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
Failure of the Plastic Surgery department to properly investigate serious untoward incidents
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure of serious incident investigations to critically analyse care and treatment against the Care Plan
Lack of overarching quality assurance for serious incident investigations
This report raised 4 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
Recruit a serious incidents investigation officer with a mandate to improve investigation processes.
Stated by Priory Group -
Action
Deliver investigation and report-writing training to senior staff conducting serious incident investigations.
Stated by Priory Group -
Action
Require senior staff, including the Group Medical Director and Director of Quality, to review every draft serious incident investigation report.
Stated by Priory Group
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Concerns raised1
Lack of robust and effective root cause analysis of serious incidents
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.
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 serious incident investigations to detect significant safety concerns and learning
This report raised 4 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
The serious incident investigation considered relevant actions and decision-making and did not fall short of its intended purpose.
Stated by The Trust
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Concerns raised1
Failure of internal serious incident investigations to identify PEG contraindications
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 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 establish how or why the anticoagulation chart was mislabelled
This report raised 4 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 robust and thorough incident investigations
This report raised 4 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
Inaccuracies in serious incident reviews affecting process validity
This report raised 10 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 the serious incident report to fulfil its learning and accuracy obligations
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 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
Prepare and provide a supplemental Root Cause Analysis report addressing the concerns and learning points from the inquest.
Stated by Epsom and St Helier University Hospitals NHS Trust
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Concerns raised1
Delays in concluding serious incident investigations and 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 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
Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.
Stated by Betsi Cadwaladr University LHB -
Action
Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.
Stated by Betsi Cadwaladr University LHB -
Action
Implement a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.
Stated by Betsi Cadwaladr University LHB
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
Legal advice was required before the investigation report could be signed off, delaying completion.
Stated by Betsi Cadwaladr University LHB
Data last updated 7 September 2026