Question to the Department of Health and Social Care:

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.

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.

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.

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.