Intended for healthcare professionals


Reporting patient safety incidents to be mandatory for English trusts from April 2010

BMJ 2009; 339 doi: (Published 11 December 2009) Cite this as: BMJ 2009;339:b5425
  1. Jacqui Wise
  1. 1London

    From April 2010 it will be mandatory for NHS trusts in England to report all patient safety incidents to the National Patient Safety Agency, bringing an end to the current voluntary system.

    Under the new system all 400 NHS trusts in England, including hospitals, primary care trusts, mental health services, and ambulance services, will be obliged to report adverse incidents—for example, when a patient dies unexpectedly or is permanently injured during the course of care. The information will be shared with the NHS regulator, the Care Quality Commission, as part of the new registration process.

    Private and voluntary healthcare providers will be brought into the new registration system from October 2010. From April 2011, primary dental care and private ambulance providers will be required to register with the commission and primary medical care providers from April 2012. The department of health said it was currently looking at how the commission’s registration system can best be applied to these providers.

    A spokesman for the department said, “The new requirement brings consistency under the new registration system for all organisations that provide healthcare, in line with the statutory requirements already in place for other non-NHS providers of healthcare, to ensure services are safe and information is used in a way that helps spread good practice.”

    He added, “We want to encourage trusts to start to apply for registration as early as possible in January and work together with the CQC [Care Quality Commission] so that if any potential problems are identified, these can be addressed in time for registration on 1 April.”

    The department of health said that 90% of NHS organisations already report patient safety incidents directly to the National Patient Safety Agency. Under the new arrangements the data will be shared with the commission which will mean services will not need to report incidents twice.

    Martin Fletcher, chief executive of the National Patient Safety Agency, said, “I believe this new requirement will further strengthen patient safety across the NHS in England. It will also mean trusts will be able to use a national reporting system that already exists, rather than implementing and learning how to use a new one. This will greatly reduce the burden on trusts.”

    Cynthia Bower, chief executive of the Care Quality Commission, said, “The change will enable us to monitor performance and intervene more quickly where providers have not done what they need to. It will also allow us to assess trends and target regulatory efforts where we see common problems.”

    She added: “Health care can be risky and things will go wrong so we must be careful and sensitive in our approach. But this means there is all the more reason to get in place a more robust and responsive system for monitoring and following up.”

    Under the new registration system, the commission has escalating powers, which it said it will use on a case by case basis and not necessarily in order. These include issuing warning notices, penalty notices and fines, imposing various conditions, suspending registration to provide certain services, prosecuting and cancelling of registration (closure).

    However, Katherine Murphy, director of the Patients Association, was sceptical about the new powers. “This announcement represents a welcome step but it will take a huge amount of effort to implement. We hope that the Department of Health will be ready to put in the necessary resources to ensure it materialises,” she said. “We know from speaking to patients and carers that things like serious falls sometimes don’t even make it into patient notes, let alone into a national reporting system. It will be important for carers and patients to have an avenue to challenge non-reporting.”

    Dr Keith Brent, deputy chairman of the BMA’s Consultants’ Committee, commented, “Doctors put the safety of their patients above all other considerations. Despite it being a period when, for short term financial reasons, their time for Supporting Professional Activities, which are used for risk management and other aspects of clinical governance to ensure safe services of ever improving quality, is under threat, that still remains doctors’ primary consideration.”

    Dr Richard Vautrey, deputy chairman of the BMA’s GPs Committee, added, “GP practices already report significant events to their primary care trust and the numbers of reports from GPs has been increasing. I believe this reflects how GPs are engaging more with this agenda.”


    Cite this as: BMJ 2009;339:b5425