Recurring concern
Unreliable senior oversight of safety incident reviews
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Request correctionFirst reported 26 Oct 2015•Latest report 30 Jan 2025
What this concern includes
Includes failures of senior oversight within safety incident, death or adverse-event review processes, including delayed or absent senior review, inadequate scrutiny of conclusions, failure to challenge deficient findings and failure to initiate appropriate further action after review.
Not included
- Excludes deficiencies in the underlying incident investigation, evidence gathering or factual accuracy where senior oversight of the review is not itself deficient.
- Excludes generic clinical leadership, management oversight or governance failures without a direct safety-incident-review connection.
- Excludes failures to implement safety actions after a properly completed senior review where the review and oversight process itself was reliable.
- Excludes routine clinical review, patient-care review or audit processes that are not reviews of safety incidents, deaths or adverse events.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2015–2025
- Stated actions
- 10
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 senior management involvement in investigations
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.1
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Action
Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.
Stated by Mills Family Limited
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Concerns raised1
Failure to effectively review how deficient investigation reports gain executive approval
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
Require Learning Review Group sign-off with Board Executive attendance for quoracy when approving patient safety investigations.
Stated by Barking, Havering and Redbridge University Hospitals NHS 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 Trust will respond separately to the concerns about care and processes.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of organisational review and investigation systems to act independently of senior management
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.
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
Provide dedicated operational and practical support and a single point of contact for officers and staff giving evidence at inquests.
Stated by Metropolitan Police Service -
Action
Use inquest outcome reviews to identify case-specific learning and wider themes, then share identified improvements through organisational learning.
Stated by Metropolitan Police Service -
Action
Provide managers with guidance following a colleague’s death and apply chief-officer oversight where workplace relationships may be a potential factor in an inquest.
Stated by Metropolitan Police Service
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
The DPS investigation was independent of Learning and Development and did not seek to support its leaders; an independent authority found no misconduct case.
Stated by Metropolitan Police Service
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Position
Inquest witnesses received support while giving their own evidence, including when that evidence was frank or critical of the MPS.
Stated by Metropolitan Police Service
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Concerns raised1
Failure of the clinical oversight board to review or audit near misses
This report raised 18 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
Operate the Joint Lessons Learnt Panel and Learning Account process to investigate incidents, assign recommendations, disseminate learning and monitor completion.
Stated by Capita PLC and Ministry of Defence -
Action
Audit incident processing through Clinical Oversight Board, joint assurance forums, Defence oversight and a commissioned external review of Sickle Cell Trait risk management.
Stated by Capita PLC and Ministry of Defence
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Concerns raised1
Insufficient senior clinical oversight of review conclusions
This report raised 16 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
Establish a senior core group to oversee action-plan implementation and monitor embedding into Trust processes.
Stated by East Lancashire Hospitals NHS Trust -
Action
Introduce weekly Executive review of divisional investigations before SIRI Panel submission.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised1
Delays in senior review of reported incidents
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.1
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Action
Operate daily incident analysis supported by the Patient Safety Team.
Stated by Leicestershire Partnership NHS 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
Daily incident analysis, supported by the Patient Safety Team, is considered sufficient to assure that correct incident-review processes are followed.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised1
Failure of senior staff to correctly review falls incident forms
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.
Data last updated 7 September 2026