BRIS-107 Response Historic AI-assessed

Create open, non-punitive NHS environment for reporting sentinel events

Recommendation

Every effort should be made to create in the NHS an open and non-punitive environment in which it is safe to report and admit sentinel events.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
No specific government response or evidence of action concerning efforts to create an open and non-punitive environment in the NHS for reporting sentinel events has been identified in the provided official sources. While general search results for the Bristol Heart Inquiry exist on gov.uk, no specific documents detailing progress were accessible.
How was this assessed?
Assessed by gemini-2.5-flash on 18 Mar 2026
Checked data held on this site (government responses, progress updates, independent evidence)
External sources searched: www.gov.uk, www.legislation.gov.uk, hansard.parliament.uk
This recommendation asks for cultural or behavioural change, which is difficult to verify objectively. The assessment is based on policy commitments, not measured outcomes.
Jurisdiction
UK-wide
Response
Historic

No government response recorded.

Source
Inquiry Bristol Heart Inquiry
Report Bristol Heart Inquiry — Final Report 18 Jul 2001
View Source
Themes & Tags
No open learning culture Duty of Candour implementation
Recommendation age 24.7 yrs
Last formal update No formal updates