Recommendation F106: Health Protection Agency Coordination and publication of providers' information on healthcare associated infections
From Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry, published 6 February 2013.
Recommendation
The Health Protection Agency and its successor, should coordinate the collection, analysis and publication of information on each provider's performance in relation to healthcare associated infections, working with the Health and Social Care Information Centre.
In brief (written by this site)
In commentary from September 2024 published in February 2026, the Department of Health and Social Care and NHS England stated that the UK Health Security Agency now collects and publishes data on hospital and community acquired infections by NHS organisation, with records for some infections dating back to 2013 (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted the government's acceptance of the recommendation alongside earlier reports that Public Health England had published mandatory surveillance figures and developed integrated data systems (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.
Public Health England, which since April 2013 has taken on the functions of the Health Protection Agency, is working together with the Health and Social Care Information Centre to coordinate the collection, analysis and publication of information in relation to Healthcare Associated Infections.
This includes a number of on-going activities: exploration of linkage of Public Health England Healthcare Associated Infections patient-level surveillance data with Hospital Episode Statistics data for enhanced epidemiological analyses; exploration of linkage of Public Health England Healthcare Associated Infections surveillance data with the death registrations (for mortality trends) to improve understanding of causality; Public Health England facilitation of voluntary surveillance within the Infections in Critical Care Quality Improvement Programme to increase the knowledge and evidence base, leading to quality improvement; a review of priority categories for Surgical Site Infection surveillance to inform strategic development and support needs of local users; taking a key role in the finalisation, roll-out and on-going development of the new Data Capture System to incorporate and support the above- mentioned surveillances activities. Public Health England is also working with trusts and Clinical Commissioning Groups to facilitate the Post Infection Review process for MRSA.
Additionally, Public Health England is providing advice and support to the Care Quality Commission in its regulatory work to develop its new surveillance model for the construction of quality indicators.
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)
UK Health Security Agency (UKHSA) is now the organisation that collects and publishes data on hospital and community acquired infections by NHS organisation. Data is available for some infections back to 2013 and 2017 for others.
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. 106, PDF page 475.
Department of Health and Social Care says in progress (11 February 2015)
Public Health England publishes as routine mandatory surveillance data on Meticillin-resistant Staphylococcus aureus (MRSA), Meticillin-sensitive Staphylococcus aureus (MSSA) and Escherichia coli (E. coli) bloodstream infections and Clostridium difficile infection (CDI) at the level of each NHS acute trust. Trusts report these data to a web-based data capture system. Public Health England is providing expertise to support the development of a new integrated and future-proofed data capture system for its mandatory healthcare associated infection surveillance programmes which can be used by all parts of the healthcare system. Public Health England also provides expertise to support NHS organisations reporting positive cases of Meticillin-resistant Staphylococcus aureus bloodstream infection in undertaking a Post Infection Review for each case. A Post Infection Review is undertaken to identify how a case occurred, actions which can prevent a reoccurrence and the organisation best placed to ensure improvements are made. Public Health England has successfully liaised with NHS England to refine the Post Infection Review process from April 2014 so that cases of Meticillin-resistant Staphylococcus aureus bloodstream infection can be more accurately assigned to either an acute trust, Clinical Commissioning Group or ‘third party’ acknowledging the complex nature of cases.
In order to assess patient outcomes, Public Health England has successfully linked data both on bloodstream infections and surgical site infection (hip replacement and other types of surgery) to the Office for National Statistics death registration data Before the end of March 2015, Public Health England will assume responsibility for producing mortality data for cases of Meticillin-resistant Staphylococcus aureus bloodstream infection and Clostridium difficile infection by linking Public Health England mandatory surveillance data with death registration data. This data will be published on an annual basis.
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 Public Health 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 Public Health England was working together with the Health and Social Care Information Centre to coordinate the collection, analysis and publication of information in relation to healthcare associated infections.
In the February 2015 Culture Change report, the Government referred to Public Health England publishing routine mandatory surveillance data on certain infections; providing expertise to support the development of a new integrated data capture system; and providing expertise to support NHS organisations regarding positive cases of MRSA in undertaking post-infection reviews.
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. 106, PDF page 441.
Source
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