Recommendation BRIS-114: Grant immunity for NHS staff reporting sentinel events within 48 hours
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
Members of staff in the NHS should receive immunity from disciplinary action by the employer or by a professional body if they report a sentinel event to the trust or to the national database within 48 hours, except where they themselves have committed a criminal offence.
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)
NHS England have published a national Freedom to speak up policy for the NHS, applicable to primary care, secondary care and integrated care systems, focusing on the importance of inclusive and consistent speaking up arrangements and driving learning through listening. With the National Guardian’s Office NHS England have also published Freedom to speak up (FTSU) guidance and a Freedom to speak up reflection and planning tool, each to help ensure staff have a voice that counts to develop a speaking up culture.
DHSC has also put in place 'Speak Up Direct' - a helpline and website to support people who want to speak up about something and need help on what to do.
If the concerns raised are considered a protected disclosure, individuals raising the concern are covered by additional legal protections.
This is addressed by the Public Interest Disclosure Act 1998, which amends the Employment Rights Act 1996.
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 Their reviewed extent of implementation reads “Superseded”.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. 114, PDF page 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)
In its January 2002 response, the Department of Health said it agreed in principle with this recommendation. The Department said it would explore, through the work of the Chief Medical Officer’s Committee on Clinical Negligence, how this could be introduced.
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. 114, PDF page 109.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding