Recommendation BRIS-108: Conduct priority studies to establish baseline of NHS sentinel events
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
Major studies should, as a matter of priority, be carried out to investigate the extent and type of sentinel events in the NHS to establish a baseline against which improvements can be made and measured.
Government response
No government response to this recommendation is on the record yet.
Delivery
DHSC and NHS England say completed (27 February 2026)
There are several examples of baselines having been established against which improvements can be made and measured e.g. MMBRACE, subsequent Public Inquiries.
The NHS Patient Safety Strategy (2019) is NHS England’s long-term approach to continuously improving patient safety. It includes major programmes including the Learn from Patient Safety Events (LFPSE) service to improve data collection and analysis of patient safety incidents; and the Patient Safety Incident Response Framework (PSIRF) which overhauls the way Trusts respond to patient safety incidents with a focus on more effective learning and engaging families. See recommendation 109 below.
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 – Closed”. Table row: section 6.2 No. 108, PDF page 119-120.
What other bodies have found
In their own words. These do not change the delivery statement above.
Thirlwall Inquiry legal team (15 May 2024)
The Government agreed with this recommendation.
In its January 2002 response, the Department of Health said that the National Patient Safety Agency was piloting a system for establishing a national database of adverse incidents and near misses to provide a baseline against which future improvements could be judged.
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 6.2 No. 108, PDF page 107.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding