Recurring concern
Failure to verify compliance and effectiveness of implemented safety changes
- Reports that mention this concern
- 7
- Times this concern has been raised
- 7
- Stated actions linked to this concern
- 11
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.
What is 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.
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 7 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- Associated British Ports
- Neath Port Talbot County Borough Council
- Royal National Lifeboat Institution
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
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Neath Port Talbot County Borough Council
Assess whether additional deterrent measures are necessary after monitoring analysis, in cooperation with RNLI and ABP.
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Associated British Ports
Conduct and complete a signage, fencing and barrier review, including risk assessment of deterrence options.
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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Royal National Lifeboat Institution
Universal signage and access restrictions are impracticable; fencing is cost-prohibitive and may be circumvented by people entering the water around it.
-
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.
Linked response
- East Lancashire 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.3
-
East Lancashire Hospitals NHS Trust
Monitor recommendations from the SOP046 audit through a SMART action plan overseen by the Trust Clinical Audit team.
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East Lancashire Hospitals NHS Trust
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.
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East Lancashire Hospitals NHS Trust
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.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- 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.1
-
NHS England
Ask regional colleagues to engage relevant Integrated Care Boards about trusts that remain non-compliant with the patient safety alert.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
NHS England
NHS England’s national team is not responsible for overseeing NHS Trust compliance with National Patient Safety Alerts.
-
NHS England
ICBs are responsible for local compliance mechanisms, while the CQC is responsible for regulatory enforcement of alert implementation.
-
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.
Linked response
- Betsi Cadwaladr 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.3
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Betsi Cadwaladr University LHB
Embed the urgent radiology-results escalation procedure through staff induction, meeting agendas, training, audit and regular review.
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Betsi Cadwaladr University LHB
Review the clinical-audit approach and align the audit programme with identified risks, including serious incidents and inquest matters.
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Betsi Cadwaladr University LHB
Roll out the newly procured electronic audit system to improve audit completion and assurance reporting.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- South London and Maudsley 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.2
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South London and Maudsley NHS Foundation Trust
Audit seven-day follow-up and discharges involving patients with unstable diabetes to assess follow-up, communication and forward planning.
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South London and Maudsley NHS Foundation Trust
Audit implementation of discharge planning, follow-up and care-coordinator support, then report and review results through safeguarding and Trust governance committees.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026