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
Serious Incident Investigation process failing to identify significant care failings and produce a good-quality report
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.
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
Commission and complete an external review of serious-incident reports, policies and procedures.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Serious Incident governance arrangements remain paused because COVID-19 released clinical staff and the Trust awaits national guidance, although reports are being progressed.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Failure to complete a serious incident report on CWB working practices
This report raised 11 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
Make internal reviews following future student suicides standard procedure.
Stated by University of Surrey
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The University was not required to produce a serious incident report because it is not a regulated healthcare service provider.
Stated by University of Surrey
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Concerns raised1
Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams
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 a serious incident investigation after a death
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.
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 governance systems to assess cases as Serious Incidents requiring investigation
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 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
Review unexpected deaths through a multidisciplinary Serious Incident Review meeting, declaring and investigating incidents where appropriate.
Stated by Barts Health NHS Trust -
Action
Appoint three Medical Examiners to review every death on the site.
Stated by Barts Health NHS Trust -
Action
Create a Deputy Medical Director post overseeing Medical Examiners and strengthening patient safety governance assurance.
Stated by Barts Health NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing Trust systems, including multidisciplinary death reviews and medical examiner scrutiny, are considered sufficient to prevent recurrence of missed Serious Incident identification.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of serious incident investigation to determine directly responsible factors
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 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
Obtain future independent clinical opinions under formal terms of reference.
Stated by East and North Hertfordshire Teaching NHS Trust -
Action
Establish a standard operating procedure for LMNS oversight of serious incident investigations and action plans.
Stated by East and North Hertfordshire Teaching NHS Trust -
Action
Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.
Stated by Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
NHS providers and local health partners are responsible for implementing the Patient Safety Incident Response Framework and supporting standards.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to involve primary care contacts in internal or serious incident reviews
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 practices governing GP involvement in Serious Incident Reviews.
Stated by Aneurin Bevan University LHB -
Action
Develop a process and pro forma to share pertinent information and invite GPs routinely to Serious Incident Reviews.
Stated by Aneurin Bevan University LHB -
Action
Use the pro forma to notify GPs of relevant unexpected deaths, request salient information, and invite review participation.
Stated by Aneurin Bevan University LHB
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Action
Liaise with the Primary Care and Community Division after the trial period to review the GP notification process and take forward suggested amendments.
Stated by Aneurin Bevan University LHB
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Concerns raised1
Use of untrained staff to conduct incident investigations
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Council assessments and reviews were undertaken by trained, qualified social workers, not untrained staff.
Stated by City of Stoke-on-Trent
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Concerns raised1
Incorrect quotation of hospital IV morphine dose guidelines in Serious Incident 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 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
Establish trained investigating officers and a team-based process for patient safety incident investigations.
Stated by East Suffolk and North Essex NHS Foundation Trust
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Concerns raised1
Failure of routine clinical governance processes to initiate formal Serious Untoward Incident investigations or similar investigations
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 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
Have senior clinicians undertake Case Review and Lessons Learned reviews for relevant patient-safety concerns.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing incident investigation processes and review were considered sufficient, so a formal serious untoward incident investigation was not undertaken.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Data last updated 7 September 2026