Recommendation F89: Information sharing
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.
In brief (written by this site)
In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was addressed through regulations and revised memorandums of understanding with the Health and Safety Executive, with patient safety incident reports provided to the Care Quality Commission (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that under a December 2017 agreement, the two regulators had arranged to notify each other about incidents within their respective jurisdictions and share relevant intelligence (The Thirlwall Inquiry legal team, May 2024).
AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026. The record below is the sources' own words.
Government response
Accepted in principle.
The Care Quality Commission is the regulator of the safety and quality of health and adult social care providers in England. Providers registered with the Care Quality Commission are required to notify it of serious untoward incidents involving death or serious injury either directly or through the National Reporting and Learning System in the case of NHS organisations. The Care Quality Commission uses the intelligence that it receives from these notifications as part of its risk assessment. An initial assessment of serious untoward incidents should be carried out by the Care Quality Commission as the specialist inspector of the health and adult social care providers, with the ability to draw on the Health and Safety Executive’s expertise in investigations and prosecutions. This will be set out in the revised liaison agreement between the Care Quality Commission and the Health and Safety Executive.
How this response relates to the recommendation
Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.
Blanket government agreement does not establish acceptance or delivery by each addressee. Some response passages cover groups of recommendations.
Scope of the government response
Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.
Delivery
DHSC and NHS England say in progress (27 February 2026)
This is addressed by the (1) implementation of RAR 2014 (2) MoU and subsequently revised MoU with Health and Safety Executive. See update above re recommendation 88
The Patient Safety Incident Response Framework (PSIRF) sets out the NHS’s approach to developing and maintaining effective systems and processes for responding to patient safety incidents for the purpose of learning and improving patient safety. Patient safety incident reports are provided to CQC.
Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Ongoing”. Table row: section 18.2 No. 89, PDF page 468.
Department of Health and Social Care says in progress (11 February 2015)
The Health and Safety Executive shares quarterly investigated Reporting of Injuries, Diseases and Dangerous Occurrences Regulations accidents, complaints, and enforcement and prosecution notices data with Care Quality Commission. This is part of the joint work by Health and Safety Executive and Care Quality Commission that is set out in a liaison agreement. The Care Quality Commission have consulted on a revised liaison agreement setting out their working arrangements including their criteria for referrals and prosecutions and better co-operation in the underpinning information-sharing arrangements. The final liaison agreement will be published in April 2015.
This agreement will make clear that when fundamental standards are in place, the Care Quality Commission will have the lead role in considering whether to take enforcement action on safety incidents which affect people using services registered with it. The Health and Safety Executive or local authorities will have the lead in considering whether to take enforcement action on safety incidents affecting people using other health and care services, and for safety incidents affecting staff and the public in all services. The new liaison agreement will also set principles for case-by-case decisions on which regulator will take the lead.
Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.
Site note: The Inquiry addressed this recommendation to healthcare providers, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
This recommendation was accepted in principle by the Government.
In the January 2014 Hard Truths report, the Government said that an initial assessment of serious untoward incidents to be carried out by the Care Quality Commission with the ability to draw on the Health and Safety Executive’s expertise.
By the December 2017 Memorandum of Understanding between the Health and Safety Executive and the Care Quality Commission, the two organisations agreed to notify the other as appropriate as soon as possible about information they received on incidents in the jurisdiction of that body and to share relevant intelligence and enforcement data.
Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 89, PDF page 433.
Source
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response, delivery statement - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding