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.
County Durham and Darlington
Concerns raised1
Failure to complete serious incident investigations within required timescales
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.8
Action
Maintain direct oversight of serious incident review performance and brief the Quality Assurance Committee and Board.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Contract additional expert capacity to address delayed serious incident reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Increase internal capacity by engaging leaders to complete incident reviews and prevent further delays.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Adopt daily patient-safety-huddle processes to identify the required type of incident review earlier.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Operate weekly review-progress meetings and monitor performance against the improvement trajectory.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Modify documentation, review report templates and use standard operating procedures to support efficient review workflows.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Action
Expand subject-matter-expert categories to lead specific review types.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Contract an external professional incident-review provider.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Exact completion dates for some serious incident reports cannot be predicted because final reports may not be available for review on time.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Leicester City and South Leicestershire
Concerns raised1
Failure of Serious Incident investigations to provide robust critical analysis and identify learning for patient safety
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.2
Action
Review the original Serious Incident report with input from the previously unavailable Locum Consultant.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 September 2023.
Action
Obtain accreditation for the Trust’s Serious Incident investigation and review processes through the Royal College of Psychiatrists’ accreditation network.
Stated by Leicestershire Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 September 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current serious incident reporting processes meet a high standard, as demonstrated by national accreditation and subsequent improvement since the case investigation.
Stated by Leicestershire Partnership NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
County Durham and Darlington
Concerns raised2
Failure to promptly obtain, secure and preserve relevant serious-incident evidence
Extensive and continuing delays in investigating serious incidents
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.23
Action
Contract and allocate additional expert reviewers to address delayed incident reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Use an external specialist company to review historical incident data and identify risks from delayed reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Adapt processes to identify the required incident review type earlier through daily patient safety huddles.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Hold weekly review-progress meetings, provide reviewer support and monitor performance against the review trajectory.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Modify documentation, review report templates and use standard operating procedures to improve efficient review workflow.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Continue expanding subject matter expert categories to lead specific types of incident reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Establish Associate Director of Patient Safety and Deputy Chief Nurse roles to oversee review quality and support reviewer supervision.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Contract and deploy additional expert capacity to address delayed incident reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Increase internal clinical and leadership capacity to complete incident reviews and prevent further delays.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Report weekly to Executive Directors on Duty of Candour compliance and review-related delays.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Use an external incident-management specialist to review historical incident data and identify risks from delayed reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Identify required review types earlier through daily patient-safety huddles using national PSIRF guidance.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Hold weekly review-progress meetings and monitor performance against the established trajectory with executive reporting.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Modify documentation, review report templates and use standard operating procedures to improve review efficiency and workflow.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Increase Serious Incident Review Panel capacity to support quality assurance without delaying release of completed reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Continue expanding subject-matter-expert categories to lead specific types of incident reviews.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Establish senior patient-safety leadership roles to oversee review standards and provide reviewers with support and supervision.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Complete inspections of six inpatient and community mental health services and the trust’s leadership and governance.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Serve a requirement notice requiring the trust to resolve serious incident, mortality, incident review and complaints backlogs and prevent recurrence.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 28 July 2023.
Action
Continue monitoring the trust’s progress in removing the serious incident backlog through the monthly quality board.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Action
Monitor the trust’s compliance with the requirement concerning serious incident, mortality, incident review and complaints backlogs and take regulatory action if improvement is inadequate.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Oversight of investigation quality is limited to inspecting and acting on delays or flaws in a provider’s investigation system.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The trust’s commissioners are better placed to improve the quality of the trust’s serious incident investigation processes.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Omissions from serious incident investigations
This report raised 14 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.1
Action
Review the Trust’s responses and related reports to determine whether further action is needed.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 22 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Many concerns concern East London Foundation Trust and Metropolitan Police policy, making NHS England inappropriate to respond to them.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Milton Keynes
Concerns raised1
Failure of incident investigations to provide detailed, evidence-challenging analysis
This report raised 6 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 patient's 9 July presentation was not typical for peritonitis, making the criticism of the diagnostic approach less clear-cut.
Stated by Milton Keynes University Hospital NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
East London
Concerns raised1
Failure of serious incident investigation to address risk-assessment and reporting deficiencies
This report raised 14 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.1
Action
Review Serious Incident processes and revisit the adequacy of evidence and learning captured in reports.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottinghamshire
Concerns raised1
Failure to follow the Mortality Review policy and complete serious incident reviews promptly
This report raised 6 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
Review and revise the mortality governance policy against neighbouring Trusts, national guidance, and identified failings, then seek governance-group approval.
Stated by UHDBStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2023.
Action
Generate and audit 72-hour reports for severe-harm incidents and unexpected deaths to assure proportionate review and compliance.
Stated by UHDBStated completedThe respondent said that this action was complete when they made their response on 27 April 2023.
Action
Disseminate the revised mortality review policy through Divisional presentations, Trust learning fora, and the Senior Leaders forum.
Stated by UHDBStated plannedThe respondent said that this action was planned when they made their response on 27 April 2023.
Worcestershire
Concerns raised1
Failure of internal investigation coordination and learning from patient-safety incidents
This report raised 7 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.
Inner North London
Concerns raised1
Failure of serious incident investigations to interview relevant decision makers and provide feedback
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.1
Action
Amend the Serious Incident reviewer responsibilities document to require relevant staff to be contacted through Human Resources for review involvement.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 January 2023.
Birmingham and Solihull
Concerns raised1
Lack of a system to audit incident processing and investigation
This report raised 18 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.1
Action
Audit incident processing through Clinical Oversight Board, joint assurance forums, Defence oversight and a commissioned external review of Sickle Cell Trait risk management.
Stated by Capita PLC and Ministry of DefenceStated plannedThe respondent said that this action was planned when they made their response on 30 December 2019.
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.
