Serious Incidents
Recommendations related to serious incidents
8
Recommendations
88% accepted
Government Response
Accepted (4)Accepted in Part (3)Awaiting Response (1)
Recommendations in This Theme
recommendation across 3 inquiries
Across 3 inquiries
Tagged Recommendations
8 total
AFA-5
Response Pending
Urology Services Inquiry
Serious Adverse Incidents
We recommend that: • The new SAI framework is fully implemented by the Department. There should be regional support for those leading the improvement in the serious incident processes in …
Department of Health NI
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 Local Authority Social Services and National Health Service Complaints (England) Regulations 2009 mandate that NHS bodies investigate and respond to complaints regarding health …
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 Department of Health and Social Care and NHS England stated in April 2025 that information regarding patient safety events is managed through the …
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 …
- Regulation 6 of the Medical Certificate of Cause of Death Regulations 2024 requires medical examiners to carry out a proportionate review of medical records …
Healthcare providers
F42
Accepted
Mid Staffs Inquiry
Use of information about compliance by regulator from: Serious untoward incidents
Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.
- The "Serious Untoward Incident" classification was removed and replaced by the Patient Safety Incident Response Framework (PSIRF), which is a contractual requirement under the …
NHS England
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 Department of Health and Social Care stated in April 2025 that the function of examining individual serious incidents has largely transferred to the …
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.
- The Patient Safety Incident Response Framework (PSIRF), which became mandatory for NHS-funded secondary care providers in Autumn 2023, requires patient safety incident reports to …
Healthcare providers