Recurring concern

Unreliable formal safety-incident management processes

First to latest report 29 May 2013 — 10 Mar 2026

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

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

Reports and published responses 103 reports

See individual reports that have raised this concern, and the actions taken in response

31 Mar2014
London (East)
Concerns raised1
1. Inadequacy of investigation documentation following a safety incident
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
20 Dec2013
Blackpool and the Fylde
Concerns raised1
1. Failure of Post Incident Reviews to thoroughly and comprehensively explore all relevant issues
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
29 May2013
Worcestershire
Concerns raised1
1. Failure to share interagency serious incident reviews
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Worcestershire Safeguarding Children Board
Stated actions 1
1. Worcestershire Safeguarding Children Board
  Share Individual Management Reviews between participating agencies as part of Serious Case Reviews.
Respondent positions 1
1. Worcestershire Safeguarding Children Board
  Existing guidance and established inter-agency sharing of Individual Management Reviews are considered sufficient to address the concern.
  Existing arrangements considered sufficient
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