Recommendation 89

Serious untoward incidents shared with Health and Safety Executive

Accepted in principle
Reports on serious untoward incidents involving death of or serious injury to patients or employees should be shared with the Health and Safety Executive.

The Care Quality Commission is the regulator of the safety and quality of health and adult social care providers in England. Providers registered with the Care Quality Commission are required to notify it of serious untoward incidents involving death or serious injury either directly or through the National Reporting and Learning System in the case of NHS organisations. The Care Quality Commission uses the intelligence that it receives from these notifications as part of its risk assessment. An initial assessment of serious untoward incidents should be carried out by the Care Quality Commission as the specialist inspector of the health and adult social care providers, with the ability to draw on the Health and Safety Executive’s expertise in investigations and prosecutions. This will be set out in the revised Liaison agreement between the Care Quality Commission and the Health and Safety Executive.

Update

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

This 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.