BRIS-109

Create single, unified system for reporting and analysing 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

There should a single, unified, accessible system for reporting and analysing sentinel events, with clear protocols indicating the categories of information which must be reported to a national database.

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

The Thirlwall Inquiry has noted action taken in response to this recommendation.

The Patient Safety Incident Response Framework or ‘PSIRF’ (2024) (which replaced the Serious Incident Framework from April 2024) is the framework used by the NHS to develop and maintain effective systems and processes for responding to patient safety incidents.

Since 2004 the NHS has operated a comprehensive national patient safety incident reporting system, initially the National Reporting and Learning System (NRLS) and now the Learn From Patient Safety Events (LFPSE) serviceLFPSE is new national NHS system for the recording and analysis of patient safety events that occur in healthcare.

All reported provider patient safety incident records are collected by LFPSE and the data is available to ICBs and NHS England. Provider incident responses should be consistent with the PSIRF. PSIRF is a requirement under the NHS Standard Contract (from 1 April 2024) and puts a strong focus on compassionate engagement and involvement of those affected by patient safety incidents, including patients, families and staff. Guidance on PSIRF is available.

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. 109, PDF page 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. The National Reporting and Learning System was set up in 2003.

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 colours its Extent of Implementation cell for this recommendation green, which it uses to mark evidence, identified by the legal team, that a recommendation has been clearly implemented. Table row: section 6.2 No. 109, 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.