Recommendation BRIS-110: National Patient Safety Agency to manage national sentinel events database
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
The national database of sentinel events should be managed by the National Patient Safety Agency, so as to ensure that a high degree of confidence is placed in the system by the public.
Government response
No government response to this recommendation is on the record yet.
Delivery
DHSC and NHS England state no delivery position (27 February 2026)
The Thirlwall Inquiry has noted action taken in response to this recommendation.
The NHS Patient Safety Agency was disbanded in 2012, and its functions transferred to the NHS Commissioning Board (now NHS England). The National Patient Safety Team now performs this function,.
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 Their reviewed extent of implementation reads “Superseded”.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 6.2 No. 110, PDF page 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.
The National Reporting and Learning System was set up in 2003 and at the time managed by the National Patient Safety Agency. The System was subsequently transferred to NHS England in June 2012.
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 colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 6.2 No. 110, PDF page 108.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding