Recurring concern
Inadequate safety incident investigations
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Request correctionFirst reported 13 Dec 2008•Latest report 25 Jun 2026
What this concern includes
Includes initiation, evidence gathering, witness testing, factual accuracy, analysis, timeliness, investigator competence and reporting within investigations of deaths, serious incidents and patient, resident or operational safety events.
Not included
- Police, conduct, regulatory or other investigations not directed at organisational safety learning
- Failure to implement an unrelated safety action not arising from an incident investigation
- Generic governance failures not directly affecting a safety incident investigation or its learning process
- Excludes downstream dissemination, learning and corrective-action controls once the investigation findings have been established.
- Reports
- 244
- Individual concerns
- 316
- Date range
- 2008–2026
- Stated actions
- 447
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 a system for independent investigation and review of serious clinical omissions
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.1
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Action
Reinforce reporting of patient-safety concerns identified during inquest preparation or other reviews, share relevant documents and regularly review inquest cases through the Patient Safety Team.
Stated by East Kent Hospitals University NHS Foundation Trust
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Concerns raised1
Inadequate analysis and organisational learning from clinical incidents
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.2
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Action
Review investigation processes to strengthen clinical oversight and scrutiny of investigation reports.
Stated by South Western Ambulance Service NHS Foundation Trust -
Action
Continue strengthening clinical oversight and scrutiny of investigation reports.
Stated by South Western Ambulance Service 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 process review identified no need for immediate structural changes to investigation processes.
Stated by South Western Ambulance Service NHS Foundation Trust
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Concerns raised1
Failure of internal investigations to identify care-plan deficiencies and prevent their repetition
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.1
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Action
Require dementia expertise to assist investigations involving residents living with dementia.
Stated by Adept Care Homes Limited
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Concerns raised1
Failure of internal investigations to identify important issues in care
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.6
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Action
Obtain or access all relevant healthcare records for future patient safety investigations.
Stated by East Cheshire NHS Trust -
Action
Introduce a standard MDT review commissioning email template specifying required clinical specialities and professional groups.
Stated by East Cheshire NHS Trust -
Action
Develop an MDT review quick-reference guide for consistent patient safety reviews.
Stated by East Cheshire NHS Trust
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Action
Update the MDT review report template with prompts covering clinical referral processes and other key enquiry areas.
Stated by East Cheshire NHS Trust -
Action
Deliver focused MDT review and After Action Review training through specialty and departmental meetings alongside the established Patient Safety Investigation programme.
Stated by East Cheshire NHS Trust -
Action
Embed MDT review training as an ongoing resource and support clinical leaders to cascade learning across clinical teams.
Stated by East Cheshire NHS Trust
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Concerns raised1
Failure to investigate falls and implement adequate learning actions
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.
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
Review every reported patient fall through local and central falls-team processes, identify learning, and implement appropriate corrective actions.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Disseminate fall-related learning and required actions to ward staff through Listen Learn Share forms and electronic RADAR alerts.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Action
Provide falls training covering the learning identified from the incidents, with staff attendance completed or being arranged.
Stated by University Hospitals Birmingham NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing local and corporate falls reviews, learning, and actions were considered sufficient; no further action was proposed.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Position
The falls team considered no further investigation necessary from its perspective, leaving further investigation to the ward team’s local process.
Stated by University Hospitals Birmingham NHS Foundation Trust -
Position
No further action was considered necessary for the November fall because the patient was receiving end-of-life care under the medical team’s plan.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Failure of patient safety incident investigators to correctly identify retrospective medical record entries
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to learn from communication failures in the care of patients with profound learning disabilities
Failure to investigate the case under the Patient Safety Framework
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
Investigations failing to identify and report safety issues
This report raised 13 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 all future serious incidents in accordance with the PSIRF framework.
Stated by Alternative Futures Group Limited
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Concerns raised1
Failure to investigate deaths under the Patient Safety Framework
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.4
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Action
Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Require multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Clarify in governance arrangements that PSIRF is one learning mechanism and not the Trust’s sole route for reviewing deaths or responding to coronial concerns.
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.2
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Position
BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Stated by Department of Health and Social Care
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Position
Existing clinical reviews, mortality review, governance meetings and reflection had identified sufficient learning, so a PSII would not add further learning.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised2
Lack of robustness in incident learning and patient safety incident investigations
Failure to revisit internal investigations in light of emerging concerns and evidence
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