First reported 29 May 2013•Latest report 10 Mar 2026
Definition
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
Distinct published reports
Individual concerns
129
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
182
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.
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
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.
Inner South London
Concerns raised2
Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses
Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations
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 concerns
Each 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
Action
Accredit the serious incident review process through SIRAN, revising policies, templates and review arrangements to meet best practice.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Provide RCA methodology training to staff and establish a forum supporting serious-incident reviewers and investigators.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Create a dedicated serious incident review post in the incident division.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Introduce Advanced Clinical Practitioners to support care planning, risk management and identification of Care and Treatment Plan deficiencies.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 25 October 2022.
Action
Implement the Patient Safety Incident Response Framework through a fortnightly working group and human-factors education incorporating learning from this case.
Stated by Central and North West London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 October 2022.
West Yorkshire Eastern
Concerns raised4
Failure to obtain timely and adequate evidence during serious incident investigations
Failure to assess workload and staffing levels in serious incident investigations
Failure to ensure serious incident investigations are conducted by suitably trained and experienced investigators
Failure to ensure serious incident investigations are conducted independently
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Provide the Emergency Department senior nursing team with a memory-capture tool to promote prompt, consistent incident recording and formalise evidence gathering.
Stated by Leeds Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Train staff conducting Patient Safety Incident Response Framework reviews, with ongoing support and updating sessions.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 October 2022.
Action
Deliver bespoke Patient Safety Incident Response Framework documentation sessions for Urgent Care senior staff with the Risk Management team.
Stated by Leeds Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 3 October 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust disputes that CPR was delayed for 15 minutes, stating that it began within 30 to 60 seconds of the patient being found.
Stated by Leeds Teaching Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
A fully independent investigation was not required because the incident was locally investigated under procedures reserving complete independence for serious incidents.
Stated by Leeds Teaching Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised3
Failure to obtain timely written accounts and interviews from key staff in serious incident investigations
Failure to include and properly weight family evidence in serious incident investigations
Failure to properly consider commissioned expert evidence in serious incident investigations
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 concerns
Each 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
Action
Use a memory-capture document in DATIX alongside immediate interviews and written statements, and reinforce its use across teams.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.
Action
Involve families directly in investigations and include their recollections and concerns, with supporting evidence, in reports.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.
Action
Reference commissioned expert opinions in investigation reports and record reasons when an opinion is not reconciled with the evidence.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
HSIB could not support the requested investigation because its northern branch had not yet been established and operations were limited to southern England.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The external expert opinion was not relied upon because it conflicted with subsequently gathered evidence and was considered less informed than staff accounts.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Failure to identify and escalate deaths through governance procedures as serious incidents for investigation
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 concerns
Each 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
Action
Review governance procedures for detecting potential incidents and emphasise internal incident reporting within clinical divisions.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Introduce incident reporting for all new inquests to formalise divisional review and identify previously unreported incidents.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Delayed stent removal should largely be addressed through individual NHS trust clinical governance systems, led by trust medical directors.
Stated by British Association of Urological SurgeonsRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
Failure of mortality and harm review to identify the need for a Serious Incident Review
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester City
Concerns raised1
Failure of serious incident investigations to obtain relevant information and make additional enquiries
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to revisit patient safety incident harm grading
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 concerns
Each 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
Action
Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Add a full-time clinical staff member to support the strengthened inquest triage and review process.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Avon
Concerns raised1
Inadequate investigation of 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 concerns
Each 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
Action
Complete a second significant event analysis using the revised investigation system.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Undertake a root cause analysis with detailed risk assessment to identify safety actions.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Produce and use a new significant event analysis policy and documentation process for future investigations.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Review the new significant event analysis system at the practice board meeting after its further use in August.
Stated by Air Balloon SurgeryStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Significant event analysis broadly met CQC requirements; root cause analysis is not specifically required and is not generally used in general practice.
Stated by Air Balloon SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised1
Failure of serious incident investigations to identify relevant guidance and explain departures from it
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 concerns
Each 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
Action
Require investigators to use comprehensive literature and independent evidence reviews and address families’ concerns in investigation reports.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Raise investigators’ awareness of Library Services support for searches of clinical guidelines and publications.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Complete a gap analysis of national patient-safety investigation standards against current practice.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Develop revised investigation processes, report templates and investigator guidance informed by the standards gap analysis.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
East London
Concerns raised1
Failure to investigate unexpected care-impacting events through Serious Incident Investigation
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 concerns
Each 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
Position
The incident did not require a Serious Incident investigation because reviews concluded it was not a Serious Incident matter.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes failures of a formal organisational safety-incident or serious-incident management framework, including incident identification, grading, coordination, investigation, monitoring and control.
