BRIS-112 Response Historic

Conduct structured analysis of sentinel events considering organisational factors

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.

Published Evidence Summary
The following publicly available evidence relates to this recommendation:
No formal government response has been recorded for this recommendation. No independent verification has been carried out.
Sources
Based on tracking data in the inquiry database.
How was this evidence gathered?
Evidence searched by baseline-data-v1 on 26 May 2026
Checked data held on this site (government responses, progress updates, independent evidence)
This recommendation applies across many organisations. The evidence above reflects central policy activity; adoption in individual organisations may vary.
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 Patient safety governance
Recommendation age 24.9 yrs
Last formal update No formal updates