Data and early warning

NHS England and the Department of Health and Social Care should rapidly evaluate advice-and-guidance processes. Patient Safety Learning read this as something to finish before further expansion.

NHS England and DHSC

Standardise assessment of fetal growth, triage, maternal early-warning scores and the recognition of deterioration.

Trusts and royal colleges

Set a dated route to interoperable hospital systems so neonatal information is entered once and can be watched continuously.

NHS England

Make boards monitor every child and baby death, with a fixed route to escalate a worrying trend.

Hospital trusts

Name a lead in each neonatal unit for regular mortality data, reporting to the board.

Hospital trusts

Publish quality information, including league tables, so people can see how services compare.

NHS England

Use data, analytics and technology as a main way of knowing whether care is good.

NHS England

Write a national quality strategy for adult social care, based on evidence.

DHSC

Build a research and data infrastructure so outcomes are actually followed up.

NHS England and NIHR

Restore a clear view of provider quality that boards, ICBs and the public can use.

CQC

Reduce the number of national targets and judge systems on outcomes, including prevention.

Government and NHS England

Monitor outcomes in a way that spots a failing maternity service early.

NHS England

Analyse NHS data inside trusted research environments rather than copying it out.

NHS England and government

Build registries for devices and a clearer record of conflicts of interest and industry payments.

MHRA and NHS

Govern controlled drugs so that one clinician's practice cannot drift without being seen.

NHS trusts

Use a model-hospital dataset so boards can see where they are outliers.

NHS trusts

Require systems to exchange data, rather than locking information inside one supplier.

NHS England

Report those investigations to the board.

Trust boards

Judge any new form by whether it improves care, not by the transaction itself.

Boards

Put trusts with worrying mortality onto an urgent support and improvement footing.

NHS England and regulators

Judge the system by whether children are safer, not by whether process was followed.

Government and local authorities

Put quality accounts, clinical dashboards and NICE quality standards into routine use.

NHS

Share information about a child at risk across health, social care and police.

Local agencies

Publish comparable outcomes and act when a service is an outlier.

NHS and regulators

Use one written route for reporting serious incidents, so fragments of evidence are assembled.

Hospitals