F88

Information sharing

Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013

Government responseDepartment of Health and Social Care: Accepted in part (Nov 2013)

DeliveryDHSC and NHS England say completed (Feb 2026)Department of Health and Social Care says in progress (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

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 to provide a check on the consistency of trusts' practice in reporting fatalities and other serious incidents.

Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →

Published evidence summary

AI-generated evidence summary

The Department of Health and Social Care and NHS England stated in September 2024 that the recommendation was implemented and closed, reporting that the Care Quality Commission has a Memorandum of Understanding with the Health and Safety Executive covering statutory incident notifications (DHSC and NHS England, Feb 2026). Previously, in May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted in principle and that an agreement between the two regulators had been concluded in December 2017 (The Thirlwall Inquiry legal team, May 2024).

AI-generated summary of the record on this page, checked by a second model and automatic checks, 26 Sep 2026.

About this summary
This recommendation applies across many organisations. The record above reflects central policy activity; adoption in individual organisations may vary.

Report-level response context

Government responded via "Hard Truths: The Journey to Putting Patients First" (2014), a single document covering all 290 recommendations with a blanket acceptance. Individual recommendation responses were not broken out.

Government response

●Department of Health and Social Care · Accepted in part · 19 Nov 2013

Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013

Accepted in principle.
Access to accurate and up to date information and intelligence is essential to the effective regulation of health and adult social care providers by the Care Quality Commission. In practice, few patient incidents fall under the category of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) and the Care Quality Commission would in any case be informed of these incidents through the statutory notifications that registered providers are required to make them. In addition, there is an information sharing agreement in place between the Health and Safety Executive and the Care Quality Commission. Currently, in addition to the information shared via the Liaison Agreement, the Health and Safety Executive shares quarterly investigated RIDDOR accidents, complaints, and enforcement and prosecution notices data.. This information will be shared on a more frequent basis under new working arrangements and will be reflected in the liaison agreement between the Care Quality Commission and the Health and Safety Executive.

Response document: Hard Truths: The Journey to Putting Patients First. Volume Two of the Government Response to the Mid Staffordshire NHS Foundation Trust Public Inquiry: Response to the Inquiry's Recommendations

Site note: This is volume two of "Hard Truths: The Journey to Putting Patients First" (Cm 8777-II), the government's response to the Inquiry's 290 recommendations, published by the Department of Health on GOV.UK on 19 November 2013 and dated to that day here. The PDF the row links to is the accessible edition, whose title page reads "January 2014". The Department of Health has been the Department of Health and Social Care since January 2018. The volume says it includes accounts from each of the national organisations the recommendations name, but it does not mark which passage each organisation wrote, so every row is filed under the Department that published it.

Delivery

●DHSC and NHS England say completed · 27 Feb 2026

CQC have a Memorandum of Understanding with the HSE. As outlined in the MOU, '18. The statutory requirements for the notification of incidents to CQC and HSE include RIDDOR and CQC’s notification requirements.'

Registered Providers are required to notify CQC of a variety of notifiable incidents under the Care Quality Commission (Registration) Regulations 2009 – this includes death of a service user, certain injury to a service users, allegations of abuse, incidents reported to or investigated by police. Failure to notify CQC of such incidents can amount to an offence under Regulation 25 of the 2009 Regulations.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025)

Site note: DHSC and NHS England's own account of progress, supplied to the Thirlwall Inquiry in September 2024 and printed in the Inquiry legal team's Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version dated April 2025, published 27 February 2026). It is not a finding of the Inquiry. Their reviewed extent of implementation reads “Implemented – Closed”. Table row: section 18.2 No. 88, PDF page 467-468.

●Department of Health and Social Care says in progress · 11 Feb 2015

The Health and Safety Executive, the Department of Health and the Care Quality Care are taking forward the recommendations of the Francis Inquiry and the Health and Safety Executive’s Triennial Review with regard to the relationship between the Health and Safety Executive and the Care Quality Commission. The Care Quality Commission have consulted on a revised liaison agreement setting out their working arrangements including their criteria for referrals and prosecutions and better co-operation in the underpinning information-sharing arrangements. The final liaison agreement will be published in April 2015. Currently, the Health and Safety Executive shares quarterly investigated Reporting of Injuries, Diseases and Dangerous Occurrences Regulations accidents, complaints, and enforcement and prosecution notices data. This is part of the joint work by the Health and Safety Executive and the Care Quality Commission that is set out in a liaison agreement.

The agreement will make clear that when fundamental standards are in place, the Care Quality Commission will have the lead role in considering whether to take enforcement action on safety incidents which affect people using services registered with it. The Health and Safety Executive or local authorities will have the lead in considering whether to take enforcement action on safety incidents affecting people using other health and care services, and for safety incidents affecting staff and the public in all services. The new liaison agreement will also set principles for case-by-case decisions on which regulator will take the lead in complex situations.

This greater simplicity and clarity about when each regulator will take the lead, is expected to result in an increase in enforcement activity by Care Quality Commission. The Health and Safety Executive is providing Care Quality Commission with support and practical assistance, to help it build up the necessary capability to deliver this.

From: Culture Change in the NHS supporting Annex (annex to Culture change in the NHS: applying the lessons of the Francis Inquiries)

Site note: This is the supporting annex published on 11 February 2015 with "Culture change in the NHS: applying the lessons of the Francis Inquiries" (Cm 9009), attached to the GOV.UK page as "Culture change in the NHS supporting annex". The annex has no title page; that title is GOV.UK's and the PDF's own. Its table has four columns (No., Recommendation, Hard Truths Government response, Progress update), and the row carries the Progress update cell. No column says which organisation wrote an update, so the row is filed under the Department of Health (now the Department of Health and Social Care), which published it.

Site note: The Inquiry addressed this recommendation to the Health and Safety Executive, not to the Department of Health. The annex gives this update in the Department's publication and does not say who wrote it, so the row is the Department's report of the progress made on it.

What other bodies have found

In their own words. These do not change the delivery statement above.

●Thirlwall Inquiry legal team · 15 May 2024

This recommendation was accepted in principle by the Government.

In the January 2014 Hard Truths report, the Government said that few patient incidents fell under the category of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations and that the Care Quality Commission would in any case be informed of these incidents through the statutory notifications that registered providers are required to make. However, information between the Health Safety Executive and the Care Quality Commission would be shared on more frequent basis. The Government said that, at the time of the February 2015 Culture Change report, the Health and Safety Executive shared quarterly investigated Reporting of Injuries, Diseases and Dangerous Occurrences Regulations accidents, complaints and enforcement and prosecution notices data. also referred to a revised liaison agreement between the Health and Safety Executive and the Care Quality Commission. A Memorandum of Understanding was agreed between the two in December 2017.

From: The Thirlwall Inquiry: Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024)

Site note: The Thirlwall Inquiry legal team's own notes on implementation, from its Review of Implementation of Recommendations from Previous Inquiries into Healthcare Issues (version of 15 May 2024). The review does not colour its Extent of Implementation cell for this recommendation green; it leaves the cell uncoloured where a recommendation was rejected, where evidence of implementation was insufficient, or where steps had been taken but implementation was not yet complete. Table row: section 16.2 No. 88, PDF page 432-433.

How this page is built

The recommendation and the government responses are verbatim from primary documents. Delivery statements and other bodies' findings are shown in their own words, each with its source. The summary is written by this site and labelled as such. The Index does not paraphrase sources or characterise intent; it records what has been published.