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
Lack of a serious untoward incident protocol
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.1
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Action
Implement a Serious Untoward Incident reporting policy to structure incident reporting and investigations.
Stated by EAM Caregroup
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Concerns raised1
Delays in receipt of Serious Incident Analysis reports
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 escalate Emergency Department incidents for Serious Incident Review
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.
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 conduct a serious incident report into a preventable death
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.4
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Action
Review externally reported deaths weekly through Morbidity and Mortality sessions, identify lessons and provide feedback to referring hospitals.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Complete the ongoing Significant Incident investigation into the death.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Investigate the identified examination and specialist-advice failures through the ongoing Significant Incident investigation.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Seek assurances from the Trust that concerns have been addressed in line with the Serious Incident Framework.
Stated by NHS England
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Concerns raised2
Failure to automatically treat ligature incidents as SIUs
Lack of clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger 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 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 of the serious-incident review and learning system
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 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 conduct Serious Incident Reviews after deaths
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 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
Commission a multi-agency learning review to identify lessons, improve practice and reduce the likelihood of similar cases.
Stated by Milton Keynes Safeguarding Board -
Action
Undertake the multi-agency learning review, including practitioner engagement, case-report analysis, concern analysis and a practice-improvement report with dissemination recommendations.
Stated by Milton Keynes Safeguarding Board
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Concerns raised1
Failure to complete cold debriefs and interim incident reports
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 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
Incident investigation failing to identify deficient post-operative care
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 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 identify and investigate matters meeting Serious Incident criteria
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.3
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Action
Establish joint serious incident investigations with the mental health trust for future incidents involving hospital-provided care.
Stated by Royal Free London NHS Foundation Trust -
Action
Agree a new incident management pathway with the mental health trust clinical lead.
Stated by Royal Free London NHS Foundation Trust -
Action
Undertake a Serious Incident investigation into the death by reviewing the mental health trust’s investigation and capturing learning for the hospital.
Stated by Royal Free London NHS Foundation Trust
Data last updated 7 September 2026