Recommendation 88

Access to Health and Safety Executive incident information

Accepted in principle
The information contained in reports for the Reporting of Injuries, Diseases and Dangerous Occurrences Regulations should be made available to healthcare regulators through the serious untoward incident system in order to provide a check on the consistency of trusts’ practice in reporting fatalities and other serious incidents.

Access to accurate and up to date information and intelligence is essential to the effective regulation of health and adult social care providers by the Care Quality Commission. In practice, few patient incidents fall under the category of Reporting of Injuries, Diseases and Dangerous Occurrences Regulations (RIDDOR) and the Care Quality Commission would in any case be informed of these incidents through the statutory notifications that registered providers are required to make them. In addition, there is an information sharing agreement in place between the Health and Safety Executive and the Care Quality Commission. Currently, in addition to the information shared via the Liaison Agreement,  the Health and Safety Executive shares quarterly investigated RIDDOR accidents, complaints, and enforcement and prosecution notices data. This information will be shared on a more frequent basis under new working arrangements and will be reflected in the liaison agreement between the Care Quality Commission and the Health and Safety Executive.

Update

The Health and Safety Executive, the Department of Health and the Care Quality Care are taking forward the recommendations of the Francis Inquiry and the Health and Safety Executive’s Triennial Review with regard to the relationship between the Health and Safety Executive and the Care Quality Commission.  The Care Quality Commission have consulted on a revised liaison agreement setting out their working arrangements including their criteria for referrals and prosecutions and better co-operation in the underpinning information-sharing arrangements. The final liaison agreement will be published in April 2015.

Currently, the Health and Safety Executive shares quarterly investigated Reporting of Injuries, Diseases and Dangerous Occurrences Regulations accidents, complaints, and enforcement and prosecution notices data. This is part of the joint work by the Health and Safety Executive and the Care Quality Commission that is set out in a liaison agreement.

The agreement will make clear that when fundamental standards are in place, the Care Quality Commission will have the lead role in considering whether to take enforcement action on safety incidents which affect people using services registered with it. The Health and Safety Executive or local authorities will have the lead in considering whether to take enforcement action on safety incidents affecting people using other health and care services, and for safety incidents affecting staff and the public in all services. The new liaison agreement will also set principles for case-by-case decisions on which regulator will take the lead in complex situations.

This greater simplicity and clarity about when each regulator will take the lead, is expected to result in an increase in enforcement activity by Care Quality Commission. The Health and Safety Executive is providing Care Quality Commission with support and practical assistance, to help it build up the necessary capability to deliver this.