Regulator patient safety alerts
Lack of clear responsibility for regulators (e.g., CQC) to review decisions not to comply with patient safety alerts.
17 items
1 source
10 inquiries
Source spread
Where this theme appears
Regulator patient safety alerts has been flagged across 1 independent accountability source:
17 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (17)
MAI-121 — Consequences for breaching event healthcare standards
Recommendation: The Department of Health and Social Care together with the Care Quality Commission should consider what the consequences of breaching the appropriate standard should be. That should include consideration of whether the sanction should be criminal in nature.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Partially accepted
Accepted in part
In progress
9 — Date for submitting Safety Cases
Recommendation: As regards existing installations the date for submission of the Safety Case should be laid down by regulation. There is an urgent need for the submission of Safety Cases, but the date should be selected by the regulatory body. The …
Unknown
8 — Safety Case before installation operates
Recommendation: No fixed installation should be established or maintained in controlled waters; and no mobile installation should be brought into those waters with a view to its being stationed there or maintained in those waters unless a Safety Case in respect …
Unknown
4 — Whole body monitoring as authorisation condition
Recommendation: The authorising departments should however consider whether provision of such facilities should be made a condition of authorisations to discharge (para 10.95).
Unknown
BRIS-111 — Require National Patient Safety Agency to inform trusts and publish reports
Recommendation: The National Patient Safety Agency, in the exercise of its function of surveillance of sentinel events, should be required to inform all trusts of the need for immediate action, in the light of occurrences reported to it. The Agency should …
Unknown
11 — Regulatory system patient safety priority
Recommendation: We recommend that the government should ensure that the current system of regulation and the collaboration of the regulators serves patient safety as the top priority, given the ineffectiveness of the system identified in this Inquiry.
Words of: Department of Health and Social Care, Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson, 16 December 2021
Gov response: Accept System and professional regulators have an overarching statutory objective to protect, promote and maintain the health, safety and wellbeing of the public. The healthcare regulators referenced in the inquiry (GMC, NMC and CQC) exist …
Accepted
In progress
76 — Immediate analysis without waiting for legislation
Recommendation: The regulatory body should ask operators which have not already done so to undertake an evacuation, escape and rescue analysis forthwith, without waiting for legislation. The timetable for completion of this analysis should be agreed between the regulatory body and …
Unknown
IBI-7e — Implementing SHOT Reports
Recommendation: Implementing SHOT reports: That all NHS organisations across the UK have a mechanism in place for implementing recommendations of SHOT reports, which should be professionally mandated, and for monitoring such implementation.
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: Work is underway to develop governance practices for the implementation of SHOT recommendations, with careful consideration given to the needs for standardisations and the needs of local organisations. Accreditation for SHOT as an organisation for …
Accepted in part
In progress
F107 — Sharing concerns
Recommendation: If the Health Protection Agency or its successor, or the relevant local director of public health or equivalent official, becomes concerned that a provider's management of healthcare associated infections is or may be inadequate to provide sufficient protection of patients …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. Public Health England is reviewing its governance framework which underpins its responsibilities (in partnership with local, regional and national partners) for sharing and escalating concerns. As part of this work and as new structures …
Accepted
In progress
F100 — National Patient Safety Agency functions
Recommendation: 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 mandatory system has not been complied with.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. All serious incidents involving severe harm and death reported by individuals to via the on-line e-form, or any route, are routinely shared with the Care Quality Commission on a weekly basis. The …
Accepted in part
F41 — Use of information about compliance by regulator from: Patient safety alerts
Recommendation: The Care Quality Commission should have a clear responsibility to review decisions not to comply with patient safety alerts and to oversee the effectiveness of any action required to implement them. Information-sharing with the Care Quality Commission regarding patient safety …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. The Care Quality Commission already monitors compliance with patient safety alerts, such as those issued by the Medicines and Healthcare products Regulatory Agency, and is able to investigate further where it identifies …
Accepted in part
F32 — Interim measures
Recommendation: Where patient safety is believed on reasonable grounds to be at risk, Monitor and any other regulator should be obliged to take whatever action within their powers is necessary to protect patient safety. Such action should include, where necessary, temporary …
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. As part of the overall single failure regime (see recommendation 19) it is important that where the Care Quality Commission, Monitor or the NHS Trust Development Authority identify breaches of fundamental standards that they …
Accepted
COVID-M5.5 — Emergency Healthcare Equipment Plan
Recommendation: UK regulators, including the Health and Safety Executive, the Health and Safety Executive for Northern Ireland, the Office for Product Safety and Standards and the Medicines and Healthcare products Regulatory Agency, should establish an emergency healthcare equipment cross-regulator plan for …
Gov response: No formal government response published. The Northern Ireland Executive had not published a response to the Module 5 report of 14 July 2026 when the Executive Office's publications list was checked on 25 September 2026.
No response yet
42 — Register external reviews with CQC
Recommendation: We further recommend that all external reviews of suspected service failures be registered with the Care Quality Commission and Monitor, and that the Care Quality Commission develops a system to collate learning from reviews and disseminate it to other Trusts. …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: 43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, …
Accepted
In progress
IBI-10a(v) — Yellow Card System Prominence
Recommendation: Steps be taken to give greater prominence to the online Yellow Card system to those receiving drugs or biological products, or who are being transfused with blood components.
Words of: UK Government, Full Government Response to the Infected Blood Inquiry's May 2024 Report (CP 1318), presented to Parliament by the Minister for the Cabinet Office, 14 May 2025
Gov response: The online Yellow Card system is UK wide and therefore this recommendation has been addressed on a UK wide basis. The Yellow Card system has provided vital feedback, but we agree with the inquiry that …
Accepted
25 — Duty to report external investigation findings
Recommendation: We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
Gov response: 43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, …
Accepted
In progress
ICL-2 — New LPG Safety Regime
Recommendation: A new safety regime should be put in place governing the installation, maintenance, monitoring and replacement of all LPG systems.
Words of: HM Government (Department for Work and Pensions), The Government response to the ICL Inquiry Report (Cm 7849), March 2010
Gov response: A key theme that emerged from stakeholders was the view that the existing legislative framework already allows for Lord Gill’s objectives to be achieved providing that it is supported by improved guidance, compliance and enforcement …
Noted