Recommendation 100

Unreported serious incidents should be shared with a regulator

Accepted in principle
Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.

All serious incidents involving severe harm and death reported by individuals via the on-line e-form, or any route, are routinely shared with the Care Quality Commission on a weekly basis. The Care Quality Commission also receives all incident reports to the National Reporting and Learning System on a weekly basis, regardless of the seriousness of the incident or the source of the report. The Care Quality Commission also has direct access to the national serious incident reporting system, STEIS (the Strategic Executive Information System), which is used by commissioners and providers to report and manage serious incidents in NHS-funded care. It is therefore able to view all the information submitted to that system regarding serious incidents as well.

The government does not support the view at this stage that there should be a mandatory reporting system for all incidents however, as set out in recommendation 98, NHS England and the Care Quality Commission are committed to working together to develop a shared and agreed approach to measuring safety in the NHS, both for regulatory and improvement purposes. NHS England and the Care Quality Commission are working together to agree a set of patient safety measures, including all incidents reported. The Care Quality Commission will also be reviewing its approach to looking at serious untoward incidents as part of our pre-inspection activity.

Update

As set out in the update to recommendation 98, NHS England and the Care Quality Commission have co-developed a new set of indicators that are used in the Care Quality Commission’s Intelligent Monitoring system that flag as at risk or at elevated risk all organisations demonstrating any of the following:

  • potential under-reporting of patient safety incidents as suggested by organisations who are reporting significantly fewer patient safety incidents than other organisations
  • potential under-reporting of patient safety incidents causing death and severe harm as suggested by organisations who are reporting significantly fewer of these kinds of incidents than other organisations
  • potential under-reporting of patient safety incidents involving no harm as suggested by organisations who report a significantly higher proportion of incidents involving harm than other organisations
  • poor organisational commitment to monthly reporting of incidents to the National Reporting and Learning System, as demonstrated by reporting 3 months or less out of six; or
  • where a hospital has significantly lower scores than other organisations in relation to the percentage of staff who report their organisations’ procedures and responses to incident reports are fair and effective via the NHS Staff Survey.