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
Failure to undertake formal investigations of incidents
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
Investigate the incident by reconstructing its timeline, staffing, roles and locations.
Stated by Blackcliffe Limited
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Concerns raised1
Failure to effectively scrutinise the ambulatory care unit following a patient death
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inaccurate conclusions in SIRI reports about care-plan effects and clinical-practice change
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.3
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Action
Train key investigators in national investigation tools and techniques and establish a trained investigator cohort.
Stated by Somerset NHS Foundation Trust -
Action
Implement investigation terms and oversight processes that define family needs and ensure key questions are addressed.
Stated by Somerset NHS Foundation Trust -
Action
Further review the investigation into Sofia’s death to challenge disputed statements and produce a balanced, sensitive report.
Stated by Somerset NHS Foundation Trust
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Concerns raised1
Failure to escalate Emergency Department incidents for Serious Incident Review
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 conduct a serious incident report into a preventable death
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.4
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Action
Review externally reported deaths weekly through Morbidity and Mortality sessions, identify lessons and provide feedback to referring hospitals.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Complete the ongoing Significant Incident investigation into the death.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Investigate the identified examination and specialist-advice failures through the ongoing Significant Incident investigation.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Seek assurances from the Trust that concerns have been addressed in line with the Serious Incident Framework.
Stated by NHS England
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Concerns raised1
Lack of clear guidance or criteria for treating ligature or other self-harming incidents as SUIs to trigger investigation
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 raised1
Lack of an effective significant-incident investigation and learning procedure
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
Develop and implement a formal follow-up investigation procedure for highway incidents reported by Greater Manchester Police.
Stated by Bury Borough Council
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Concerns raised2
Failure to ensure understanding of the meaning of countersigning risk assessment checklists
Failure to address inaccuracies in moving and handling risk assessment checklists during investigations
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.2
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Action
Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.
Stated by Eldercare (UK) Limited -
Action
Add an internal review step to investigations while preserving employees’ rights to appeal after formal investigation.
Stated by Eldercare (UK) Limited
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 investigation was conducted with sufficient rigour and accuracy despite concerns about its thoroughness.
Stated by Eldercare (UK) Limited
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Concerns raised1
Failure of independent highway safety investigations to identify obscured junction visibility
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 raised1
Failure of the serious-incident review and learning system
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026