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AfPP Response to Westminster Debate on Preventing Surgical Fires in the NHS

Released on - 21/12/2021

AfPP Response to Westminster Debate on Preventing Surgical Fires in the NHS

On Thursday 16 December 2021, MPs held a general debate on preventing surgical fires in the NHS in Westminster Hall. The topic was put forward for debate by Jim Shannon, MP for Strangford, following a report published by the Surgical Fires Expert Working Group (EWG) in September 2020, “A case for the prevention and management of surgical fires in the UK”.

The EWG was made up of industry experts from the Association for Perioperative Practice (AfPP) and other Centre for Perioperative Care (CPOC) Partners.

During the debate’s conclusions, Maria Caulfield MP, Minister for Patient Safety and Primary Care, stated:

“Surgical fires are not [classified as] a never event at the moment because there are no clear guidelines that staff can follow that can absolutely rule out any particular fire from happening. That is the crux of the matter. Fires should absolutely be preventable, and we should learn the lessons when a surgical fire takes place, but we do not have the guidelines to be able to say to staff what has to be followed to absolutely prevent a fire from happening in the first place.”

In response to this, AfPP are now calling for the EWG to reconvene and produce guidance on the prevention of surgical fires for review by NHS England.

Jim Shannon MP Westminster Debate

Jim Shannon MP leading the debate at Westminster Hall

Lindsay Keeley, Registered Theatre Nurse and Patient Safety & Quality Lead at AfPP, said:

“The operating theatre is by nature a high-risk environment because of the activity undertaken. One of the hazards identified in the EWG investigation in 2020 was the prevention and management of a surgical fire in the perioperative setting.

Surgical fires should never happen. But evidently they do, and they go unreported due to discrepancies in the reporting process to class surgical fires as a `Never Event` or `Near Miss`.”

As part of the 2020 report, the Association surveyed almost 7,000 of their members. Surprisingly, 50% reported they had witnessed a surgical fire. Between 2010-2018 there were a total of 96 recorded surgical fire incidents declared by NHS England Acute Trusts and Wales Health Boards.

Lindsay Keeley added:

“This discrepancy between self-reported and officially reported incidences of surgical fires evidences the issues both staff and patients continue to face in the operating theatre environment.

“It is clear from the findings of the EWG that surgical fires do happen, and that lack of preventative measures are unacceptable and wholly preventable. Mandatory education and training are fundamental in eliminating the occurrence and risk of surgical fires within the perioperative environment. National standards and guidance are required in support of this mandate.”

The Association continues to push four recommendations made by the EWG to make progress towards the mandatory reporting of surgical fires and near misses, both in the NHS and the independent sector:

  1. Professional associations to explore the value of a national awareness campaign for healthcare professionals.
  2. Mandating of surgical perioperative education and training syllabus on surgical fire prevention.
  3. NHS England to explore how to evolve the procurement process of sanitising products, to reduce surgical fire risk and encourage procurement of proven surgical fire-safe technologies.
  4. NHS England to explore the development of a standardised patient safety alert system highlights the risks of surgical fires to the health service and sets out clear and effective actions for providers to take on this safety-critical issue.

This statement is the latest call to action from AfPP regarding the prevention of surgical fires. It follows a letter addressed to Maria Caulfield MP in November 2021, ahead of the recent debate.

The charity hopes that the EWG can begin to produce guidelines in 2022 and the UK can move forward with getting surgical fires recognised as Never Events.

Joint letter from Jim Shannon MP and AfPP to Maria Caulfield MP in November 2021

Dear Minister,

Following your appointment as Minister for Patient Safety and Primary Care, I write to you regarding the serious matter of surgical fires and to request a meeting with you in order to discuss the importance of updating national guidelines to prevent such fires from occurring in hospital theatre settings.

You may be aware that surgical fires can cause life-changing injuries to patients, and significant trauma to the clinical theatre staff involved in such events. NHS Resolution has confirmed that between 2009 to 2019 it was notified of 631 clinical negligence claims related to operating theatre fires, yet there is a significant discrepancy in the number of incidents recorded at the Trust level and those recorded at the national level. In fact, almost half of respondents to a survey of perioperative staff confirmed they had witnessed a surgical fire in their career.

Surgical fires are preventable, yet as noted in a written answer by your predecessor to a question I tabled on this issue last year (110129, tabled on 02 November), “there is currently no national guidance or safety recommendations that provides such safeguards to prevent surgical fires in operating theatres”.

The absence of national guidelines has resulted in an inconsistent approach to prevention within NHS hospitals and has prevented surgical fires from being defined as a Never Event. According to research by the Expert Working Group on the Prevention of Surgical Fires, only 38% of NHS hospitals in England have specific protocols and training programmes in place to address the prevention and management of surgical fires.

With this in mind, we would appreciate the opportunity to meet with you to discuss the findings and recommendations put forward by the multi-disciplinary Expert Working Group on the Prevention of Surgical Fires – chaired by the Association for Perioperative Practice (AfPP). The Group has collaborated to develop best practice guidelines aimed at preventing fires occurring in hospital theatres which are outlined in the Group’s report: ‘A case for the prevention and management of surgical fires in the UK’.

The report was officially launched in Parliament last year on 17 November 2020 where it was welcomed by key figures working in the NHS, patient groups, and relevant professional bodies.

However, despite the AfPP and the Expert Working Group collaborating to develop best practice guidelines aimed at preventing fires occurring hospital theatres, outlined in the Group’s report published last year, the issue has not received sufficient attention among relevant regulatory bodies and only limited progress has been achieved.

As Minister for Patient Safety, I would be grateful for any support you can provide as we continue to build momentum around tackling the occurrence of surgical fires to encourage the Centre for Perioperative Care (CPOC) to acknowledge the dangers presented by surgical fires and the potential impact they can have on patients and healthcare professionals alike and to adopt the national guidance prepared by the Expert Working Group.

With your expert guidance, we can look to raise this serious issue and begin to put concrete steps in place to reduce the risk of patient harm and safeguard the NHS against ever-increasing litigation claims.

Given the seriousness of this matter, I would be grateful if you could give due consideration to the findings of the Expert Working Group and the recommendations put forward. Please find the report enclosed alongside this letter for your attention.

Please do let me know your availability for a meeting to discuss this in more detail. I am very much looking forward to hearing from you.

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