Recommendation BRIS-115: Discipline NHS staff who cover up or fail to report sentinel events
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
Members of staff in the NHS who cover up or do not report a sentinel event may be subject to disciplinary action by their employer or by their professional body.
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)
In November 2014, the government introduced a statutory (organisational) duty of candour for NHS trusts and NHS foundation trusts, with Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The duty places a direct obligation upon trusts to be open and honest with patients and service users, and their families, when something goes wrong that appears to have caused or could lead to moderate harm or worse in the future (known as a ‘notifiable safety incident’).
Since November 2014, providers of health and social care registered with Care Quality Commission, including Trusts — have been required to comply with the requirements in Regulation 5 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (known as the Fit and Proper Person Regulation)
In August 2023, NHS England published a strengthened Fit and Proper Person Test Framework in response to the 2019 Kark Review to introduce:
• a means of retaining information relating to testing the requirements of the FPPT for individual directors,
• a set of standard competencies for all board directors,
• a new way of completing references with additional content whenever a director leaves an NHS board and an extension of the applicability to some other organisations, including NHS England and the CQC.
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 Their reviewed extent of implementation reads “Superseded”.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. 115, 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. 115, PDF page 109.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding