Recommendation BRIS-113: Make reporting of sentinel events easy using all communication means
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
The reporting of sentinel events must be made as easy as possible, using all available means of communication (including a confidential telephone reporting line).
Government response
No government response to this recommendation is on the record yet.
Delivery
DHSC and NHS England say completed (27 February 2026)
Please refer to our response to recommendation 109.
The Patient Safety Incident Response Framework or ‘PSIRF’ (2024) is the approach used by the NHS to develop and maintain effective systems and processes for responding to patient safety incidents.
NHS England have published a national Freedom to speak up policy for the NHS, applicable to primary care, secondary care and integrated care systems. All NHS organisations and others providing NHS healthcare services in primary and secondary care in England are required to adopt the Freedom to Speak Up Policy as a minimum standard to normalise speaking up for the benefit of patients and workers. This is embedded in the NHS Standard Contract...
Speak Up Direct is available to all health and social care staff who want independent help and support about how to speak up about something.
NHS England’s national Patient Safety Team now performs this function - see the following for examples:
• Patient safety review and response reports • Introducing National Patient Safety Alerts
• National patient safety incident reports
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. 113, PDF page 121-122.
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 its aim was for most reports of adverse incidents to the National Patient Safety Agency to be transmitted electronically and that a confidential telephone line would also be established.
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. 113, PDF page 108-109.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding