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.
Lancashire and Blackburn with Darwen
Concerns raised3
Failure to grade fatal severe harm correctly
Failure to notify external and internal patient-safety bodies of serious incidents
Failure to categorise a death-causing harm event correctly
This report raised 17 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.6
Action
Evaluate the operating effectiveness and consistency of serious-incident controls following PSIRF adoption.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Participate actively in developing regional maternity guidance and principles for consistent identification and reporting of incidents.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Publish and update national guidance on recording patient safety events and levels of harm.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Enhance engagement with level 3 centres to improve handover of maternity events and concerns relevant to external reporting.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Maintain contractual oversight and scrutiny of the Trust’s patient-safety-event reporting, challenging unexpected variation.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Operate a regional procedure for escalating serious maternity patient-safety incidents to regional and national NHS England teams.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Oxfordshire
Concerns raised2
Use of narrowly scoped and time-pressured structured reviews of incidents
Use of incident reviewers with potential conflicts of interest
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 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
Modify the Structured Judgement Review template to prompt reviewers to identify concerns about the review’s scope or focus.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2025.
Action
Require reviewers to confirm before completing a Structured Judgement Review whether they have a conflict of interest.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing Structured Judgement Review process requires whole-record review, allows sufficient time, and enables concerns about care quality to be escalated.
Stated by Oxford University Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure of Serious Incident investigations to identify healthcare failings
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.
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
Operate the Learning Review Group to oversee learning responses, PSIRF adherence and development of improvement actions.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Action
Monitor safety actions and improvement plans through the Improvement Oversight Panel, including scheduled three-month progression reviews.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Yorkshire and York
Concerns raised1
Failure to debrief choking-incident staff within 72 hours
This report raised 9 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
Implement and use a policy requiring a hot debrief or other incident response after relevant events.
Stated by York and Scarborough Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 October 2024.
East London
Concerns raised1
Inadequate patient safety incident investigations
This report raised 1 other concern. 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.
Birmingham and Solihull
Concerns raised1
Automated Datix review and approval failing to ensure human identification of patient-safety incidents
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 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
Incidents are not automatically approved: every incident receives individual review before closure, although low-harm records are automatically stamped after managerial review.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Central and South East Kent
Concerns raised1
Failure of the hospital SI process to include information from family and other interested persons
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 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.6
Action
Transition incident management to the Patient Safety Incident Response Framework, including patient and family involvement.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Action
Adopt NHS guidance on engaging and involving patients, families and staff after patient safety incidents.
Stated by East Kent Hospitals University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024.
Action
Update the Incident Management Policy to strengthen patient and family involvement, subject to ratification.
Stated by East Kent Hospitals University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024.
Action
Use the national Patient Safety Incident Investigation report template and include patient and family involvement in learning response reports.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2024.
Action
Implement a Learning Response Review and Improvement Tool for peer review of reports.
Stated by East Kent Hospitals University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2024.
Action
Establish a Peer Review Panel to review learning response reports.
Stated by East Kent Hospitals University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
No actions by NICE are considered necessary to address the issues raised in the report.
Stated by National Institute for Health and Care ExcellenceNo action considered necessaryThe respondent said that no further action was needed.
Position
The concerns are local Trust issues outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
East London
Concerns raised2
Failure of serious incident investigations to identify relevant reviewing clinicians
Unfit serious incident investigation reports
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.
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
Use the Patient Safety Investigation Response Framework with multidisciplinary investigations and centrally allocated investigating officers.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Action
Operate a weekly Incident Oversight Learning Group to review concerning incidents and commission further learning responses where needed.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Action
Require Learning Review Group sign-off with Board Executive attendance for quoracy when approving patient safety investigations.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 4 July 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust will respond separately to the concerns about care and processes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised2
Failure to ensure factual accuracy in Serious Incident Review reports
Delays in completing Serious Incident Reviews
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 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.4
Action
Correct inaccuracies in the Serious Incident Review and reshare the amended report with relevant safeguarding teams.
Stated by Manchester City CouncilStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Share consultation agencies’ information for review and accuracy checking before finalising Serious Incident Reviews.
Stated by Manchester City CouncilStated plannedThe respondent said that this action was planned when they made their response on 27 June 2024.
Action
Establish a service-wide system to ensure investigations are completed in a timely manner.
Stated by Manchester City CouncilStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Implement processes preventing investigations from depending on a single person.
Stated by Manchester City CouncilStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Rutland and North Leicestershire
Concerns raised1
Failure of serious incident investigations to robustly and critically examine all relevant care issues
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
Run a rapid improvement programme using quality-improvement methodology to identify improvements to the serious-incident investigation and reporting process.
Stated by Leicestershire Partnership NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2024.
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Includes failures of a formal organisational safety-incident or serious-incident management framework, including incident identification, grading, coordination, investigation, monitoring and control.
