Includes failures of a formal organisational safety-incident or serious-incident management framework, including incident identification, grading, coordination, investigation, monitoring and control.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Department of Health and Social Care16
Barking, Havering and Redbridge University Hospitals NHS Trust10
NHS England10
Care Quality Commission9
Barts Health NHS Trust5
Tees, Esk and Wear Valleys NHS Foundation Trust5
East London NHS Foundation Trust3
Greater Manchester Mental Health NHS Foundation Trust3
Midlands Partnership University NHS Foundation Trust3
Tameside and Glossop Integrated Care NHS Foundation Trust3
General Medical Council2
Great Western Hospitals NHS Foundation Trust2
Leicestershire Partnership NHS Trust2
National Institute for Health and Care Excellence2
Norfolk and Suffolk NHS Foundation Trust2
NHS trust74
Ministerial department19
Healthcare site13
Executive non-departmental public body10
Health and social care service regulator9
English metropolitan district council3
English unitary authority3
Health professional body3
Integrated care board3
Multi-service care provider3
Private limited company3
Registered charity3
Type not available3
Company limited by guarantee2
Health and care professional regulator2
Reports and published responses 103 reports
See individual reports that have raised this concern, and the actions taken in response
East London
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
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.
Linked responses
Barking, Havering and Redbridge University Hospitals NHS Trust
Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Barking, Havering and Redbridge University Hospitals NHS Trust
Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.
Barking, Havering and Redbridge University Hospitals NHS Trust
Require multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.
Barking, Havering and Redbridge University Hospitals NHS Trust
Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.
Barking, Havering and Redbridge University Hospitals NHS Trust
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Barking, Havering and Redbridge University Hospitals NHS Trust
Existing clinical reviews, mortality review, governance meetings and reflection had identified sufficient learning, so a PSII would not add further learning.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Devon, Plymouth and Torbay
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.
Linked response
Torbay and South Devon NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Torbay and South Devon NHS Foundation Trust
Review structured judgement review scores through care-group governance and executive meetings to determine further patient-safety investigation.
Torbay and South Devon NHS Foundation Trust
Adopt PSIRF and operate weekly Executive Incident Review Meetings to determine proportionate investigation responses, including retrospective incidents.
Torbay and South Devon NHS Foundation Trust
Update and publish the Trust PSIRF policy and plan to reflect new patient-safety insight data.
Shropshire, Telford and Wrekin
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.
Linked responses
NHS England
the Shrewsbury and Telford Hospital NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
the Shrewsbury and Telford Hospital NHS Trust
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
the Shrewsbury and Telford Hospital NHS Trust
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
NHS England
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
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.
Linked response
Barking, Havering and Redbridge University Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Barking, Havering and Redbridge University Hospitals NHS Trust
Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Barking, Havering and Redbridge University Hospitals NHS Trust
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Barking, Havering and Redbridge University Hospitals NHS Trust
The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Barking, Havering and Redbridge University Hospitals NHS Trust
Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
No action considered necessaryThe respondent said that no further action was needed.
Barking, Havering and Redbridge University Hospitals NHS Trust
Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
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.
Linked response
Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barts Health NHS Trust
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
East London
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.
Linked response
Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Barts Health NHS Trust
Issue Trust-wide communication requiring significant or unexpected complications to be recorded on Datix for PSIRF consideration.
Barts Health NHS Trust
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Barts Health NHS Trust
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Black Country
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.
Linked response
The Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
The Trust
Update the medication-error policy to align with the Patient Safety Incident Response Framework.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
The Trust
The Trust cannot obtain Responsible Officer feedback or appraisal reflection because the clinician left the organisation and no longer works in the NHS.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
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.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Tameside and Glossop Integrated Care NHS Foundation Trust
A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.
No action considered necessaryThe respondent said that no further action was needed.
Devon, Plymouth and Torbay
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.
Linked response
University Hospitals Plymouth NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
University Hospitals Plymouth NHS Trust
Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
University Hospitals Plymouth NHS Trust
Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
University Hospitals Plymouth NHS Trust
Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
University Hospitals Plymouth NHS Trust
Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
University Hospitals Plymouth NHS Trust
Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.