Recommendation BRIS-112: Conduct structured analysis of sentinel events considering organisational factors
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of individuals, but also the wider contributing factors within the organisation which may have given rise to the event.
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)
Please refer to our response to recommendation 109.
The Learn from Patient Safety Events (LFPSE) service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. It supports providers and commissioners to access data in order to better understand their local recording practices and culture, and to support local safety improvement work.
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 Their reviewed extent of implementation reads “Superseded”.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. 112, PDF page 121.
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 this was already a requirement of its Risk Management System and would be reinforced by root cause analysis of serious incidents. The Department said the National Patient Safety Agency would issue guidance.
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. 112, PDF page 108.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding