Recommendation F105: Transparency use and sharing of information
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
In brief (written by this site)
In commentary provided in September 2024, the Department of Health and Social Care and NHS England stated that mortality information from various sources, including incident reporting and the Summary Hospital-level Mortality Indicator, should be triangulated under the Learning from Deaths policy (DHSC and NHS England, Feb 2026). Earlier, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and summarised previous work on proposals for retrospective case note reviews of patient deaths across trusts (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.
As part of Professor Sir Bruce Keogh’s Review of the Quality and Safety of Care and Treatment Provided by 14 Hospital Trusts in England, NHS England provided detailed reports from the National Reporting and Learning System for each of the 14 trusts that were looked at. That process was informative and resulted in key lines of inquiry for the inspection teams on the ground. It in effect acted as a pilot for a stronger method of utilising the National Reporting and Learning System data in Care Quality Commission inspections. It was also found that data from the National Reporting and Learning System correlated well with other datasets to indicate problems with safety. NHS England will work with the Care Quality Commission to build on the learning from Sir Bruce Keogh’s Review to address this.
NHS England is also leading work to develop proposals for ensuring every trust undertakes retrospective case note reviews of patient deaths according to a consistent methodology to further encourage learning from adverse events. This will help trusts address common issues associated with avoidable hospital mortality, such as management of deteriorating patients.
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 state no delivery position (27 February 2026)
Information on mortality from various sources should be triangulated as set out in the Learning from Deaths policy. This includes information from Summary Hospital-level Mortality Indicator (SHMI) and incident reporting. It also includes Implementing the Learning from Deaths Framework and guidance.
‘Learning from Deaths – a dashboard for NHS Providers’ provides a tool to record relevant incidents of mortality, deaths reviewed and lessons learnt to encourage future learning and the improvement of care.
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 “Superseded”. Table row: section 18.2 No. 105, PDF page 475.
Department of Health and Social Care says in progress (11 February 2015)
NHS England was already exploring the development of a standardised process for supporting the NHS to undertake retrospective case note review. Introducing a national standard approach for undertaking case note review would build on innovative work at the London School of Hygiene and Tropical Medicine and has the potential to enable NHS Trusts to develop a better understanding of actually avoidable deaths.
• Although case note reviews are a “gold standard approach” they can be time and resource intensive.
• NHS England are moving ahead now to develop a national rate and produce an estimate number of avoidable deaths for each hospital. This will be done by someone independent of Trusts and the numbers will be made public. Trusts will be expected to report annually to the Secretary of State for Health on their actions to reduce avoidable deaths.
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 NHS England, 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 by the Government.
In the January 2014 Hard Truths Report, the Government said that NHS England was leading work to develop proposals for ensuring every trust undertakes retrospective case note reviews of patient deaths according to consistent methodology, to further encourage learning from adverse events. In the February 2015 Culture Change Report, the Government said that NHS England was exploring the development of a standardised process for supporting the NHS to undertake retrospective case note review.
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. 105, PDF page 440-441.
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