Recurring concern
Failure to verify compliance and effectiveness of implemented safety changes
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Request correctionFirst reported 31 Oct 2014•Latest report 4 Jun 2025
What this concern includes
Includes failures to assess compliance with procedural changes or expectations, review continued compliance with safety alerts, or obtain evidence that implemented safety changes are effective, where the control is intended to assure that corrective or preventive changes have been embedded and work as required.
Not included
- Excludes failures to implement or complete identified safety actions where no separate compliance or effectiveness-verification failure is identified.
- Excludes routine audits or inspections not specifically intended to verify compliance with implemented safety changes or their effectiveness.
- Excludes generic governance, training, documentation or learning deficiencies that are not tied to assurance of a specific implemented safety change, alert or corrective measure.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2014–2025
- Stated actions
- 11
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
Lack of evidence that other breakwater deterrence measures are effective
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.2
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Action
Assess whether additional deterrent measures are necessary after monitoring analysis, in cooperation with RNLI and ABP.
Stated by Neath Port Talbot County Borough Council -
Action
Conduct and complete a signage, fencing and barrier review, including risk assessment of deterrence options.
Stated by Associated British Ports
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
Universal signage and access restrictions are impracticable; fencing is cost-prohibitive and may be circumvented by people entering the water around it.
Stated by Royal National Lifeboat Institution
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Concerns raised1
Inadequate assessment of compliance with procedural changes and expectations
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 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
Monitor recommendations from the SOP046 audit through a SMART action plan overseen by the Trust Clinical Audit team.
Stated by East Lancashire Hospitals NHS Trust -
Action
Update the central action-monitoring process by adding Patient Safety Group assurance requirements and informing divisions to include PSII action-plan monitoring in governance meetings.
Stated by East Lancashire Hospitals NHS Trust -
Action
Use the approved divisional report template to govern PSII action plans through the Corporate Patient Safety Group and escalate delays or problems for discussion and support.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised1
Lack of auditing of training, templates and supervision effectiveness
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
Unclear NHS England monitoring of compliance with National Patient Safety Alerts
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
Ask regional colleagues to engage relevant Integrated Care Boards about trusts that remain non-compliant with the patient safety alert.
Stated by NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
NHS England’s national team is not responsible for overseeing NHS Trust compliance with National Patient Safety Alerts.
Stated by NHS England
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Position
ICBs are responsible for local compliance mechanisms, while the CQC is responsible for regulatory enforcement of alert implementation.
Stated by NHS England
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Concerns raised1
Failure to audit compliance with and effectiveness of introduced changes
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
Embed the urgent radiology-results escalation procedure through staff induction, meeting agendas, training, audit and regular review.
Stated by Betsi Cadwaladr University LHB -
Action
Review the clinical-audit approach and align the audit programme with identified risks, including serious incidents and inquest matters.
Stated by Betsi Cadwaladr University LHB -
Action
Roll out the newly procured electronic audit system to improve audit completion and assurance reporting.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Lack of a process to review continued compliance with CAS alerts
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of audit and assurance of departmental safety changes
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.
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
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Action
Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Audit implementation of discharge planning, follow-up and care-coordinator support, then report and review results through safeguarding and Trust governance committees.
Stated by South London and Maudsley NHS Foundation Trust
Data last updated 7 September 2026