Serious Incidents
Recommendations related to serious incidents
6
Recommendations
100% accepted
Government Response
Accepted (3)Accepted in Part (3)
Recommendations in This Theme
recommendation across 2 inquiries
Across 2 inquiries
Tagged Recommendations
6 total
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…
F114
Accepted
Mid Staffs Inquiry
Complaints handling
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
- The Patient Safety Incident Response Framework (PSIRF), mandatory for NHS trusts from autumn 2023, requires trusts to consider all sources of information — including …
Healthcare providers
F260
Accepted in Part
Mid Staffs Inquiry
Information standards
The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It …
- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …
F278
Accepted
Mid Staffs Inquiry
Death certification
It should be a routine part of an independent medical examiners's role to seek out and consider any serious untoward incidents or adverse incident reports relating to the deceased, to …
- The government's response in "Hard Truths" (Cm 8777, November 2013) accepted this recommendation (Hard Truths: the Journey to Putting Patients First, DHSC, November 2013). …
Healthcare providers
F44
Accepted in Part
Mid Staffs Inquiry
Use of information about compliance by regulator from: Media
Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement for …
- The Care Quality Commission (Registration) Regulations 2009, Regulations 16 and 18, require providers to notify CQC of deaths and other serious incidents (SI 2009/3112, …
CQC
F89
Accepted in Part
Mid Staffs Inquiry
Information sharing
Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.
- HSE and CQC published a memorandum of understanding (most recently revised 2014) providing for reciprocal information sharing. Under the MoU, CQC shares serious incident …
Healthcare providers