Westminster Hall

Thursday 16th December 2021 Westminster Hall

Thursday 16 December 2021

[Christina Rees in the Chair]

backbench business

Thursday 16th December 2021 Westminster Hall

Surgical Fires in the NHS

Thursday 16th December 2021 Westminster Hall

13:30

[Christina Rees (in the Chair)]

I remind Members that they are expected to wear face coverings when not speaking in the debate. That is in line with Government and House of Commons Commission guidance. I also remind Members that they are asked by the House of Commons to have a covid lateral flow test twice a week if coming on to the parliamentary estate. That can be done either at the testing centre on the estate or at home. Please also give each other and members of staff space when seated and when entering and leaving the room.

[Jim Shannon (Strangford) (DUP)]

I beg to move,

That this House has considered the matter of preventing surgical fires in the NHS.

It is a joy to see you in the Chair, Ms Rees, for the third time this week, and to be here myself to make a contribution to the debate. I am pleased that other hon. Members are present: the hon. Member for Coatbridge, Chryston and Bellshill (Steven Bonnar); the shadow Minister, the hon. Member for Ilford North (Wes Streeting); and the Minister. It is no secret that I am very fond of the Minister. She and I have worked together in the House on many health issues, and I very much look forward to her response. This topic is of significant importance, so I am glad to see other Members in the Chamber to make what I am convinced will be significant contributions.

As Members are aware, health has been my portfolio in this House for quite some time—almost 10 years—which means I have been exposed to some of the more challenging issues to face the healthcare system across the United Kingdom. Today’s discussion is about one of those: surgical fires in operating theatres. It is certainly one of the most concerning issues that I have come across in my time in this House. Did I know much about it? I probably did not, but once it was brought to my attention in this place and back home in Northern Ireland, where it is a devolved matter and the responsibility of a Minister in the Assembly, I became aware of it.

I spoke to the Minister present before the debate, and she has some of the questions in my speech from my staff and others. I very much look forward to her response to the questions that I will pose today. First, however, I pay tribute to the work of the expert working group on the prevention of surgical fires, who brought the matter to my attention and whose report on the prevention and management of surgical fires I recommend to the Minister and all Members of the House. It is a thorough and detailed report, which encapsulates the issues that we will discuss in the debate and gives the Minister and her Department the opportunity to respond, I hope in a positive way.

I had the pleasure of chairing the parliamentary launch of the working group’s report in November last year. I am sure that their report and campaign will feed into much of the debate—it certainly will through my comments, and I am pretty sure it will through those of other hon. Members as well.

I want to underline what we mean by surgical fires and the serious dangers they pose to patients and clinicians alike. A surgical fire is a self-descriptive name: it is a fire that occurs during surgery in an operating theatre. In order for a surgical fire to occur, three elements must be present: the ignition source, the fuel and the oxidiser. Ignition sources include electrosurgical units, fibre-optic light sources and lasers. The fuels regularly include alcohol-based skin prepping agents that have been used in excess or applied inappropriately. The oxidiser is simply an oxygen-rich environment in which nitrous oxide is present, alongside the oxygen. Those are the three ingredients, or the three elements that are the reason for surgical fires. I do not believe that it is impossible to address the issue, through the Department and the Minister’s response, so that we can ensure that such fires do not happen.

The statistics, which the people working in the background have gained from across the whole United Kingdom, highlight just how worrying this matter is. The report states:

“Injuries caused by a surgical fire most commonly occur on the head, face, neck and upper chest.”

By and large, that is where operations focus on, and a fire can leave victims with debilitating pain and lifelong physical and psychological scarring—I will later give the example of someone whom I met in this House at a presentation that we did some time ago. A surgical fire can also cause harm to operating theatre staff, who are exposed to similar risks. It can affect not just the patient on the table who is having the operation, but the staff, so there is a dual responsibility for safety—obviously for the patient, but also for the staff.

Like so many members of the public and those of us present for the debate, I had absolutely no idea that surgical fires posed a threat to patients across the United Kingdom, and I was unaware of the extent of the injuries that they can cause, so I am extremely pleased that this subject is being debated, even though we are in the graveyard slot. We are going into recess after today, so most Members have probably left. That is unfortunate, because others had wished to participate but could not stay. The omicron variant has also been part of the problem, and that is perhaps the case for the shadow Minister who was originally going to participate in the debate but could not do so. We are ever mindful that although we may be small in number, the debate is none the less important, and we want to put that on the record.

Today’s debate is about raising awareness about the seriousness of surgical fires and pushing for the next steps to ensure that they no longer happen. Ultimately, that is the goal of the debate—to ensure that precautions are taken so that surgical fires do not happen. What I will outline in my contribution will helpfully enable the Minister and her Department to take the necessary action.

I am sure that many Members will be asking the same question that I did when this issue was first brought to my attention: how common are surgical fires? That is a question that many of us ask. The reality is that nobody knows entirely, but the expert working group sent out a freedom of information request to trusts, health boards and relevant bodies across the United Kingdom. Although there were significant discrepancies across all organisations, the NHS England acute trusts and Welsh health boards stated that they recorded some 96 surgical fires between 2010 and 2018. The report states:

“A search of the National Reporting and Learning System (NRLS) data from between 2004 and 2011 identified just 13 reported surgical fires.”

The important point is that, by comparison,

“NHS Resolution claim to have been notified of 631 clinical negligence claims relating to surgical burns to patients”

between 2009 and 2019. NHS Resolution also claims to have paid out £13.9 million

“in damages and legal costs on behalf of NHS organisations.”

The data that some of the trusts and health boards hold as their evidential base indicate to me that the issue is bigger than many people thought. The fact that some £13.9 million has been paid out in damages and legal costs emphasises that point with a strong evidential base. I am sure that the figure is still a stark underestimate of the scale of the problem, and not all incidents will have been recorded. I suspect the number of claims could be bigger than 631, and that does not even account for all the near-misses that may have occurred in operating theatres across the United Kingdom.

According to a survey by the Association for Perioperative Practice, which is one of the largest membership organisations for operating theatre staff, almost half of its members have personally witnessed a surgical fire—again, an evidential base to prove that this issue is like picking at a scab, because the evidential base and examples are far-reaching and quantitative. There is no question but that there is a clear and obvious discrepancy in how surgical fires are reported, which raises questions about the true number of such incidents.

One of the key questions is what reason is behind the large discrepancy in reporting and why the number of surgical fire incidents that occur each year cannot be accurately quantified. The answer is quite simple: it is not mandatory for trusts to report these events when they take place. I am astounded that that is the case. There is evidence to show that £13.9 million was spent in pay outs for damages and legal costs, and that there were 631 fires. How can it be possible that it is not mandatory to report when someone is set alight during surgery? It is bound to be a fairly dramatic situation. These figures do not even cover the near-misses that must occur on a regular basis.

As the Minister may know, over the past year I have tabled a few parliamentary questions, asking the Government to provide an answer about the number of surgical fires that occur every year, but each time they have been unable to do that. I find it concerning that the Government accept that surgical fires are an issue within the NHS but they still do not know the true scale of the problem. Such is the magnitude and severity of this issue that I would have thought the Government might respond. I say that very respectfully, which is my way of doing things, Ms Rees; when I ask questions, I ask them both to get the answer and to improve the situation. That is probably why I always see the glass as half full, rather half empty. I look to the Minister for a response on that.

The Government are still not monitoring or reporting issues that threaten the safety of patients in the UK. This is also a structural problem that requires proper education and training, and puts in place the necessary protocols to mitigate and reduce the risk as much as possible. One would assume that trusts across the country all have protocols in place to prevent such fires from occurring, but I am sad to report that that is not the case.

According to research by the expert working group, which examined specific protocols and training programmes addressing surgical fires in local NHS trusts, only a limited number of trusts across the UK actually have surgical fire protocols. I think it is vital that they should have them, but many rely on general fire safety guidelines, where there is often no mention of surgical fire risk and prevention processes. Again, I look forward to the Minister’s response about what protocols and safety measures can be put in place.

According to a survey by the Association for Perioperative Practice, over half the respondents reported not having surgical fire protocols to date, while almost two thirds reported that their organisation did not provide training courses or education for operating theatre healthcare professionals on preventing surgical fires. Again, there has to be a clear change of focus among healthcare professionals to ensure that this issue is addressed.

A third of respondents reported receiving training and education, and that training included both high-risk management courses and more generic fire safety training, which was more reactive than preventative. I am a great believer in early diagnosis and preventative measures, rather than reactive measures, so I hope that as a result of this debate we will have measures put in place to address those issues. The training is clearly not adequate for the seriousness of the danger at the moment. The lack of prevention and management protocol is completely unacceptable and represents a clear and present danger to all patients who undergo surgery in the NHS.

It is truly astonishing that surgical fires are already recognised as a safety concern in other countries. I will give examples of those, because if other countries can see the risk, difficulty, impact and severity of this, then I know that our NHS, which we all treasure and love, can deal with the issue equally well, if not better. Yet there is insufficient guidance about how to prevent and manage surgical fires in the UK.

In the United States, the Food and Drug Administration already provides a list of specific recommendations on reducing the incidence of surgical fires. These include conducting a fire risk assessment at the beginning of each surgical procedure, which seems to be logical. Again, maybe the Minister can give us some indication of whether that is a procedure that the NHS will adopt. Those recommendations also include additional safety procedures such as planning and practice on how to manage a surgical fire, including how to use carbon dioxide fire extinguishers. Are those things available in the NHS? They should be, so if not, is there an intention to put them in place? As a result of introducing the necessary protocols, educational tools and reporting systems, the number of surgical fires in the United States has dropped by 71% since 2004. By putting the right strategy and safety measures in place, we reduce the threat. That is my goal today, and that is the approach we should be trying to emulate within the NHS.

The expert working group’s report made a number of recommendations on the prevention and management of surgical fires. I do not intend to read out the entire report—even though I have three hours, I do not want to put people to sleep when they want to go home—but I want to highlight four of its key recommendations. First, professional associations should explore the value of a national awareness campaign for healthcare professionals. Secondly, education on surgical fire prevention should be mandated in the surgical and perioperative education and training syllabus. Thirdly, NHS England should explore how to evolve the procurement process for sanitation products, in order to reduce surgical fire risk and encourage procurement of proven surgical fire-safe technologies. Fourthly, NHS England should explore the development of a standardised patient safety alert system that aligns the processes and outputs of all bodies and teams, and ensure that they set out clear and effective actions for providers to take on safety-critical issues. If I were to ask for nothing else today, I would ask for those four recommendations to be acted on, because that would be a massive step forward.

It is clear to me, as I hope it is clear to other Members, that effective education and training are the primary means of preventing the incidence of surgical fires. Despite some form of fire safety training being mandatory for all NHS staff during their induction and ongoing employment, that training does not address the unique features involved in preventing or extinguishing a surgical fire. The response to different kinds of surgical fires can differ, as can an individual’s role, depending on who is present at the time. I know that the past year and a half—almost two years—have been extremely difficult due to covid, and that the NHS, the Minister and the Government have other priorities, but this is about prevention. It is about making sure that surgical fires do not happen again, and it is logical to try to do so: it would have stopped that £13.9 million from being paid out in damages and legal fees. Meanwhile, preventative measures and effective management strategies require additional education and training, and the absence of such training currently acts as a barrier to eliminating incidents of surgical fire and ensuring an appropriate response.

As I have highlighted, providing detailed guidance and encouraging the individuals who constitute the perioperative team to consider their role in surgical fire prevention has led to a statistically significant decline in the incidence of such fires in the United States. Their incidence has fallen by 71%—wow! I did not do the mathematics, but if we brought that 631 down by 71%, it would be approximately three quarters of that number. It is clear to me that surgical fire training should be made mandatory across the NHS and the private sector, and should be updated at least every two years. Again, I refer to those four asks: we need to make sure that those matters are taken on board, so that we have a proper system in place for the future as well.

Despite education being an essential method of preventing surgical fires, it is no use if it is not mandated, and if we still fail to tackle the institutional failure to truly record the scale of the problem. Following discussions with the expert working group and others, I call on the Minister to instruct the Centre for Perioperative Care to investigate the possibility of making surgical fires a never event, meaning that they never happen again. We would like to see surgical fires made a never event as part of the CPC’s work on redeveloping the national safety standards for invasive procedures to ensure they remain fit for purpose.

Classifying surgical fires as a never event would require mandatory reporting of incidents or near misses, while also mandating essential education for surgeons and other perioperative staff across all NHS trusts. Even without knowing the details of surgical fires, the name itself suggests they should be a never event. The concept of a surgical fire is terrifying enough that if we asked a lay person whether it should be classified as a never event, they would likely agree that it should never happen—indeed, they would probably be astounded that it even did. Only by classifying surgical fires as a never event can the national safety standards continue to be fit for purpose.

I have been paying keen attention to some of the Government’s responses to my questions about surgical fires over the past year. I realise that the Government have previously stated that they have no plans to classify surgical fires as a never event. Again, I urge the Minister, in the light of the evidential base we now have, to do just that. I note in the latest response to me that the Minister says that it is not possible to make surgical fires a never event because

“there is currently no national guidance or safety recommendations to prevent surgical fires in operating theatres”.

I say respectfully that we need to do that. If we can do that, we can move forward.

I have good news for the Minister—I always try to bring good news, and not just because it is Christmas. The expert working group has already developed national guidelines. Its report made safety recommendations for perioperative staff, and the group is waiting for them to be adopted. What the expert working group has done could be a template for exactly what the NHS needs to do. It has informed me that it is more than willing to pass on its hard work directly to Government. If the Minister is agreeable, I would be happy to have a meeting to exchange those views, and those papers as well, with the Centre for Perioperative Care expediting the process. I believe there is now no reason not to classify surgical fires as a never event.

We should not forget the most important impact of surgical fires: the human impact. As I mentioned earlier, I had the pleasure of chairing the launch of the report last year. During the event, I also had the pleasure and the privilege of listening to a patient who had experienced a surgical fire. He explained to us the impact that the incident had on his life. What happened to this gentleman is quite tragic. I will quote his story, but I will not name him, and I will be careful what I say in relation to him.

He told the group that he had visited the hospital for a routine procedure, but that when he woke up the staff informed him that his body had been set alight during surgery. He told us how he had been burnt on the left side of his chest and upper arm, and of the impact that this trauma had on him. He was not aware of the fire because he was under anaesthetic having an operation. He went on to explain how it had prevented him from continuing his career in social care, which he had been in since the age of 16, because he was disabled as a result of the incident. He explained how it had left him physically and psychologically drained, and how it had left him in pain, unable to carry out simple household tasks such as making a cup of tea—he did not have the stretch or lift in his arm any more. He told us of the impact that the fire had on his family. His partner became his carer and he could no longer spend time with his granddaughter. Having five grandchildren—three girls and two boys—I know how much I enjoy spending time with my grandchildren.

That is a jarring story—one that is all the more shocking and disturbing the more details that are revealed. I am not going to name him because there are legal discussions going on with the trusts involved and because he has nothing but praise for the nurses who have cared for him since the incident. He understands that nobody set out for it to happen, but it happened, and it happened because the precautions were not in place, because there was no safety measures and no training. The so-called never event happened.

He is a very kind man—a gentleman. However, no matter how good the nurses have been to him, it would be remiss of me not to mention how inadequately his situation was addressed. To cause severe harm to a patient is beyond the pale; it is against every medical principle that exists. The NHS and all its staff are tasked with saving life, and that is what they do to the best of their ability. We must not forget the impact on the operating theatre staff, who may also experience a psychological cost from these experiences. It is equally essential that surgeons learn how to give both physical and emotional support to the victims of surgical fires. They are the ones who have suffered most, and surgeons must be empathetic to them and their needs.

What is also concerning is that, despite this serious incident taking place, the hospital appears not to have made the appropriate changes to its systems and protocols. We all learn lessons—every day of my life, I learn lessons; I am not so proud that I do not learn from all those around me and those who I speak to. The patient required follow-up treatment in the same hospital and, on inquiring what had been done to prevent the incident from happening again, was told that nothing had changed; there had been no updates. How disappointing.

As I mentioned, I cannot name the patient, but I pay tribute to his bravery and his determination to prevent this from happening to another person. That is one of the reasons why he told us his story. He wanted to provide us with the evidential basis for what had taken place and to ensure that it did not happen to somebody else. He is truly an admirable person. I thank both him and his partner for sharing their story with me and, ultimately, with everyone in the House and Westminster Hall and with the Minister and her Department.

I am coming to the end of my speech, Ms Rees. I will begin summing up, so that we can also hear from others. I look forward to hearing some thoughtful and insightful contributions from the shadow Ministers and, specifically, the Minister. As I have stated, I hope this debate will bring greater attention to the issue of surgical fires and shine a spotlight on this danger. It is clear to me, from reading the expert working group’s report and patients’ testimonies and from listening to expert guidance, that more needs to be done to prevent surgical fires. That is why I am so pleased to play my part in today’s debate in support the aims of the expert working group.

I hope that in the short time—it feels like a long time perhaps, Ms Rees—that we have been making the case today that it is clear that we are supporting the aims of the expert working group. There needs to be mandatory reporting of both surgical fires and near misses, because until we can effectively quantify the scale of the problem, we cannot effectively address it. Similarly, we need to introduce effective and mandatory education for all surgeons and perioperative practitioners in order to prevent surgical fires from occurring and to ensure that they are effectively managed when they do occur. This can also be done by classifying surgical fires as a never event. NHS operating staff are already aware of the threat of surgical fires, but they have not received the proper support and guidance to ensure that these incidents are prevented.

I therefore hope that our actions today will start the necessary change. Whether we are talking about simple steps such as introducing a checklist to ensure the taking of appropriate preventive measures, such as using the correct antiseptic skin solution, or ensuring the presence of the appropriate tools and equipment for the management of fires, which we should have as a precautionary measure in all operating theatres, these are all necessary steps to ensure the safety of patients and operating theatre staff alike. This is about the patient; it is about the staff; it is about getting it right. If we do not, we will have to confront the reality that many more people will be harmed by our failure to act. Classifying surgical fires as a never event is, I believe, the only way to effectively prevent patients and NHS staff from coming to harm.

I thank hon. Members for attending the debate and ask them to consider the reaction of their constituents if they were asked about surgical fires. If a Member here were asked about this matter, what would he or she want done in relation to it? They would surely all agree that such fires should never be allowed to happen. Making them a never event is the common-sense option, and I hope that others will join me in urging that that rational action be taken on this issue.

The people to whom I have referred, including the gentleman who made his own personal submission, are real human beings. They are people who have gone through operations and been confronted with the reality of this issue. We know about 631 of them in the United Kingdom, and we believe there are more. Addressing this issue would put an end to the need for the £13.9 million of damages and legal charges. We live in an age in which we must also be careful with the money we spend. If we are not, things may happen that cost the NHS money. People have been affected by this issue, and people will continue to be at risk until we act. I therefore invite the Minister and other hon. Members to join me in what I believe is a very worthwhile campaign to make surgical fires a thing of the past—as I said before, a never event.

13:59

[Steven Bonnar (Coatbridge, Chryston and Bellshill) (SNP)]

It is a pleasure to serve under your chairmanship, Ms Rees. I congratulate the hon. Member for Strangford (Jim Shannon) on securing this debate on such an important matter. Surgical fires are rarely ever spoken about across the UK, but they are a more common occurrence than is perhaps first considered. When these tragic events do occur, they are very serious and can cause injury to both the patient and our healthcare professionals. Most surgical fires occur in, on or around a patient undergoing a medical or surgical procedure, with the most common injuries being on the head, face, neck and upper chest. The majority of the fires are caused either by a skin preparation solution not being given enough time to dry or because swabs soaked with the fluid were left in the operating field within an unsafe distance of an ignition source.

The sources can include drapes, towels, endotracheal tubes and swabs, and alcohol preparation solutions that have not been allowed to dry fully and as a consequence have pooled on or under a patient. Electrosurgical units, lasers and fibre-optic light sources are all well-described ignition sources for surgical fires, which have a devastating effect on patients physically and mentally. There are numerous personal accounts of patients who have been harmed due to those types of fires, and in nearly all cases they were wholly avoidable.

More recently, in one case a patient undergoing surgery for pancreatic cancer caught fire and suffered 40% burns and died a week later in hospital as a result of those injuries. It is even more vital that we have the protective measures in place to prevent these avoidable incidents from ever happening again.

Between 2010 and 2018 there were a total of 96 recorded surgical fires, as the hon. Member for Strangford pointed out. Those were declared by NHS England acute trusts and Wales health boards. The figures are similar in Scotland, from what I have been able to ascertain.

When doing my research for this debate, I spoke to a few of my constituents who work in the surgical field, based at the fantastic University Hospital Monklands, which cares for so many of my constituents. I am going to take this opportunity—I am sure Members would like to join me—to place on record my eternal gratitude to all those based at Monklands and across NHS Lanarkshire, as well as across all the nations of the UK, for the incredible work that they do all year round. We wish them all a safe and peaceful Christmastime. I spoke to my surgical constituents to get a real feeling of the impacts of such events, but also of any prolonged or psychological effects of such incidents on staff and patients. The information I received from my surgical constituents was illuminating and very concerning.

Recent research conducted by the National Reporting and Learning System found that from January 2012 to December 2018, 37 reported surgical fires were identified, in which 52% of patients suffered some degree of harm and 8% were recorded as receiving severe harm. Those statistics are of course alarming for us all. However, the data does not show the full scale of incidents that occurred from surgical fires because of the discrepancies between data held at national and local levels. That raises a question about the true number of incidents across the health boards. Is it greater than what has already been suggested? Is there even more cause for concern than we already believe? We need to explore that to get the answers to those questions.

We need a standardised approach to conduct a clear and effective reporting of incidents and decide on the correct steps to mitigate the risk of further surgical fires. It might surprise right hon. and hon. Members that the last time the term “surgical fires” was even uttered was almost seven years ago in 2015 by NHS England’s surgical services patient safety expert group—that is a mouthful—and yet nothing ever came of its work.

Three years later in May 2019, a short life working group for the prevention of surgical fires was established by a group of experts from healthcare organisations and bodies across the UK. The group aims to compile a series of recommendations and guidance that would make the case for surgical fires being ruled out and made the never event that the hon. Member for Strangford wishes to see. I join him in recommending to the Minister that it is crucial for theatre staff to have the training and for professional associations to explore the value of a national awareness campaign for healthcare professionals. We should mandate the inclusion of surgical fire prevention in the surgical and perioperative education and training syllabus.

NHS bodies should explore how to evolve the procurement process of sanitising products, to reduce surgical fire risk and encourage the procurement of proven surgical fire-safe technologies. I call upon all boards across the UK to explore the development of the standardised patient safety alerts system that aligns the processes and outputs of all bodies and teams. It is vital that such recommendations are implemented, especially given the expertise of those who have provided such information.

The prevention of surgical fires is an urgent and serious patient safety issue in all UK hospitals. It is also very costly, as research has found that nearly £14 million has been paid out in damages and legal costs on behalf of NHS organisations across the UK for such fires. It is essential that we understand when these incidents happen and fully examine whether we should successfully implement changes that prevent their future occurrence. It would be helpful if the NHS published an update on its progress on this matter, so that we can better understand the urgency of the action that is being taken.

Surgical fires are recognised as an international patient safety concern, so for all patients across the UK it is vital that we seek to mitigate their potential impacts as soon as possible. Sadly, it is not always possible to prevent patient safety incidents from happening, but preventive actions can and should be taken to prevent further harm to our patients in the near future.

14:05

[Wes Streeting (Ilford North) (Lab)]

It is a pleasure to see you in the Chair, Ms Rees. I apologise on behalf of the shadow Minister for patient safety, my hon. Friend the Member for Nottingham North (Alex Norris), who is isolating, so I am afraid that you are stuck with me, the shadow Secretary of State for Health, which at least gives me the opportunity early on to place on the record my commitment to patient safety.

I congratulate the hon. Member for Strangford (Jim Shannon) on securing this important debate and on underlining—in terms of the policy detail and what the data tells us or does not tell us, as well as in very stark human terms—why this issue is so significant. As he said, I have no doubt that there would have been more hon. Members present for this debate if it were not for the omicron risk and the fact that this is the final afternoon before the House adjourns for Christmas.

Surgical fires are a serious patient safety issue. In the contributions we have heard today—from the hon. Member for Strangford and the spokesperson for the Scottish National party, the hon. Member for Coatbridge, Chryston and Bellshill (Steven Bonnar)—the case for further action to prevent these incidents is clear.

Although rare, surgical fires can cause serious harm to both patients and healthcare professionals, and, as we have heard, in some cases they tragically result in life-changing injuries. The Department for Health and Social Care has declared that it does not know how many surgical fires happen across the NHS, because it does not collect such data centrally, but we know that they happen. In the period between 2010 and 2018, there were a total of 96 recorded surgical fire incidents declared by NHS England acute trusts and Welsh health boards. A search of the NHS’s National Reporting and Learning System for the period between January 2012 and December 2018 identified 37 reports of surgical fires. There is a discrepancy between those two figures. In my opinion, even one preventable incident of surgical fire in the NHS is one too many.

Although surgical fires are preventable, the absence of national guidelines has resulted in an inconsistent approach within UK hospitals to their prevention, with fewer than 40% of healthcare organisations in England having specific protocols and training programmes in place to address the prevention and management of surgical fires. Among healthcare organisations across the UK, 50% of healthcare organisations in Northern Ireland have specific surgical fire prevention guidelines, compared with 38% in England, 20% in Wales and 10% in Scotland, and only a limited number of trusts across the UK—23—have protocols and training programmes that specifically address surgical fires.

We know that these incidents occur as a result of particular circumstances, yet the majority of local trusts rely on general fire safety guidelines, in which there is often no mention of surgical fire risks and prevention processes for them.

The hon. Members who have spoken in this debate have discussed the findings of the expert working group’s report, which was published last year, so there is no need for me to go over the report’s recommendations; we have already heard them. However, it would be good to hear from the Minister this afternoon as to whether she has had the chance to consider those recommendations and understands where the Department intends to go in taking action to respond to them.

As the hon. Member for Strangford said in his opening speech, the report also supported surgical fires becoming classified as a never event. The NHS in England defines never events as

“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.”

Patient groups have argued that surgical fires should be classified as never events. They argue that if they were classified in this way, they could be monitored and investigated as such. Staff would also be empowered to manage incidents in the appropriate way.

However, the Government have recently said that they have no plans to revise the NHS never events policy and framework to classify surgical fires in operating theatres as never events. As the hon. Member for Strangford pointed out, the reason for that is that we currently have no national guidance or safety recommendations to prevent surgical fires in operating theatres. I endorse what he said. I think that the way to address that is to ensure that we have national guidance and safety recommendations and then to update the NHS never events policy. It would be good to hear from the Minister what progress, if any, has been made in developing that guidance and, if the Government intend to act in that way, when it might be published.

I would also like briefly to address some wider issues related to patient safety that are relevant to the debate. Unfortunately, in the last financial year prior to the pandemic 472 serious patient safety issues were classified as never events across the NHS in England. Clearly, that figure demonstrates that there is work to be done across the NHS to ensure everyone gets the best care and that improvements still need to be made. In striving for that, we of course need to listen carefully to the experiences of the patients affected and to ensure that staff feel safe to come forward during patient safety investigations and that processes are transparent, so that lessons can be learned.

We also need to do more to ensure that the environments in which care is delivered are safe. Currently, there is a £9.2 billion repair backlog across the NHS estate. That means that broken pipes and crumbling buildings are putting patients at risk. In the past financial year there were more than 1,600 serious patient safety incidents with an estates and facilities cause.

Although I am responding on behalf of the Opposition, I am sure the House and the Minister will indulge in me making a parochial constituency point. Whipps Cross hospital is in urgent need of redevelopment and refurbishment, and I think that is very much on the Government’s radar—I am led to believe that Whipps Cross is near the top of the list. The Minister may not be able to reply on Whipps Cross this afternoon—I appreciate that it is probably without the scope of what she was expecting to talk about—but the issue is none the less on the record for the Department to consider, and we will be very persistent about it on a cross-party basis locally.

Chronic workforce shortages across our health and care services are also putting patients at risk. We went into the pandemic with 100,000 vacancies across the NHS, including a shortage of 40,000 nurses. I am struck whenever I speak to staff working in the NHS, including the shadow Minister for mental health, my hon. Friend the Member for Tooting (Dr Allin-Khan), who has enormous experience in this respect, that too often staff are coming home from work worried about staffing shortages, patient safety and whether they have been able to deliver the best care. That is really important for patient safety and the confidence of staff working in challenging environments. In June, a report by the Health and Social Care Committee warned that staff burnout caused by workforce shortages was at an emergency level and posed

“an extraordinarily dangerous risk to the future functioning of”

healthcare services.

Last month, NHS leaders warned that pressures on the system were likely to have an impact on patient safety, and a survey revealed that nine out of 10 felt that staffing pressures were putting patients’ health at risk. It is clear that the NHS is now in desperate need of a serious plan to provide the modern, safe facilities and equipment that patients deserve, alongside a long-term strategy to recruit and retain the staff to deliver safe, quality care. The safety of patients must be the golden thread running through every aspect of healthcare delivery, and I want our healthcare system to be the safest in the world. I hope that the Minister will consider the points raised in the debate carefully and assure the Members present that the prevention of patient safety incidents, including surgical fires, is of paramount importance to her Department.

Since this is the last day before we rise for the recess, and in the light of the wider challenges facing the country, I wish you, Ms Rees, and all hon. Members and staff throughout both Houses of Parliament a very merry Christmas. I say a special thank you to Ministers and staff at the Department of Health and Social Care, the agencies for which they are responsible, the entire workforce across health and social care, the armed forces and the emergency services for all that they are doing to get our country through the pandemic, to respond to the challenges of the omicron variant and to get Britain boosted. I ought to wrap up, because I am due to get my booster later this afternoon, and I do not wish to miss my appointment. I look forward to hearing what the Minister says, and I wish her and all her civil servants and colleagues in the Department of Health and Social Care a very merry Christmas and a happy new year.

[Christina Rees (in the Chair)]

I echo everything the hon. Gentleman said in wishing everyone a merry Christmas and thanking them for everything they do.

14:14

[The Parliamentary Under-Secretary of State for Health and Social Care (Maria Caulfield)]

It is a pleasure to serve under your chairmanship, Ms Rees. I thank the hon. Member for Strangford (Jim Shannon) for securing this hugely important debate. While he is right that we may be small in number this afternoon, it is the quality not the quantity of the Members that counts.

Health is a devolved matter, so I can really only respond on behalf of the NHS in England to the issues the hon. Gentleman raised, but, as the SNP spokesman, the hon. Member for Coatbridge, Chryston and Bellshill (Steven Bonnar), said, surgical fires are a priority area of concern in all the devolved nations. Patient safety is our absolute focus. We want to provide the public with the safest care possible. As the hon. Member for Strangford said, a fire affects not only patients but the NHS staff working in those units. We traditionally think of surgical fires as taking place in hospital-based settings such as theatres, but more and more minor surgery is taking place in community facilities such as primary care facilities. This issue is expanding to other areas of the NHS, so it is important that lessons learned in hospital trusts are learned in the community as well.

Supporting a culture of safety in the NHS is critical, and we have put in place a number of measures aimed at supporting the NHS. The key is learning from incidents. Where there have been surgical fires in the past, it is important to identify their causes and how they could be prevented in the future. It is also important to hear from staff, who will sometimes not be surprised when an incident occurs or who may have flagged issues a number of times before attention is taken.

We are taking a number of initiatives to improve patient safety across the board. The first is establishing the health safety investigation branch, which conducts independent reviews and investigations into any patient safety concerns, including surgical fires. We are also introducing a statutory duty of candour to ensure that NHS organisations are open and honest towards patients. If a surgical fire happens, as in the hon. Gentleman’s tragic example, a patient who may have been asleep at the time should be made aware of that and receive an apology and support afterwards. Sometimes the fires are quite minor and the patient is not affected, but it is important that they know that an incident happened. We are also setting out in legislation the first ever patient safety commissioner, which will be for England only. They will be a champion for patients in relation to medicines and medical devices and will certainly look at the issue of surgical fires.

Regrettably, despite some of the progress and some of the measures we are putting in place, and despite the high quality of care provided by NHS staff, incidents happen that cause harm to patients and put staff at risk. If a surgical fire is extensive enough to take a theatre out of service for a time, that has a knock-on effect for other patients on surgical waiting lists, who may be delayed as a result. Minimising the risk of surgical fires is an area we take very seriously, and although rare, when they do occur in or around the operating table, they can cause extensive damage and put patients and staff at risk.

The issue is how to best minimise the risk of fires in the first place. As has been pointed out, work is going on into this area. NHS England’s national patient safety team has been involved with the expert working group on the prevention of surgical fires, which the hon. Gentleman referred to and which is chaired by the chief executive of the Association for Perioperative Practice. We will continue to support the development of its guidance. I am happy to meet the hon. Gentleman to follow this up, because as highlighted by the shadow Minister the working group published a report in September last year on the prevention and management of fires and made a number of recommendations. It is the view of the national patient safety team that further work on surgical fire prevention following the report is best developed alongside the wider national safety standards for invasive procedures. Those standards were created to support all aspects of patient safety in the surgical environment and are currently being led by the Centre for Perioperative Care, which is responsible for ensuring that national safety standards for invasive procedures continue to be fit for purpose.

[Jim Shannon]

I am very encouraged by the Minister’s response. I referred to four key recommendations, which she referred to. She also referred to the fact that there are ongoing negotiations and discussions with the expert group. Has there been an opportunity to push for those four key recommendations as part of the change that is needed?

[Maria Caulfield]

That is certainly an area that we can discuss further when we meet. I am very happy to do that. The hon. Gentleman is right that experts in this field are best placed to consider whether we have the right standards in place. Work is ongoing to ensure that the standards in place are the correct approach to minimise the risk of surgical fires happening in the first place and to advise the NHS on the issue.

The hon. Member for Strangford talked about the fire triangle of ignition, heat and oxygen. There are potential risk factors in all three of those areas that can make a fire more likely. As I said at the beginning of my remarks, we are working on learning lessons about where fires have happened, to make sure that we learn from those experiences.

In terms of the data, I am obviously concerned that there is no central record of how many surgical fires are taking place, but a new learn from patient safety events service is coming in next year and will better record patient safety events, improve data collection and help NHS trusts to collect the data, use it and learn from it. Although that is not specific to surgical fires, I am keen that fires in general, including surgical fires, are reduced as much as possible and that we learn from these events when they happen.

I am also keen that staff training is a priority. There is a legal duty on NHS trusts to ensure that their staff are trained in fire safety when first employed but also on an ongoing basis. Very often, particularly in theatre, new equipment comes in. The hon. Member for Coatbridge, Chryston and Bellshill (Steven Bonnar) talked about lasers and diathermy equipment. As those machines and that equipment are introduced and upgraded, it is important that staff are trained properly and are able to flag faults with the equipment and ensure that action is taken quickly, for a whole host of reasons. A theatre is a very risky place not just in terms of fire but for a number of reasons.

All colleagues touched on never events. By its very nature, a never event is something that should never happen, but there are not many classified never events if we look on the list. In theatre, there is a never event on swabs used in theatre procedures. We have very clear guidance and procedures in place when swabs are used—they are counted in and counted out to absolutely make sure that nothing is left behind after an operation. That is key.

Surgical fires are not a never event at the moment because there are no clear guidelines that staff can follow that can absolutely rule out any particular fire from happening. That is the crux of the matter. Fires should absolutely be preventable and we should learn the lessons when a surgical fire takes place, but we do not have the guidelines to be able to say to staff what has to be followed to absolutely prevent a fire from happening in the first place. When I meet the hon. Member for Strangford, we need to look at the guidelines and make sure they are coming forward. I have been informed by NHS England that it cannot classify surgical fires as a never event at the moment, until the national guidance or safety recommendations are in place. It has also confirmed that it always reviews any new guidance when it is published. That is the nub of the issue.

The shadow Minister touched on the Whipps Cross hospital renovation. Sadly, that is not in my portfolio, but it does come in the portfolio of the Minister for Health, the hon. Member for Charnwood (Edward Argar), so I will speak to him to try to get an update on progress.

In conclusion, I want to reassure the House that patient safety remains a top priority for the Government. The risk of surgical fire is a real issue, and surgical fires do put patients and staff at risk. The issue is taken very seriously by the Department, and work continues in this field to ensure that the correct guidance is there to minimise the risk of surgical fires occurring in the first place. I look forward to, hopefully, sharing some progress with Members in the new year.

I thank all Members and staff for their hard work this year. It has been a very tough year for everyone, so hopefully everyone will get to enjoy their Christmas. Like the shadow Minister, I also thank all the staff at the Department of Health and Social Care and across the NHS, who may be having a very tough Christmas this year, and I place on record our thanks and gratitude to them—their hard work has not gone unnoticed. With that, I thank everyone, and especially the hon. Member for Strangford for securing the debate.

[Christina Rees (in the Chair)]

Thank you for your remarks, Minister—they are much appreciated.

00:02

[Jim Shannon]

I thank the hon. Member for Coatbridge, Chryston and Bellshill (Steven Bonnar) for his contribution. He developed the debate in the way we hoped he would, referring to the strong evidential base, the urgent need and the update on progress, as well as patient safety and preventive action.

I am pleased to see the shadow Minister, the hon. Member for Ilford North (Wes Streeting), in his place. I wish him well in his new role—I should have done that at the beginning, and I apologise for not doing it. Being the true MP that he is, he took the opportunity to make a mark for his constituency, as we all would, by the way—none of us misses that opportunity. I thank him for a very constructive contribution, in which he referred to the training that is needed now, the national guidelines and the never event. Incidents can be prevented—I think that is the thrust of the debate. I thank him for that and wish him well for the future in his new role.

I want to say a big thank you to the Minister, who clearly responded on the key issues. The first one, which is important in relation to the example I gave, was that if we get it wrong, we apologise and we change the system. That is a key issue. It is never hard to do, but sometimes difficulties seem to arise. I thank her for her comments on that. She also referred to the four key recommendations and the data to be collated. I thank her for agreeing to a meeting—we will do that.

On staff training, this is not just about patient safety; it is about the staff as well. On the never event, I think that that will be really important when the expert working group meets the Minister and her officials. For patients and staff, work continues to progress, and I very much thank the Minister for her constructive response to all three of us here today.

I take this opportunity to wish a merry Christmas and a happy new year to you, Ms Rees, to my colleagues the hon. Members for Coatbridge, Chryston and Bellshill and for Ilford North, and especially to the Minister and her Department. The Minister and I have worked together on many things, and we will work on many more if God spares us to the new year. Her Department, her Parliamentary Private Secretary—the hon. Member for Grantham and Stamford (Gareth Davies)—and all the officials certainly make our jobs easier. We could not do this job without them.

I am a very simple person when it comes to these things. I wish to make progress and to do that alongside people. I never want to score a point—that is not my form. I think that we have made progress today and that we will make progress on other things in the new year, which I am looking forward to. Once again, I wish a merry Christmas and a happy new year to all of you and your families. I hope that we will see each other here on 5 January 2022.

[Christina Rees (in the Chair)]

I thank the hon. Gentleman for his good wishes. I wish you all a merry Christmas too.

Question put and agreed to.

Resolved,

That this House has considered the matter of preventing surgical fires in the NHS.

14:30

Sitting adjourned.