Make reporting of sentinel events easy using all communication means

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

Please refer to our response to recommendation 109.

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

NHS England have published a national Freedom to speak up policy for the NHS, applicable to primary care, secondary care and integrated care systems. All NHS organisations and others providing NHS healthcare services in primary and secondary care in England are required to adopt the Freedom to Speak Up Policy as a minimum standard to normalise speaking up for the benefit of patients and workers. This is embedded in the NHS Standard Contract...

Speak Up Direct is available to all health and social care staff who want independent help and support about how to speak up about something.

NHS England’s national Patient Safety Team now performs this function - see the following for examples:

• Patient safety review and response reports • Introducing National Patient Safety Alerts
• National patient safety incident reports

The Government agreed with this recommendation.

In its January 2002 response, the Department of Health said that its aim was for most reports of adverse incidents to the National Patient Safety Agency to be transmitted electronically and that a confidential telephone line would also be established.