Recommendation BRIS-118: Integrate sentinel event reporting into all NHS trust staff training and communications.
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
The process of reporting of sentinel events should be integrated into every trust’s internal communications, induction training and other staff training. Staff must know what is expected of them, to whom to report and what systems are in place to enable them to report.
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)
The importance of incident reporting is a long-standing principle included in the NHS Patient Safety Strategy.
NHS England launched the NHS Patient Safety Syllabus in 2021. By June 2024, Level 1 of the training under this syllabus has been accessed over 2 million times, level 2 over 1 million, and level 1 for boards over 80,000. Work on training and education in patient safety needs to be ongoing to continue to support new staff and improve learning throughout the system. The work to develop the NHS Patient Safety Syllabus and Level 1 and 2 of the training under the syllabus was done in partnership with the Academy of Medical Royal Colleges.
Many organisations, including NHS England, have made training in level 1 of the patient safety syllabus mandatory for all staff. Work continues to develop and deliver training under the syllabus.
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 Their reviewed extent of implementation reads “Superseded”.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. 118, PDF page 124.
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 would be included in revised guidance on its Risk Management System and guidance from the National Patient Safety Agency.
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. 118, PDF page 110.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding