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
Lack of a serious untoward incident protocol
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- EAM Caregroup
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
-
EAM Caregroup
Implement a Serious Untoward Incident reporting policy to structure incident reporting and investigations.
-
Concerns raised1
Delays in receipt of Serious Incident Analysis reports
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to escalate Emergency Department incidents for Serious Incident Review
This report raised 4 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.
-
Concerns raised1
Failure to conduct a serious incident report into a preventable death
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barking, Havering and Redbridge University Hospitals NHS Trust
- NHS England
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
-
Barking, Havering and Redbridge University Hospitals NHS Trust
Review externally reported deaths weekly through Morbidity and Mortality sessions, identify lessons and provide feedback to referring hospitals.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Complete the ongoing Significant Incident investigation into the death.
-
Barking, Havering and Redbridge University Hospitals NHS Trust
Investigate the identified examination and specialist-advice failures through the ongoing Significant Incident investigation.
-
NHS England
Seek assurances from the Trust that concerns have been addressed in line with the Serious Incident Framework.
-
Concerns raised2
Failure to automatically treat ligature incidents as SIUs
Lack of clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger investigation
This report raised 2 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.
-
Concerns raised1
Failure of the serious-incident review and learning system
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.
-
Concerns raised1
Failure to conduct Serious Incident Reviews after deaths
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Milton Keynes Safeguarding Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Milton Keynes Safeguarding Board
Commission a multi-agency learning review to identify lessons, improve practice and reduce the likelihood of similar cases.
-
Milton Keynes Safeguarding Board
Undertake the multi-agency learning review, including practitioner engagement, case-report analysis, concern analysis and a practice-improvement report with dissemination recommendations.
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Concerns raised1
Failure to complete cold debriefs and interim incident reports
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.
-
Concerns raised1
Incident investigation failing to identify deficient post-operative care
This report raised 7 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.
-
Concerns raised1
Failure to identify and investigate matters meeting Serious Incident criteria
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Free London 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.3
-
Royal Free London NHS Foundation Trust
Establish joint serious incident investigations with the mental health trust for future incidents involving hospital-provided care.
-
Royal Free London NHS Foundation Trust
Agree a new incident management pathway with the mental health trust clinical lead.
-
Royal Free London NHS Foundation Trust
Undertake a Serious Incident investigation into the death by reviewing the mental health trust’s investigation and capturing learning for the hospital.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026