Recommendation R12: Single written channel for serious incident reports
From The Allitt Inquiry Report, published 11 February 1994.
Recommendation
We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved (para 5.14.12)
Government response
Recommendation 12. We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved. We will shortly be writing to all Regional Directors requiring them to establish lines of reporting with Chief Executives of all NHS Trusts so that there can be swift and effective reporting of any such untoward incidents.
Delivery
DHSC and NHS England state no delivery position (27 February 2026)
Since 2004, the NHS has operated a comprehensive national patient safety incident reporting system, initially the National Reporting and Learning System (NRLS) and now the Learn From Patient Safety Events (LFPSE) service. All provider patient safety incident records are collected by LFPSE and the data is available to Integrated Care Boards and NHS England. Provider incident responses should be consistent with the Patient Safety Incident Response Framework. The current overarching framework for the reporting of patient safety incidents is the Patient safety Incident Response Framework (2023).
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 Their reviewed extent of implementation reads “Superseded”.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 3.2 No. 12, PDF page 19.
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 November 1994, the Secretary of State for Health said the Department of Health would shortly be writing to all regional directors requiring them to establish lines of reporting with chief executives of NHS trusts, so that there could be swift and effective reporting of any untoward incidents.
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 3.2 No. 12, PDF page 19.
Responsible bodies
Themes and tags
Who has spoken
- Department of Health and Social Care
Response - DHSC and NHS England
Delivery statement - Thirlwall Inquiry legal team
Finding