Recommendation 44

Addressing serious incidents or avoidable harm

Accepted in part
Any example of a serious incident or avoidable harm should trigger an examination by the Care Quality Commission of how that was addressed by the provider and a requirement by the trust concerned to demonstrate that the learning to be derived has been successfully implemented.

The Care Quality Commission’s new approach to inspection includes a published set of ‘Intelligent Monitoring’ indicators for monitoring quality in providers: for the first time indicators in relation to acute trusts were published on 24 October 2013, and these will be published quarterly. The indicators use information on serious incidents and avoidable harm, all of which is valuable to the Care Quality Commission. Whilst it would not be feasible to follow up on every reported  incident of patient  harm as there are more than  250,000  incidents  each year with over  200,000  of these categorised as low  harm incidents, the Care Quality Commission has defined a number of these indicators as “tier one indicators”, which always trigger rigorous follow up action to obtain assurance. Tier one indicators include serious incidents such as “never events”. The Care Quality Commission’s new intelligent hospital monitoring system will also trigger a response whenever there is a statistically significant number of severe harm incidents or avoidable deaths at a provider location. The Care Quality Commission also analyses information over time and takes action on patterns of differences between expected and observed outcomes of care, and patterns of incidents.

The indicators on their own will not be used to draw definitive conclusions or judge the quality of care – that will be a matter for inspection. Instead the indicators will be used as ‘smoke detectors’, which will start to sound if a hospital is outside the expected range of performance for one or more indicators. The Care Quality Commission will then assess what the most appropriate response should be. Providers are required to inform the Care Quality Commission of a range of incidents that may point to failings in the care provided.

The Care Quality Commission will consider further ways to monitor and act on incidents and avoidable harm as its new system of monitoring providers matures, in order continuously to improve its sensitivity to this aspect of quality of care. However, it needs to avoid any duplication with local arrangements for ensuring that providers address serious incidents and avoidable harms and demonstrate learning, as set out in NHS England’s Serious Incident Reporting and Learning Framework. For this reason, while the Care Quality Commission should ensure high priority to responding to concerns about patient safety, it should not follow up any serious incident or avoidable harm, given that other arrangements are in place and the Care Quality Commission needs to target its resources where it will have greatest impact in promoting better quality care.


The Care Quality Commission’s Intelligent Monitoring system triggers a response where there are a statistically significant number of severe harm incidents or avoidable deaths at a provider. ‘Never events’ trigger an automated elevated risk in Intelligent Monitoring which inspectors are expected to follow up individually. The Care Quality Commission uses this information to determine whether to inspect a provider and what line of enquiry to take on inspection.

The Care Quality Commission is currently reviewing internally its role and approach to serious incident reporting and investigations, this includes a thematic probe into complaints, concerns and whistleblowing, a part of which is the examination of what the Care Quality Commission does with this information and how it can be used better.