Recurring concern
Inadequate safety incident investigations
- Reports that mention this concern
- 244
- Times this concern has been raised
- 316
- Stated actions linked to this concern
- 447
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 244 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to undertake formal investigations of incidents
Linked response
- Blackcliffe Limited
Stated actions 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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Blackcliffe Limited
Investigate the incident by reconstructing its timeline, staffing, roles and locations.
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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.
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.
Linked response
- Somerset NHS Foundation Trust
Stated actions 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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Somerset NHS Foundation Trust
Train key investigators in national investigation tools and techniques and establish a trained investigator cohort.
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Somerset NHS Foundation Trust
Implement investigation terms and oversight processes that define family needs and ensure key questions are addressed.
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Somerset NHS Foundation Trust
Further review the investigation into Sofia’s death to challenge disputed statements and produce a balanced, sensitive report.
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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.
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.
Linked responses
- Barking, Havering and Redbridge University Hospitals NHS Trust
- NHS England
Stated actions 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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Barking, Havering and Redbridge University Hospitals NHS Trust
Review externally reported deaths weekly through Morbidity and Mortality sessions, identify lessons and provide feedback to referring hospitals.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Complete the ongoing Significant Incident investigation into the death.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Investigate the identified examination and specialist-advice failures through the ongoing Significant Incident investigation.
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NHS England
Seek assurances from the Trust that concerns have been addressed in line with the Serious Incident Framework.
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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.
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.
Linked response
- Bury Borough Council
Stated actions 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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Bury Borough Council
Develop and implement a formal follow-up investigation procedure for highway incidents reported by Greater Manchester Police.
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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.
Linked response
- Eldercare (UK) Limited
Stated actions 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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Eldercare (UK) Limited
Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.
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Eldercare (UK) Limited
Add an internal review step to investigations while preserving employees’ rights to appeal after formal investigation.
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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Eldercare (UK) Limited
The investigation was conducted with sufficient rigour and accuracy despite concerns about its thoroughness.
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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.
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026