Reporting and learning from safety incidents

Over the past year we have seen developments relating to: 

• NHS England’s Learning from Patient Safety Events programme 
• A consultation on Never Events 
• PHIN’s publication of adverse events for private patients 

Learning from Patient Safety Events (LFPSE) and Never Events

We welcome ongoing engagement with LFPSE as it moves towards full implementation following the decommissioning of the National Reporting and Learning System (NRLS) in the summer of June 2024. Over the course of the past year more independent providers have begun reporting to LFPSE and we look forward to continued uptake over the next 12 months. As well as those organisations that have connected to LFPSE this year, we have seen several more review their risk management systems and internal processes as part of their journey towards future reporting.

We note that NHSE has plans to begin publishing LFPSE data over for next year, and we look forward to the increased transparency that this will bring in relation to the reporting and learning from safety incidents across the sector. We expect that initially there will be considerable variation in the level of reporting from both NHS and independent sector providers, especially as new metrics will be available for the first time such as the range of harm and the psychological impact of safety incidents. This variation is to be expected, but as more providers report and common definitions are established, we would anticipate more consistency in approach across all organisations reporting to LFPSE.

While reporting to LFPSE is not mandatory for independent organisations in the same way that it is for NHS providers, IHPN’s long-standing position is that we encourage all providers to report to LFPSE.

Never events

NHS England’s consultation on Never Events took place during the first half of 2024. It looked at whether the framework should be reviewed to strengthen barriers to Never Events, following reports from the Care Quality Commission and the Health Services Safety Investigations Body.

Although the number of Never Events among independent providers relating to the treatment of NHS patients is small4 we welcome measures to reduce Never Events to zero across all provider types, so await the conclusions of the consultation with interest.

PHIN adverse event data

We now have several years of data published by the Private Healthcare Information Network (PHIN) about adverse events for privately-funded patients treated both by independent providers and NHS private patient units (PPUs).

Information is available since 2020, and we are pleased to note that levels of data completeness have risen considerably over that time. The latest tranche of data that was published in December 2024 shows that 82% of independent providers are submitting information of a high enough quality for adverse event rates to be calculated and published – an increase of over 10% over the past year. IHPN will continue to work with PHIN and providers to push this figure higher still. The equivalent figure for NHS PPUs is considerably lower (46%), though this also represents a welcome increase on the 28% reported a year earlier.

Extreme caution needs to be exercised when comparing incident rates. For example, it would be wholly inappropriate to compare mortality rates for patients with terminal diagnoses with those undergoing routine surgery. We were therefore pleased to work with PHIN over the past year towards a new way of reporting mortality data so that mortalities could be identified as expected or unexpected.