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
Report-level response context
Government response
●Department of Health and Social Care · Accepted in part · 19 Nov 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.
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.
●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.
What other bodies have found
●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.
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