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F103

Transparency use and sharing of information

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

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

DeliveryDHSC and NHS England state no delivery position (Feb 2026)Department of Health and Social Care says completed (Feb 2015)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The National Patient Safety Agency or its successor should regularly share information with Monitor.

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

In February 2026, the Department of Health and Social Care and NHS England stated that the recommendation was superseded, as the National Patient Safety Agency no longer exists and it is the successor to both that agency and Monitor (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and cited earlier government reporting on data sharing (The Thirlwall Inquiry legal team, May 2024). The department had previously reported in February 2015 that the recommendation was completed, recording that monthly data-sharing arrangements had been established in April 2014 (Department of Health, Feb 2015).

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

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 · 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.
NHS England is actively working directly with Monitor to ensure they have access to patient safety data they require and that they are able to use it appropriately. NHS England agrees that the Care Quality Commission will also play a key role in coordinating the patient safety information to be shared or highlighted with organisations such as Monitor. More widely, NHS England is working to collate and make available a patient safety measurement framework to provide more clarity on patient safety data available, and what it can be used for and not used. Ultimately NHS England, Monitor, the Care Quality Commission and the NHS Trust Development Authority will work to bring together a common dataset for quality which could be used in a consistent way by all commissioners and regulators.
National Clinical Assessment Service previously a division of the National Patient Safety Agency was transferred to the NHS Litigation Authority in April 2014. The NHS Litigation Authority is also developing a data sharing process for sharing relevant information with Monitor, the Care Quality Commission and the NHS Trust development Authority to support patient and staff safety.

Extract from: 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 state no delivery position · 27 Feb 2026

Pursuant to section 281 of the Health and Social Care Act 2012, the National Patient Safety Agency no longer exists. NHS England is the successor to both NPSA and Monitor.

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 “Superseded”. Table row: section 18.2 No. 103, PDF page 474.

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

NHS England and Monitor have established data sharing arrangements for the sharing of National Reporting Learning System data including the agreement to share the National Reporting and Learning System data monthly. This agreement has been in place since April 2014. In addition, the Care Quality Commission’s Intelligent Monitoring system which NHS England has helped to develop now provides the authoritative view of patient safety and wider quality-related data in the NHS.

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 NHS England, 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 by the Government.

In the January 2014 Hard Truths report, the Government said that NHS England were actively working with Monitor to ensure they have access to patient safety data they require and that they will be able to use it appropriately. In the February 2015 Culture Change Report, the Government said that NHS England and Monitor had established data sharing arrangements of the sharing of National Reporting Learning System data, including an agreement to share this data monthly since April 2014.

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. 103, PDF page 439-440.

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.