Question to the Department of Health and Social Care:

To ask the Secretary of State for Health, how many Never events were investigated by NHS England in each year since 2012; how many and what proportion of those events related to mental health patients; what criteria NHS England uses to investigate incidents reported to the Strategic Executive Information System; and what mechanisms exist to ensure that actions and recommendations relating to the investigation of such incidents are implemented locally.

NHS England does not investigate individual ‘never events’ since this is the responsibility of the provider of care within which the serious incident occurred.

Never events are types of Serious Incidents as defined by the Serious Incident Framework (available online at: http://www.england.nhs.uk/wp-content/uploads/2013/03/sif-guide.pdf) and must be reported to the Strategic Executive Information System (STEIS) and investigated in accordance with this Framework. There are 25 never events categories defined in the current list within the companion Never Events Policy Framework which is available online at:

https://www.gov.uk/government/publications/healthcare-never-events-policy-framework-update

The number of never events reported is published monthly by category on NHS England’s website:

http://www.england.nhs.uk/ourwork/patientsafety/never-events/ne-data/

Although there are two never event categories directly relevant to mental health (13. ‘Suicide using non-collapsible rails’ and 14. ‘Escape of a transferred prisoner’), never event reports are not classified by care setting.

There were 338 never events reported to the STEIS in financial year 2013/14, one of which involved the escape of a transferred patient from a mental health facility. In 2012/13 290 never events were reported to STEIS, one of which again involved the escape of a transferred patient from a mental health facility. There were no reports in either year associated with the category ‘suicide using a collapsible rail’. Mental health patients may have experienced never events in other categories.

As described within the Serious Incident Framework, it is the provider of the care, within which the serious incident occurred, that is responsible for reporting, investigating and responding to the serious incident. Commissioners are accountable for quality-assuring the robustness of their providers’ investigations and the development and implementation of effective actions by the provider, to prevent recurrence of similar incidents. Serious incident investigations should be closed by the relevant commissioner when they are satisfied that the investigation report and action plan meet the required standard. Providers and commissioners are expected to establish mechanisms for monitoring on-going or long-term actions to ensure they are fully implemented.