F104

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: CQC

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

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

Recommendation, verbatim from the inquiry

●Inquiry recommendation

The Care Quality Commission should be enabled to exploit the potential of the safety information obtained by the National Patient Safety Agency or its successor to assist it in identifying areas for focusing its attention. There needs to be a better dialogue between the two organisations as to how they can assist each other.

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 September 2024, in commentary published in February 2026, the Department of Health and Social Care and NHS England stated that patient safety incident reports are provided to the Care Quality Commission (DHSC and NHS England, Feb 2026). In May 2024, the Thirlwall Inquiry legal team noted that the recommendation had been accepted and cited earlier updates regarding joint safety work between both organisations (The Thirlwall Inquiry legal team, May 2024). The department had previously reported the recommendation completed in February 2015, stating that the commission had secured free access to incident reporting information collected across national systems (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.
A new start – Consultation on changes to the way Care Quality Commission regulates, inspects and monitors care set out the Care Quality Commission’s intentions to gather information from a range of sources to inform its work. It noted that the Care Quality Commission’s Chief Inspectors will use the expert judgements of their teams of inspectors, together with information and evidence held both by the Care Quality Commission and its partners in the system, to provide a single, authoritative assessment of the quality and safety of care services.
A New Start made clear that the Care Quality Commission would be looking, among other things, at whether a service is safe (i.e. people are protected from physical, psychological or emotional harm) and set out proposals for safety indicators. The consultation closed on 12 August 2013, and responses were considered alongside the recommendations from the Berwick Review, Improving the Safety of Patients in England, which included recommended actions around better streamlining of data requests via the Care Quality Commission acting as the coordinating hub for intelligence about quality and safety of care. On 17 October 2013, the Care Quality Commission published the responses to its consultation in A new start: Responses to our consultation on changes to the way Care Quality Commission regulates, inspects and monitors care services, which showed that there is broad agreement with the new approach.NHS England and the Care Quality Commission are committed to working together to develop a shared and agreed approach to measuring safety in the NHS, both for regulatory and improvement purposes. They are working to develop a set of patient safety measures that are best suited for use the Care Quality Commission in their surveillance model and NHS England is providing patient safety expertise on how patient safety data might be used by the Care Quality Commissions for its surveillance and inspection processes. A joint statement between NHS England and the Care Quality Commission is being published setting out how the two organisations will align their work to support inspection and surveillance work for safety.
The National Clinical Assessment Service, previously a division of the National Patient Safety Agency transferred to the NHS Litigation Authority in April 2013. The NHS Litigation Authority is also putting in place an information sharing agreement with regulators, which will include relevant information relating to the National Clinical Assessment Service.

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 in progress · 27 Feb 2026

NHS England patient safety incident reports are provided to the CQC. Please see response to recommendation 35 for information on how NHS England works in partnership with CQC.

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 – Ongoing”. Table row: section 18.2 No. 104, PDF page 474.

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

NHS England and the Care Quality Commission have worked jointly to ensure a shared view of patient safety data (and what it means) is developed, and that this is reflected in the new Care Quality Commission’s surveillance model for acute and specialist NHS trusts. The Care Quality Commission now has free and unfettered access to all incident reporting information collected by the National Reporting and Learning System and through the Strategic Executive Information System. The Care Quality Commission and NHS England’s Patient Safety Domain regularly meet to share information, review and co-develop initiatives to improve patient safety. For example, NHS England and the Care Quality Commission have co-developed a new set of indicators that are used in the Care Quality Commission’s Intelligent Monitoring system. In March and July 2014, the Care Quality Commission updated its surveillance model for acute and specialist NHS trusts.

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 Care Quality Commission, 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 and the Care Quality Commission were working together to develop a set of patient safety measures and were publishing a joint statement between them on how the two organisations would align their work.

In the February 2015 Culture Change Report, the Government said that NHS England and the Care Quality Commission had worked jointly to ensure a shared view of patient safety data, which was reflected in the Care Quality Commission’s new surveillance model. The Government also stated that the Care Quality Commission had free and unfettered access to all incident reporting information collected by the National Reporting and Learning System and through the Strategic Information System.

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. 104, PDF page 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.