Recurring concern

Unreliable formal safety-incident management processes

Pin Get email alerts Request correction

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

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.

  1. London (East)

    AI-generated summary

    Roy Joseph Godfrey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inadequacy of investigation documentation following a safety incident

    Wider context from the report

    “7. I heard a great deal of evidence from the London Ambulance Service in relation to a thorough investigation they had conducted into this case. They had the assistance of an independent clinical advisor and had identified all of the relevant issues. They had taken all of the action required to address those issues. BUPA Care Homes however had provided a one page document headed “Summary of Investigation”. This was the only investigation document ”

    Source location

    Roy Joseph Godfrey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Blackpool and the Fylde

    AI-generated summary

    Roy Frank Fletcher · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Roy Frank Fletcher, who had a long history of depression, left Parkwood Hospital on 6 July 2010 after exiting through a partially open ward door and following another service user out of the building. He was found deceased at approximately 7.30 pm at a local holiday park, having taken his own life by hanging. The report raised concerns that the Trust’s post-incident review was not sufficiently thorough, including that it had not explored how he exited or whether similar incidents had occurred.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of Post Incident Reviews to thoroughly and comprehensively explore all relevant issues

    Wider context from the report

    “I am concerned that the review undertaken was significantly lacking for the following reasons: • CCTV footage shows that at the relevant time the Deceased shows him following another Service User out of the reception area at the hospital. It seems no steps had been taken to speak to that Service User in order to establish if he had been aware that he was a vehicle for the Deceased’s exit from hospital, and if so on what basis. • Further, the oral evidence provided to the inquiry by ████████ suggested that the review had not explored whether other service users had left the relevant ward, or the reception area of the hospital in similar circumstances. Having concluded this inquest, I now write to the Trust to confirm that in my view the Trust should take action because: • When Post Incident Reviews are undertaken it is important that they are thorough and comprehensive and that all of the relevant issues are explored prior to recommendations being made arising from that review and the organisation making recommendation for remedial action, if any, to be undertaken. • If such reviews are lacking, there is a risk that an organisation may not appreciate whether a problem is a persistent one, potentially helpful changes to procedures may not be put in place and future deaths may occur which may otherwise have been prevented. ”

    Source location

    Roy Frank Fletcher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Worcestershire

    AI-generated summary

    Dana Louise Baker · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Dana Louise Baker was a looked after child whose foster placement broke down, after which she stayed with an adult friend and the following day hanged herself in a public place. The principal concerns were inadequate knowledge, understanding and communication between agencies, and the confidential handling of Individual Management Reviews, which prevented agencies from understanding areas of mutual concern.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to share interagency serious incident reviews

    Wider context from the report

    “(2) The IMR's are kept confidential and not even shared as between Agencies concerned. Some IMR authors indicated that they could not comment on areas of "mutual concern" because they were unaware of the content of other Agency's IMR's. ”

    Source location

    Dana Louise Baker · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.

    Verbatim wording from the response

    “The sharing of IMRs between agencies on the Panel has always been a key element of the SCR process and the more collaborative 'systems approach'”

    Source location

    2014-0242-Response-by-Safeguarding-Children-Board
    Page 2 · response
    Published 29 May 2014

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing guidance and established inter-agency sharing of Individual Management Reviews are considered sufficient to address the concern.

    Verbatim wording from the response

    “I would suggest that the current government guidance contained in Working Together to Safeguard Children 2013, together with the knowledge that Worcestershire Safeguarding Children Board has fully embraced this guidance, would help to address the issue of the sharing of IMRs which you have raised in the Regulation Report. Government guidance has been developed in the time since EW's death and WSCB has responded positively to this change.”

    Source location

    2014-0242-Response-by-Safeguarding-Children-Board
    Page 2 · response
    Published 29 May 2014

    Open published response
Back to top

Data last updated 7 September 2026