Ensure patients receive acknowledgement, explanation, and apology when care goes wrong

Bristol Heart Inquiry · Bristol Heart Inquiry — Final Report · Issued 18 July 2001

Government responseNot tracked (historical inquiry)

DeliveryDHSC and NHS England state no delivery position (Feb 2026)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

When things go wrong, patients are entitled to receive an acknowledgement, an explanation and an apology.

Bristol Heart Inquiry, Bristol Heart Inquiry — Final Report · 18 Jul 2001 Source PDF →

Government response

●No formal government response recorded

The Index has not yet recorded a verbatim government response to this recommendation.

Delivery

●DHSC and NHS England state no delivery position · 27 Feb 2026

Please see our response to Recommendation 33 (duty of candour). Under regulation 20(3)(d) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936), a notification given to a person by a registered person discharging its duty of candour must include an apology.

Saying sorry meaningfully when things go wrong is vital for everyone involved in an incident, including the patient, their family, carers, and the staff that care for them. It is part of the Duty of Candour. NHS Resolution publish supporting guidance.

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 Their reviewed extent of implementation reads “Superseded (Duty of candour implemented following Mid Staffordshire Inquiry 2013)”. Table row: section 6.2 No. 34, PDF page 86-87.

What other bodies have found

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

●Thirlwall Inquiry legal team · 15 May 2024

The Government agreed with this recommendation.

In its January 2002 response, the Department of Health referred to the entitlement of patients to a full explanation and apology when something went wrong, whether or not they wished to make a complaint. The Department said that current complaints procedure provided for acknowledgements to be made within 2 days; full investigation and resolution within 20 working days; and an explanation and/or apology to be offered as appropriate.

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 6.2 No. 34, PDF page 83.

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.