BRIS-108

Conduct priority studies to establish baseline of NHS sentinel events

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

Government responseNot tracked (historical inquiry)

DeliveryDHSC and NHS England say completed (Feb 2026)

Recommendation, verbatim from the inquiry

●Inquiry recommendation

Major studies should, as a matter of priority, be carried out to investigate the extent and type of sentinel events in the NHS to establish a baseline against which improvements can be made and measured.

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 say completed · 27 Feb 2026

There are several examples of baselines having been established against which improvements can be made and measured e.g. MMBRACE, subsequent Public Inquiries.

The NHS Patient Safety Strategy (2019) is NHS England’s long-term approach to continuously improving patient safety. It includes major programmes including the Learn from Patient Safety Events (LFPSE) service to improve data collection and analysis of patient safety incidents; and the Patient Safety Incident Response Framework (PSIRF) which overhauls the way Trusts respond to patient safety incidents with a focus on more effective learning and engaging families. See recommendation 109 below.

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 – Closed”. Table row: section 6.2 No. 108, PDF page 119-120.

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 said that the National Patient Safety Agency was piloting a system for establishing a national database of adverse incidents and near misses to provide a baseline against which future improvements could be judged.

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. 108, PDF page 107.

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.