Incident Reporting
Recommendations related to incident reporting
9
Recommendations
100% accepted
Government Response
Accepted (5)Accepted in Part (4)
Recommendations in This Theme
recommendation across 3 inquiries
Across 3 inquiries
Tagged Recommendations
9 total
IHRD-6
Accepted
Hyponatraemia Inquiry
Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
Government reports this recommendation as delivered. Implementation status based on Department of Health NI Implementation Programme updates.
Northern Ireland Executi…
HSC Trusts
11
Accepted
Morecambe Bay Investigation
Raise awareness of incident reporting and duty of candour
The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also …
- In July 2015, the government stated that the Trust had "begun to review how investigations into incidents are carried out and started a programme …
University Hospitals of …
23
Accepted
Morecambe Bay Investigation
Clear standards for incident reporting in maternity
Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and …
- In July 2015, the government stated: "We accept this recommendation in principle" and announced a new Independent Patient Safety Investigation Service to supplement existing …
Department of Health and…
F100
Accepted in Part
Mid Staffs Inquiry
National Patient Safety Agency functions
Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that …
- The Learn from Patient Safety Events (LFPSE) service accepts reports from individual staff members as well as organisational reporters. Individual clinicians or other healthcare …
CQC
F105
Accepted
Mid Staffs Inquiry
Transparency use and sharing of information
Consideration should be given to whether information from incident reports involving deaths in hospital could enhance consideration of the hospital standardised mortality ratio.
- The Summary Hospital-level Mortality Indicator (SHMI) is published quarterly by NHS England (formerly by the Health and Social Care Information Centre, now NHS Digital, …
NHS England
F12
Accepted
Mid Staffs Inquiry
Fundamental standards of behaviour
Reporting of incidents of concern relevant to patient safety, compliance with fundamental standards or some higher requirement of the employer needs to be not only encouraged but insisted upon. Staff …
- The statutory duty of candour was introduced through Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, requiring registered …
Healthcare providers
F88
Accepted in Part
Mid Staffs Inquiry
Information sharing
The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order …
- HSE and CQC published a memorandum of understanding setting out arrangements for information sharing between the two organisations. Under the MoU, HSE shares information …
F98
Accepted in Part
Mid Staffs Inquiry
National Patient Safety Agency functions
Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part …
- The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 20 (duty of candour), requires registered providers to act in an open …
NHS England
F99
Accepted in Part
Mid Staffs Inquiry
National Patient Safety Agency functions
The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has …
- The Learn from Patient Safety Events (LFPSE) service, which replaced the National Reporting and Learning System (NRLS, decommissioned June 2024), was specifically designed to …
NHS England