Information standards
Mid Staffs Inquiry · Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · Issued 6 February 2013
Source — verbatim from the inquiry
●Inquiry recommendation
The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied to, and processed by, the Information Centre and, through them, made publicly available in the same way as other quality related information.
Mid Staffs Inquiry, Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry · 6 Feb 2013 Source PDF →
Published evidence summary
Publicly available evidence relating to this recommendation:
- The National Reporting and Learning System (NRLS) was the longstanding national system for reporting patient safety incidents. It was decommissioned on 30 June 2024 and replaced by the Learn from Patient Safety Events (LFPSE) service, which can be used by all organisations registered with an ODS code including primary care (NHS England, LFPSE).
- LFPSE uses standardised categories and severity classifications for recording patient safety events, providing a more comprehensive national dataset than its predecessor. Data is collected by NHS England and is used for national analysis and learning.
- The Patient Safety Incident Response Framework (PSIRF), which replaced the previous Serious Incident Framework from autumn 2023, changed the approach from mandatory investigation of defined categories to locally-determined proportionate responses. This represents a shift from standardised statistical reporting of serious incidents to a more flexible, learning-focused model.
- Francis recommended that statistical information about serious untoward incidents should meet the same transparency and accessibility standards as other healthcare information, and that data should be supplied to and processed by the Information Centre. While LFPSE centralises patient safety event data within NHS England, the transition from NRLS to LFPSE and from the SI Framework to PSIRF means the statistical landscape for serious incidents is evolving. There is no single nationally agreed statistical metric (such as a rate per 1,000 admissions) that all trusts must report against for serious incidents.
Response — verbatim from government
●Department of Health and Social Care
The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" in March 2013. Key reforms included a new Chief Inspector of Hospitals, strengthened Care Quality Commission inspection regime, a statutory duty of candour, and the fit and proper person test for NHS directors. Volume 2 (Cm 8754) contains the government's detailed responses to each of the 290 recommendations. See: https://assets.publishing.service.gov.uk/media/5a7cd486ed915d63cc65d167/34658_Cm_8777_Vol_1_accessible.pdf
Department of Health and Social Care · 19 Nov 2013 Written response →
Evidence trail — what's actually happened since
- 6 Feb 2023 · Academic Review - Ten Years After Francis Research published 2023 marking ten years since the Francis Report found mixed results. Structural and legislative changes largely delivered (duty of candour, FPPR, CQC overhaul, revalidation, Freedom to Speak Up Guardians). However, cultural change not fully embedded; understaffing, fear of speaking up, and poor complaint handling persist in parts of the NHS. View source → Reasonable Progress
- 11 Feb 2015 · UK Government - Culture Change in the NHS Government published "Culture Change in the NHS" (Cm 9009) reporting progress on all 290 recommendations. Key achievements: 19 hospitals placed in special measures; those trusts recruited 109 additional doctors and 1,805 additional nurses; 129 board-level changes made; excess avoidable deaths fell by 450 in less than a year. View source → Good Progress
- 19 Nov 2013 · UK Government - Hard Truths Vol 1 & 2 Government published "Hard Truths: The Journey to Putting Patients First" (Cm 8777) in two volumes. Vol 1 set out new actions; Vol 2 provided detailed response to each of the 290 recommendations. Approximately 204 of 290 recommendations were fully accepted. View source → Good Progress
Each entry above links to a primary source — gov.uk written statement, consultation response document, or inspection report. The Index does not characterise government intent; it tracks what has been published.
How this page is built
Source and Response are verbatim from primary documents. The Evidence trail records published activity since — written statements, consultation outcomes, inspection findings, parliamentary references. The Index does not paraphrase or characterise intent; it tracks what has been published. Where the evidence is the absence of action (a missed deadline, a slipped timetable), that absence is documented from primary sources rather than inferred.
This recommendation's data is verified periodically against primary sources. The Index is monitored for staleness weekly.