Recommendation BRIS-120: NPSA to urgently apply engineering design approaches to reduce sentinel events.
From Bristol Heart Inquiry — Final Report, published 18 July 2001.
Recommendation
The proposed National Patient Safety Agency should, as a matter of urgency, bring together managers in the NHS, representatives of the pharmaceutical companies and manufacturers of medical equipment, members of the healthcare professions and the public, to seek to apply approaches based on engineering and design so as to reduce (and eliminate to the extent possible) the incidence of sentinel events.
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 National Patient Safety Agency was abolished and it’s functions now sit within NHS England
In July 2020, the Independent Medicines and Medical Devices Safety Review was published. The review made several recommendations to improve patient safety, including the establishment of a Patient Safety Commissioner to advocate for patients’ voices and ensure that their concerns are addressed and the establishment of specialist centres to provide comprehensive treatment for those affected by issues like implanted mesh. The government accepted the majority of the review’s recommendations and has been working on their implementation, including tighter regulations on the medical interventions included in the report and better support for affected patients. Dr Henrietta Hughes was appointed the first Patient Safety Commissioner in 2022.
Also, NHS England has introduced steps to improve patient safety, such as the NHS Patient Safety Strategy in 2019 to drive a culture of patient safety through learning across the NHS.
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 Their reviewed extent of implementation reads “Superseded”.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. 120, PDF page 124-125.
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 it was working with the Design Council to look at ways of improving patient safety through new engineering and design solutions.
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. 120, PDF page 110-111.
Themes and tags
Who has spoken
- DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding