BRIS-112

Conduct structured analysis of sentinel events considering organisational factors

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

All sentinel events should be subject to a form of structured analysis in the trust where they occur, which takes into account not only the conduct of individuals, but also the wider contributing factors within the organisation which may have given rise to the event.

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 refer to our response to recommendation 109.

The Learn from Patient Safety Events (LFPSE) service is a national NHS system for the recording and analysis of patient safety events that occur in healthcare. It supports providers and commissioners to access data in order to better understand their local recording practices and culture, and to support local safety improvement work.

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 Their reviewed extent of implementation reads “Superseded”. Table row: section 6.2 No. 112, PDF page 121.

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 this was already a requirement of its Risk Management System and would be reinforced by root cause analysis of serious incidents. The Department said the National Patient Safety Agency would issue guidance.

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. 112, PDF page 108.

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.