Question to the Department of Health and Social Care:

To ask the Secretary of State for Health and Social Care, how her Department records instances of near misses for (a) surgical fires and (b) other patient safety incidences.

Any unexpected or unintended incident which could have or did lead to harm to one or more patients can be recorded on the Learn from Patient Safety Events (LFPSE) service, to support local and national learning. This can include surgical fires or burns. We are informed that NHS England does not define the severity of harm related to surgical fires or burns specifically. Grading the severity of harm related to a patient safety incident that is recorded on LFPSE, should be done using NHS England’s guidance on recording patient safety events and levels of harm, which asks that near miss events be graded as no harm. The guidance is available at the following link:

https://www.england.nhs.uk/long-read/policy-guidance-on-recording-patient-safety-events-and-levels-of-harm/

If a surgical fire or burn is assessed locally and constitutes a patient safety event, it would fall under the scope of the Care Quality Commission’s (CQC) Regulations 16 or 18, and must be reported to the CQC. This means that the most serious surgical fires or burns which result in serious harm or the death of a service user, are subject to mandatory reporting. NHS trusts can comply with this requirement by recording patient safety events using the LFPSE service, and NHS England shares all such data with the CQC, who are responsible for regulating compliance with CQC regulations. CQC Regulations 16 and 18 are available respectively, at the following links:

https://www.cqc.org.uk/guidance-providers/regulations/regulation-16-notification-death-service-user

https://www.cqc.org.uk/guidance-providers/regulations-enforcement/regulation-18-notification-other-incidents

Although the recording of wider patient safety events onto LFPSE is a voluntary process, providers are encouraged to record all patient safety incidents, irrespective of the level of harm, to support local and national learning.

The LFPSE service and its predecessor, the National Reporting and Learning System, do not have specific categories for surgical fires or burns. Determining how many patient safety events related to surgical fires or burns were recorded by National Health Service providers in each of the last five years would require a search of the free text of recorded patient safety events, using key words, and a subsequent expert clinical review of all potential records to determine relevance to the question. This could only be provided at disproportionate cost.