Recurring concern
Inadequate safety incident investigations
Pin
Get email alerts
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.
-
Concerns raised1
Failure of internal investigations to capture identified care concerns
This report raised 19 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The internal investigation was suspended because continuing it could compromise the police investigation.
Stated by Jeesal Residential Care Services Limited
-
Concerns raised1
Delays in investigating adverse 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.2
-
Action
Operate a new serious-incident process with daily review, executive oversight, rapid learning escalation, appointed investigators and senior reviewers.
Stated by Betsi Cadwaladr University LHB -
Action
Require timely completion and weekly governance tracking of investigations, with advance approval for extensions.
Stated by Betsi Cadwaladr University LHB
-
Concerns raised1
Failure of Plastic Surgeons to attend round-table analysis during SI investigations
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
-
Action
Revise the Serious Incident Reporting and Investigating policy to require crucial staff to attend multidisciplinary round-table discussions.
Stated by Bradford Teaching Hospitals NHS Foundation Trust
-
Concerns raised1
Failure of internal investigation to identify concerns about emergency response and CPR safety
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.2
-
Action
Revise and immediately implement the internal investigation procedure, assigning interim investigations to a fully trained State Registered Nurse.
Stated by Premier Rescue Ambulance Service Ltd -
Action
Investigate the possibility of appointing a qualified independent assessor for future internal investigations.
Stated by Premier Rescue Ambulance Service Ltd
-
Concerns raised1
Failure to trigger serious or untoward incident review following repeated falls
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.
-
Concerns raised1
Serious Incident Investigation process failing to identify significant care failings and produce a good-quality report
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
-
Action
Commission and complete an external review of serious-incident reports, policies and procedures.
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
-
Position
Serious Incident governance arrangements remain paused because COVID-19 released clinical staff and the Trust awaits national guidance, although reports are being progressed.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
-
Concerns raised1
Failure to commence a timely investigation of falls-related matters
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
-
Action
Review the internal coroner process and introduce formal safeguarding-team triage to monitor trends and support risk assessment.
Stated by Anchor Hanover Group
-
Concerns raised1
Failure to formally review falls risk assessments and care policies after a resident death
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
-
Action
Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
Stated by Cole Valley Nursing Home
-
Concerns raised1
Lack of internal review of fatal accident circumstances
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
-
Action
Complete an internal review of Regional Operations Centre handling of the December 2019 incident and identify learning from it.
Stated by National Highways
-
Concerns raised1
Failure to consider staffing levels in internal investigations
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.
Data last updated 7 September 2026