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National Patient Safety Agency

NPSA award Clinical Outcome Review Programme contracts

6 January 2011

The National Patient Safety Agency (NPSA) has awarded the contracts that will make up the Clinical Outcome Review Programme, formerly known as the Confidential Enquiries Programme.


The Clinical Outcome Review Programme will assess quality of care and promote improvements in patient safety by enabling clinicians, managers and policy makers to learn from adverse events and from examples of good practice. The programme contains four elements, which are: Medical and Surgical, Mental Health, Maternal and Newborn and Child Health.


The contract for Medical and Surgical has been awarded to the National Confidential Enquiry into Patient Outcome and Death (NCEPOD). NCEPOD will maintain a database of all cases of severe harm or death occurring within thirty days of surgery in the public, private and independent healthcare sectors. Using the database, confidential case reviews will determine whether the healthcare provided to patients met appropriate standards and if incidents of severe harm or death were avoidable. NCEPOD will publish annual reports containing the findings of this work.


The Mental Health contract has been awarded to the University of Manchester Centre for Suicide Prevention, who will monitor suicides and other specified causes of death within mental health services. Themed reviews will provide recommendations to improve patient care and will cover a range of topics such as risk assessment, care delivery and management of self-injury.


The Maternal and Newborn contract has been awarded to the University of Oxford National Perinatal Epidemiology Unit. A national childbirth audit will be undertaken, examining maternal, perinatal and infant (up to one year old) incidents of severe harm and death. The work will also include a clinical audit of maternal, perinatal and infant deaths and severe harm. The findings will help inform the development of national policies and clinical guidelines.


The contract for Child Health has been awarded to the Royal College of Paediatrics and Child Health. They will retrospectively examine all cases of severe harm or death in children aged 1-18 to establish whether appropriate standards of care were met and if the severe harm or death was avoidable. Analysis of these data will help contribute to the improvement of clinical care, service provision, commissioning of services and the development of clinical guidelines and national policies.


Sarndrah Horsfall, Acting Chief Executive of the NPSA, said: “The Clinical Outcome Review Programme will make a unique contribution to improvements in patient care. These contracts and the data provided by each supplier will support clinicians, managers and policy makers in gathering learning from adverse events and it will contribute to ongoing work aimed at improving healthcare practice.”


Murray Devine, Head of Patient Safety Policy, Department of Health, said: “The Clinical Outcome Review Programme will make a very important contribution to developing high quality and safe practice across the healthcare sector. The findings from this programme will assess quality and stimulate improvement in safety and effectiveness by enabling health practitioners to learn both from adverse events and from examples of high quality care.”


The existing contracts for the Confidential Enquiries Programme are due to expire in March 2011. The decision to award these contracts was made following an EU competitive tendering process, ensuring delivery of value for money and the best mix of quality and effectiveness. The selection panel was made up of representatives from devolved administrations, Department of Health, NPSA and key expert stakeholders.


Notes to editors


1. Media enquiries to the NPSA Press Office:


Dominic Stevenson – 020 7927 9351 / dominic.stevenson@npsa.nhs.uk


Fiona Carr – 020 7927 9556


Out of hours – 0788 411 5956


2. Following the publication of the Arms Length Body Review on 26 July 2010, the NPSA has stressed the importance for all NHS organisations across England and Wales to continue reporting patient safety incidents through the National Reporting and Learning System. This is so that trends in safety incidents can be identified and acted upon as early as possible.  This aspect of our work will continue within the new proposed structure of the NHS Commissioning Board and we will continue to work together in partnership with NHS organisations to make services even safer for patients.  We will continue to monitor the implementation of all patient safety alerts and guidance.