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.
Department of Health and Social Care31
Care Quality Commission21
NHS England20
Betsi Cadwaladr University LHB11
Barking, Havering and Redbridge University Hospitals NHS Trust10
Barts Health NHS Trust8
Greater Manchester Mental Health NHS Foundation Trust8
Pennine Care NHS Foundation Trust7
Essex Partnership University NHS Foundation Trust6
Nottinghamshire Healthcare NHS Foundation Trust5
Tameside and Glossop Integrated Care NHS Foundation Trust5
Tees, Esk and Wear Valleys NHS Foundation Trust5
Health and Safety Executive4
Medicines and Healthcare products Regulatory Agency4
NHS Greater Manchester Integrated Care Board4
NHS trust146
Ministerial department39
Healthcare site27
Executive non-departmental public body21
Health and social care service regulator21
Private limited company20
Local health board14
Integrated care board11
Type not available11
English metropolitan district council8
Police force8
Health professional body6
Health and care professional regulator5
Independent healthcare provider5
Multi-service care provider5
Reports and published responses 244 reports
See individual reports that have raised this concern, and the actions taken in response
North Yorkshire and York
Concerns raised3
Failure to identify and preserve the accounts of staff directly involved in errors
Failure of investigations to identify and question relevant medical team members
Delays in commencing investigations and after-action reviews of recognised errors
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
York and Scarborough Teaching Hospitals 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.1
York and Scarborough Teaching Hospitals NHS Foundation Trust
Embed the Patient Safety Incident Response Framework within Trust processes.
West Sussex, Brighton and Hove
Concerns raised1
Lack of independent review of deaths for learning and practice change
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Care Quality Commission
Department of Health and Social Care
NHS Surrey and Sussex Integrated Care Board
Sussex Medical Chambers
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
NHS Surrey and Sussex Integrated Care Board
Review the serious incident and identify all associated learning and recommendations.
NHS Surrey and Sussex Integrated Care Board
Follow up completion of serious-incident recommendations through enhanced contract quality meetings.
NHS Surrey and Sussex Integrated Care Board
Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
NHS Surrey and Sussex Integrated Care Board
The ICB is not responsible for investigating serious incidents involving individual patient care.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS Surrey and Sussex Integrated Care Board
Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Department of Health and Social Care
The provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sussex Medical Chambers
The Integrated Care Board is responsible for commenting on actions taken following Mr Hankin's death.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Care Quality Commission
Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
Outside remitThe respondent said that this matter was outside its role or authority.
Care Quality Commission
The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Swansea and Neath Port Talbot
Concerns raised1
Lack of understanding of evidence requiring preservation during domestic explosion investigations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Health and Safety Executive
South Wales Police
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
South Wales Police
Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.
Health and Safety Executive
Prepare national training material on work-related aspects of investigations, including advice for first responders.
Health and Safety Executive
Develop a proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
South Wales Police
The National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Health and Safety Executive
The existing Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester North
Concerns raised1
Ineffective investigation of deaths of detained patients
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Pennine Care 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.2
Pennine Care NHS Foundation Trust
Review governance and decision-making around selecting and approving the learning review after the death.
Pennine Care NHS Foundation Trust
Consider and decide whether to change the process for reassessing learning reviews when additional information becomes available.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Pennine Care NHS Foundation Trust
The Trust disputes that a further investigation was required because no evidence then linked the death to problems in its care.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Eastern)
Concerns raised1
Failure to undertake a formal investigation of incidents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Doncaster and Bassetlaw Teaching Hospitals 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.1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Investigate the incident through the broader thematic analysis and draft the thematic review and associated actions for Executive Team presentation.
Manchester South
Concerns raised1
Failure to undertake serious incident investigations for learning
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Tameside and Glossop Integrated Care NHS Foundation Trust
A formal investigation was not considered necessary because the circumstances did not meet the Trust’s investigation criteria.
No action considered necessaryThe respondent said that no further action was needed.
North East Kent
Concerns raised1
Failure to conduct internal investigations for learning
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
East Kent Hospitals University NHS Foundation Trust
Manor Clinic
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
East Kent Hospitals University NHS Foundation Trust
Provide additional support to the Medical Examiner team to identify cases for further investigation.
East Kent Hospitals University NHS Foundation Trust
Continue reviewing learning from incidents, complaints, claims and inquests to improve governance and patient safety.
East Kent Hospitals University NHS Foundation Trust
Undertake a full multidisciplinary case-note review of care and treatment preceding the final admission to identify earlier holistic recognition of decline.
Manor Clinic
Include unexpected deaths routinely in clinical meeting discussions.
North West Wales
Concerns raised1
Failure to conduct sufficiently thorough neonatal investigations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Betsi Cadwaladr University LHB
Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.
Betsi Cadwaladr University LHB
Implement a programme for investigating officers.
Betsi Cadwaladr University LHB
Direct that investigations across women’s and neonatal services use a single investigation officer.
Betsi Cadwaladr University LHB
Direct women’s-services investigations to use the Integrated Concerns Policy framework and templates.
Betsi Cadwaladr University LHB
Appoint a quality governance officer to neonatal services to provide specialist investigation and review capacity.
Birmingham and Solihull
Concerns raised1
Failure to investigate deaths and learn from work-related events and welfare support
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
West Midlands Fire Service
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
West Midlands Fire Service
Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.
West Midlands Fire Service
Share learning from the case to improve support for senior officers nationally.
East London
Concerns raised1
Failure of governance and safety-review processes to identify, investigate, reflect upon, and remediate sub-optimal practice
Linked responses
Barts Health NHS Trust
Department of Health and Social Care
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
Barts Health NHS Trust
Report each new inquest in Datix, present it at PSIRM, and expedite any outstanding M&M review to inform the required learning response.
Barts Health NHS Trust
Contact families during PSIRM reviews so their concerns inform the review and decision on the level of investigation required.
Barts Health NHS Trust
Complete a specialist review of governance processes relating to this case, engage the Foster family, and share the outcome with HM Coroner.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
Under PSIRF, not all deaths require investigation; Trusts must document and explain decisions under the existing patient safety incident response governance process.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Department of Health and Social Care
Trusts are responsible for documenting patient safety incident response decisions and explaining when no specific learning response is undertaken.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.