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 identify serious incidents and remediate sub-optimal practice
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
Implement the Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.
Stated by Barts Health NHS Trust -
Action
Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.
Stated by Barts Health NHS Trust -
Action
Recruit a learning-from-deaths lead to drive improvement and engage families, medical examiners and coroners.
Stated by Barts Health 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
The case was not classified as a serious incident because reviews concluded that care failures did not cause or alter the outcome.
Stated by Barts Health NHS Trust
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Position
The primarily local concerns are for Barts Health NHS Foundation Trust to address.
Stated by Department of Health and Social Care
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Concerns raised3
Inadequate PSIRF processes for addressing serious patient incidents
Failure to define which statements are to be taken for serious patient incident investigations
Failure to retain recordings of calls for serious patient incident investigations
This report raised 10 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
Revise the patient-safety screening form to prompt retrieval and preservation of available patient-call recordings for investigations and inquests.
Stated by Norfolk and Suffolk NHS Foundation 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
Norfolk and Suffolk NHS Foundation Trust is responsible for addressing the care concerns and providing details of PSIRF implementation.
Stated by NHS England
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Concerns raised1
Failure to properly investigate and risk assess catastrophic injury and death incidents in social housing
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
Establish a procedure and reporting framework for recording high-rise falls fatalities and near misses and identifying when window safety reports are required.
Stated by Sheffield City Council
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Concerns raised3
Failure to identify un-actioned service-involvement requests in post-death incident reviews
Inaccurate identification of required improvements as good practice in post-death incident reviews
Failure to consult families about concerns that could direct post-death incident reviews
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.2
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Action
Complete the further review and addendum to incorporate newly identified information and issues from the inquest findings.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Share the completed review addendum with the coroner and the deceased’s family.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Failure of the local authority to undertake meaningful significant event analysis of care failings
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
Complete and submit the section 44 Safeguarding Adult Review referral for consideration by the Safeguarding Adults Board subcommittee.
Stated by London Borough of Newham -
Action
Convene reflective-practice sessions for frontline operational staff on professional curiosity, cultural needs and risk management in light of the case.
Stated by London Borough of Newham -
Action
Create and circulate an anonymised seven-minute briefing on lessons learned from the case across Adults and Health staff groups.
Stated by London Borough of Newham
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Action
Convene a multi-disciplinary shared learning event with ELFT staff to explore the case themes from clinician and practitioner perspectives.
Stated by London Borough of Newham
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Concerns raised2
Delays in completing serious incident investigations
Failure to preserve evidence while memories are fresh during serious incident investigations
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.
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 PFD appears to arise from unrelated advice about a future investigation, not outstanding concerns from evidence heard at this inquest.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
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Concerns raised1
Serious Event Analysis failing to fully explore relevant risks
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.
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 Practice could not arrange a timely SEA because it received no hospital notification or medical cause of death until after the inquest.
Stated by Limehouse Practice
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Concerns raised1
Failure to carry out a serious incident investigation when records indicate a relevant pre-admission incident
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.
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 complete serious incident investigations in a timely and responsive way
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 undertake an adequately scoped serious investigation of community care incidents
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.6
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Action
Review the case at the Pressure Ulcer Assurance Group to identify further care gaps and learning.
Stated by North East London NHS Foundation Trust -
Action
Ensure incident reports capture concerns across integrated services.
Stated by North East London NHS Foundation Trust -
Action
Implement PSIRF governance processes, including PSIG review of whether incidents require investigation and the appropriate investigation form.
Stated by North East London NHS Foundation Trust
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Action
Investigate all pressure ulcers associated with sepsis through full Patient Safety Incident Investigations.
Stated by North East London NHS Foundation Trust -
Action
Provide Directorate oversight and expert review of category 2–4 pressure-ulcer incidents and stronger or deep-tissue injuries.
Stated by North East London NHS Foundation Trust -
Action
Establish multidisciplinary pressure-ulcer review panels and thematic learning through PSIG and the Pressure Ulcer Assurance Group.
Stated by North East London NHS Foundation 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
CQC criminal enforcement is unavailable because the incident does not meet the relevant enforcement threshold.
Stated by Helen Whately MP
Data last updated 7 September 2026