Provide opportunity to report sentinel events in confidence

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

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

NHS England’s patient safety event recording policy encourages staff of all levels to record events which they believe may impact upon the safety of their patients. This includes areas of good practice which can be learned from. NHS England also supports staff to record anonymously, to provide psychological safety where individuals may fear the repercussions of speaking up. The recently introduced Learn from Patient Safety Events (LFPSE) service, the national database of records of patient safety incidents from across England, supports this policy, and allows frontline staff and safety/governance teams to collaboratively develop the record of what happened.

Freedom to speak up

In the case of concerns, NHS England has published a Freedom to Speak Up policy for the NHS which provides the minimum standard for local Freedom to Speak Up policies across the NHS. 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. It is the role of every NHS Board to assess how effective the speaking up arrangements in place are at an organisational level. Freedom to Speak Up is also part of the Care Quality Commission Well Led framework. As such, the Care Quality Commission will consider whether arrangements for speaking up are sufficient and working well.

The Government agreed with this recommendation.

In its January 2002 response, the Department of Health said information reported to the National Patient Safety Agency would be held in confidence.