following link:</p><p> </p><p><a href="https://improvement.nhs.uk/resources/never-events-data/" target="_blank">https://improvement.nhs.uk/resources/never-events-data/</a></p><p> </p><p>The last column contains the total of Never Events reported by NHS trusts.</p><p> </p><table><tbody><tr><td><p>Year</p></td><td><p>Total number of Never Events</p></td><td><p>Total number of Never Events from NHS trusts</p></td></tr><tr><td><p>2013/14</p></td><td><p>338</p></td><td><p>322</p></td></tr><tr><td><p>2014/15</p></td><td><p>306</p></td><td><p>288</p></td></tr><tr><td><p>2015/16</p></td><td><p>442</p></td><td><p>412</p></td></tr><tr><td><p>2016/17</p></td><td><p>445</p></td><td><p>414</p></td></tr><tr><td><p>2017/18 (provisional data subject to change as local investigations take place)</p></td><td><p>469</p></td><td><p>434</p></td></tr></tbody></table> answering member constituency Gosport answering member printed Caroline Dinenage question first answered 19/06/2018 10:18:13 answering member 4008 label Biography information for Dame Caroline Dinenage
tabling member	4418 label Biography information for Justin Madders

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

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

749475

registered interest
date	06/07/2017
answering body	Leader of the House
answering dept id	34
answering dept short name	Leader of the House
answering dept sort name	Leader of the House
hansard heading	Patients: Safety
house id	1
legislature	25259 pref label House of Commons
question text	To ask the Leader of the House, when and in which House the Government plans to introduce the Patient Safety Bill.
tabling member constituency	Kingston upon Hull North
tabling member printed	Diana Johnson
uin	3492
answer	answer is ministerial correction date of answer 11/07/2017 answer text <p>The Government has set out an ambitious programme of 27 bills and drafts bills and noted that additional bills will be announced as the session progresses. The timescales for forthcoming bills and draft bills will be announced in the usual manner in due course.</p><p> </p> answering member constituency South Northamptonshire answering member printed Andrea Leadsom question first answered 11/07/2017 16:11:25 answering member 4117 label Biography information for Andrea Leadsom
tabling member	1533 label Biography information for Dame Diana Johnson

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