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
Flawed investigations failing to identify systemic failures and learning
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- The Children's 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.6
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The Children's Trust
Implement a revised incident management policy and process based on national best practice.
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The Children's Trust
Strengthen the clinical governance framework to identify recurring themes and trends and support organisational learning.
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The Children's Trust
Implement the national Patient Safety Incident Response Framework for incident investigations.
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The Children's Trust
Review all incidents through multidisciplinary panels representing the organisation.
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The Children's Trust
Apply internal governance oversight to externally commissioned investigations and scrutinise their findings.
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The Children's Trust
Conduct thematic reviews of serious incidents and use findings to inform staff training and service improvements.
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Concerns raised1
Failure of the death investigation process
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Berkshire 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.4
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Royal Berkshire NHS Foundation Trust
Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.
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Royal Berkshire NHS Foundation Trust
Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.
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Royal Berkshire NHS Foundation Trust
Change General Surgery SJR allocation so a subspecialist conducts the review and a second, preferably external-subspecialty, surgeon reviews and signs it.
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Royal Berkshire NHS Foundation Trust
Introduce a parallel anaesthetist-led SJR to add an independent anaesthetic perspective and identify learning.
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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Royal Berkshire NHS Foundation Trust
The Trust considers its established death investigation processes robust and sufficient to underpin learning and patient safety.
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Concerns raised1
Failure to investigate errors to establish why they happened and prevent recurrence
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Oxford University 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
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Oxford University Hospitals NHS Foundation Trust
Report and investigate the incident under the Patient Safety Incident Response Framework.
-
Concerns raised2
Failure to learn from serious incidents and consider recommendations for future care
Inadequate analysis of serious incidents
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Plymouth NHS 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.5
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University Hospitals Plymouth NHS Trust
Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
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University Hospitals Plymouth NHS Trust
Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
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University Hospitals Plymouth NHS Trust
Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
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University Hospitals Plymouth NHS Trust
Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
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University Hospitals Plymouth NHS Trust
Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
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Concerns raised1
Lack of assured ongoing funding for MSNI investigations
This report raised 19 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- NHS Lancashire and South Cumbria Integrated Care Board
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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NHS Lancashire and South Cumbria Integrated Care Board
Nationally led MSNI funding prevents assurance about funding continuing beyond 2027.
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Concerns raised2
Insufficient scrutiny of witness accounts during investigations
Failure to establish accurate circumstances of falls during investigations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Northumbria Healthcare 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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Northumbria Healthcare NHS Foundation Trust
Require trained Governance Leads to participate in all internal investigations and ensure witness statements receive managerial or Deputy Director sign-off before finalisation.
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Northumbria Healthcare NHS Foundation Trust
Brief Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.
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Northumbria Healthcare NHS Foundation Trust
Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.
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Concerns raised1
Failure of internal investigations to verify relevant witness information and clinical address records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Birmingham and Solihull Mental Health 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
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Birmingham and Solihull Mental Health NHS Foundation Trust
Provide Meet and Greet workers in community mental health team receptions to verify demographic, contact and accommodation information.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Remind clinical staff to record address and contact-number changes on the service-user demographic record in Rio.
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Concerns raised1
Absence of a formal internal post-death investigation report
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
Inadequate investigation of post-fall incidents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Care Home Manager
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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Care Home Manager
Update falls risk assessments within 24 hours and document follow-up in care records.
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Care Home Manager
Implement root-cause analysis and incident-investigation tools for falls.
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Care Home Manager
Hold staff meetings reinforcing accurate incident assessment, timely reporting and compliance with policy and guidance.
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Concerns raised2
Limited internal review of procedure-related circumstances
Failure to consider NatSSIPS2 standards in detail during internal review
This report raised 1 other concern. 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