Incident Reporting
Recommendations related to incident reporting
13
Recommendations
69% accepted
Government Response
Accepted (5)Accepted in Part (4)Awaiting Response (4)
Recommendations in This Theme
recommendation across 5 inquiries
Across 5 inquiries
Tagged Recommendations
13 total
R16
Response Pending
Muckamore Abbey Inquiry
Missed care incident reporting
If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
Northern Ireland Executi…
R45
Response Pending
Muckamore Abbey Inquiry
Incident trend analysis on board dashboards
Incident reports of any violent or aggressive behaviour by either people with learning disabilities and autistic people or staff should be analysed and trend data reported on every HSCT Board’s …
Northern Ireland Executi…
IHRD-6
Accepted
Hyponatraemia Inquiry
Support for Candour Compliance
Support and protection should be given to those who properly fulfil their duty of candour.
- The Department of Health NI reported that support mechanisms for staff exercising the duty of candour were being developed (IHRD Implementation Programme, Department of …
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 …
- In April 2025, DHSC and NHS England stated that the designation of 'serious incident' had been abolished and replaced by the Learn from Patient …
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.
- In April 2025, DHSC and NHS England stated that mortality information is triangulated via the Learning from Deaths policy and a dashboard for NHS …
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 …
- NHS England decommissioned the National Reporting and Learning System (NRLS) on 30 June 2024, replacing it with the Learn from Patient Safety Events (LFPSE) …
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 …
- The Care Quality Commission and the Health and Safety Executive (HSE) maintain a Memorandum of Understanding (MoU) that covers the sharing of statutory notifications, …
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 Learn from Patient Safety Events (LFPSE) service replaced the National Reporting and Learning System (NRLS) for recording and analyzing patient safety events (Learn …
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 uses machine learning to analyze safety events and includes recording forms for primary care settings (Learn …
NHS England
R11
Historic
Allitt Inquiry
Incident report on monitoring alarm failure
We recommend that in the event of failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again …
Department of Health and…
R12
Historic
Allitt Inquiry
Single written channel for serious incident reports
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 …
Department of Health and…