Recurring concern
Unreliable root cause analysis processes
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Request correctionFirst reported 3 Dec 2013•Latest report 14 May 2024
What this concern includes
Includes failures of the dedicated root cause analysis process, including initiation, investigator competence and training, evidence and stakeholder input, critical analysis, identification of lessons, action planning, completion and confirmation of resulting actions.
Not included
- Excludes generic incident investigation or organisational-learning failures where root cause analysis is not the specifically identified process.
- Excludes failures in implementing safety actions where no root cause analysis or root cause analysis action plan is involved.
- Excludes generic clinician training deficiencies unrelated to undertaking root cause analysis.
- Excludes deficiencies in the underlying clinical or operational process investigated when the root cause analysis process itself is not unsafe.
- Reports
- 26
- Individual concerns
- 27
- Date range
- 2013–2024
- Stated actions
- 56
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 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 to provide confirmation of fulfilment of Root Cause Analysis recommendations
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
Incomplete action plans annexed to root cause analyses
This report raised 11 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
Update and monitor individual and overarching maternity services improvement action plans through governance boards.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Failure to ensure consideration and implementation of root cause analysis recommendations
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 to implement strategies to prevent recurrence of the identified failure
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.4
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Action
Establish a weekly Serious Incident meeting to review new incidents, report progress, and flag overdue actions.
Stated by Wirral University Teaching Hospital NHS Foundation Trust -
Action
Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
Stated by Wirral University Teaching Hospital NHS Foundation Trust -
Action
Reduce the haemoglobin delta-check threshold from 25% to 20%.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
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Action
Raise the haemoglobin telephone-alert threshold from below 70 g/L to below 75 g/L and audit its operation.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
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Concerns raised1
Failure to make timely progress in addressing previously recognised care failings
This report raised 14 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 obtain key worker input for root cause analysis
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.1
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Action
Review Serious Incident Requiring Investigation policies to require investigators to engage all known stakeholders and services involved in a person’s care.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Concerns raised1
Failure to complete timely and accurate Root Cause Analysis reports
This report raised 15 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.7
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Action
Provide dedicated full-time RCA investigator capacity in the adult mental health directorate.
Stated by Oxford Health NHS Foundation Trust -
Action
Monitor RCA investigation allocation, progress and timeliness weekly, with quarterly reporting to the Board of Directors.
Stated by Oxford Health NHS Foundation Trust -
Action
Survey RCA investigators to assess whether training changes meet their needs.
Stated by Oxford Health NHS Foundation Trust
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Action
Commission an external review of the quality of serious-incident investigations to identify improvements.
Stated by Oxford Health NHS Foundation Trust -
Action
Review RCA investigator training and develop an additional module on involving and working with families.
Stated by Oxford Health NHS Foundation Trust -
Action
Deliver the revised RCA training, including the additional family-involvement module.
Stated by Oxford Health NHS Foundation Trust -
Action
Introduce a standard requiring all investigators to complete refresher RCA training at least every three years.
Stated by Oxford Health NHS Foundation Trust
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 second RCA did not need to revisit immediate actions because the initial review had already identified them and the actions required.
Stated by Oxford Health NHS Foundation Trust
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Concerns raised1
Failure to seek and obtain final RCA reports from external organisations
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 share root cause analyses with relevant internal safety and healthcare leaders
This report raised 8 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
Automatically provide redacted root-cause analyses of relevant deaths to the prison Governor going forward.
Stated by Care UK
Data last updated 7 September 2026