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