Recommendation 260

Information standards for serious untoward incidents

Accepted in principle
The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied to, and processed by, the Information Centre and, through them, made publicly available in the same way as other quality related information.

Where appropriate to do so, information standards should be applied to the reporting of serious incidents and that such information should be made as transparent and accessible as possible.  The Government also supports the principle outlined in the UK Statistics Authority’s Code of Practice for Official Statistics that statistical producers will publish data that meets the needs of users and are readily available to them alongside a full and frank commentary.

Responsibility for the reporting of patient safety incidents was transferred to NHS England in 2012 following the abolition of the National Patient Safety Agency.  See recommendation 257 for further details.  NHS England publishes patient safety incident data each month from the National Reporting and Learning System, including information on levels and severity of harm to patients.

NHS England is exploring the extent to which information on serious incidents can be disclosed in more detail without breaching the Data Protection Act 1998. It should be noted, however, that information reported on serious incidents is provided specifically to ensure the robust management of the response to a specific serious incident. The reported information is, therefore, sensitive and has to be appropriately protected. It is not collected for the purposes of measuring activity or outcomes and is in that sense very different from other types of information collected by the Health and Social Care Information Centre.

NHS England is reviewing the National Reporting and Learning System with a range of key stakeholders including the Health and Social Care Information Centre.  As part of the review NHS England will consider the reporting of data from the National Reporting and Learning System and the data standards that apply to it to ensure that, where appropriate, they are the same as those applied by the Health and Social Care Information Centre to other data streams.

NHS England is also reviewing the Strategic Executive Information System, the reporting mechanism for both clinical and information incidents, in order to consider procuring a replacement. As information incidents are also reported through the information governance toolkit held by the Health and Social Care Information Centre, consideration will be given by NHS England and the Health and Social Care Information Centre to streamlining these reporting mechanisms to reduce burden.


Work to re-commission the National Reporting and Learning System is underway in NHS England with ongoing stakeholder and expert engagement being used to inform the design phase. The options development and appraisal will be progressed in Q3 and Q4 of 2014/15 with the revised design confirmed by the end of March 2015, subject to approvals. The procurement of the new system will then progress over the 2015/16 financial year.

The current functions of the Strategic Executive Information System and the National Reporting and Learning System will be incorporated; one single incident reporting system is a key tenet of the proposed changes in order to reduce the risks associated with duplication and to streamline reporting processes. Extensive consultation with stakeholders has taken place and the intelligence gathered is now informing the identification and development of a range of possible options to progress the work. The next stage will be to undertake a formal options assessment process, including technical feasibility.

NHS England have published monthly data on Never events reported to the Strategic Executive Information System since April 2014. In order to publish further the Strategic Executive Information System data that is publically comprehensible and does not risk identifying individuals, data fields currently collected in the Strategic Executive Information System will need to be revised. We are working through proposed changes to ensure these data field changes are both technically feasible and acceptable to patients and system users with a view to applying any changes made for the start of FY 15/16.