Recurring concern
Unreliable formal safety-incident management processes
- Reports that mention this concern
- 103
- Times this concern has been raised
- 129
- Stated actions linked to this concern
- 182
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 103 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Incomplete serious incident review lacking formal interviews of relevant clinicians
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cornwall Partnership NHS Foundation Trust
Stated actions 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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Cornwall Partnership NHS Foundation Trust
Ensure all key clinicians within investigation terms of reference participate in future Serious Incident investigations.
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Cornwall Partnership NHS Foundation Trust
Review the Trust’s Serious Incident investigation process.
-
Concerns raised1
Failure to escalate matters for comprehensive serious incident or root cause review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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
Serious incident reviews failing to identify treatment concerns
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Midlands Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Midlands Partnership University NHS Foundation Trust
Review and amend the Serious Incident Review Process, with structured internal and external governance arrangements.
-
Midlands Partnership University NHS Foundation Trust
Employ a full-time Serious Incident Review Co-ordinator and Administrator to support investigations and improve the quality of serious incident reports and reviews.
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Midlands Partnership University NHS Foundation Trust
Require commissioners to conduct a challenge review before signing serious incident reports for release.
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Concerns raised1
Failure to include involved registrars’ input in untoward incident investigations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to undertake a serious incident review after a patient death shortly after discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Surrey and Borders Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Surrey and Borders Partnership NHS Foundation Trust
Contact provider organisations early and agree responsibility for reporting and serious-incident investigations.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Surrey and Borders Partnership NHS Foundation Trust
Responsibility for reporting and leading the serious incident investigation was assigned to the lead provider, while the Trust expected to participate.
-
Concerns raised1
Failure to conduct a formal Serious Incident Investigation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to investigate serious incidents and prevent recurrence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- North West Anglia NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
North West Anglia NHS Foundation Trust
Revise the Trust’s Serious Incident process within the wider quality-improvement programme.
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Concerns raised2
Insufficiently robust post-untoward-incident investigations
Failure of the system for determining the correct level of post-event analysis to be sufficiently robust
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring 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 Untoward Incident Investigation to consider concerns about clinical communication and consultant notification
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure to communicate continuing caller contact to incident managers
Lack of co-ordinated management, monitoring and control of serious incidents
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026