Recurring concern
Unreliable formal safety-incident management processes
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Request correctionFirst reported 29 May 2013•Latest report 10 Mar 2026
What this concern includes
Includes failures of a formal organisational safety-incident or serious-incident management framework, including incident identification, grading, coordination, investigation, monitoring and control.
Not included
- Excludes failures limited to implementing corrective actions after incident learning has already been established.
- Excludes generic organisational learning, governance or incident-reporting deficiencies where no serious-incident management process is identified.
- Excludes the underlying clinical or operational hazard and failures in ordinary care that are not part of serious-incident management.
- Excludes investigations concerning deaths, complaints, crime or regulatory matters where the reported concern is not the management of a serious or untoward incident.
- Excludes operational emergency-response, rescue and event-planning protocols that are not part of a formal organisational safety-incident management framework.
- Reports
- 103
- Individual concerns
- 129
- Date range
- 2013–2026
- Stated actions
- 182
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to investigate the case under the Patient Safety Framework
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to investigate deaths under the Patient Safety Framework
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Require multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Clarify in governance arrangements that PSIRF is one learning mechanism and not the Trust’s sole route for reviewing deaths or responding to coronial concerns.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Stated by Department of Health and Social Care
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Position
Existing clinical reviews, mortality review, governance meetings and reflection had identified sufficient learning, so a PSII would not add further learning.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Lack of understanding of when Serious Incident Reports should be made or actioned retrospectively
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Review structured judgement review scores through care-group governance and executive meetings to determine further patient-safety investigation.
Stated by Torbay and South Devon NHS Foundation Trust -
Action
Adopt PSIRF and operate weekly Executive Incident Review Meetings to determine proportionate investigation responses, including retrospective incidents.
Stated by Torbay and South Devon NHS Foundation Trust -
Action
Update and publish the Trust PSIRF policy and plan to reflect new patient-safety insight data.
Stated by Torbay and South Devon NHS Foundation Trust
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Concerns raised1
Failure to investigate what went wrong and why between treating and administration teams
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Stated by the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS England -
Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS England
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Concerns raised1
Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Position
Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Position
Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Failure of patient safety governance to identify incidents requiring investigation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to identify incidents requiring investigation through the Patient Safety Framework
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Issue Trust-wide communication requiring significant or unexpected complications to be recorded on Datix for PSIRF consideration.
Stated by Barts Health NHS Trust -
Action
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Stated by Barts Health NHS Trust -
Action
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to demonstrate compliance with the medication-error management policy
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Update the medication-error policy to align with the Patient Safety Incident Response Framework.
Stated by The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust cannot obtain Responsible Officer feedback or appraisal reflection because the clinician left the organisation and no longer works in the NHS.
Stated by The Trust
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Concerns raised1
Failure to undertake serious incident investigations for learning
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised2
Failure to learn from serious incidents and consider recommendations for future care
Inadequate analysis of serious incidents
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
Stated by University Hospitals Plymouth NHS Trust -
Action
Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
Stated by University Hospitals Plymouth NHS Trust -
Action
Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
Stated by University Hospitals Plymouth NHS Trust
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Action
Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
Stated by University Hospitals Plymouth NHS Trust -
Action
Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
Stated by University Hospitals Plymouth NHS Trust
Data last updated 7 September 2026