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 investigate in-patient falls
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
Operate a monthly Falls Review Panel to investigate injurious inpatient falls, identify learning, agree remedial actions and monitor fracture-related fall trends.
Stated by Aneurin Bevan University LHB -
Action
Report inpatient falls through RLDatix and investigate falls causing fractures, with escalation through serious-incident and Duty of Candour processes where moderate or greater harm occurs.
Stated by Aneurin Bevan University LHB -
Action
Strengthen the Serious Incident process by appointing investigating officers before initial meetings, providing investigation training, and applying enhanced governance and approval of reports and action plans.
Stated by Aneurin Bevan University LHB
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Action
Use standardised Serious Incident agendas to define investigation scope, capture robust terms of reference, involve families from the outset and prompt reporting to external agencies.
Stated by Aneurin Bevan University LHB
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Concerns raised1
Inadequate incident investigation following a serious suicide attempt or 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.8
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Action
Review IR1 incidents through assigned IR2 managers, monthly completion reports, and supervision-based learning.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Conduct serious-incident discussions and thematic reviews through MHSOP safety, risk, quality-assurance and improvement forums.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Disseminate learning from serious incidents through the MHSOP Learning the Lessons bulletin and service and team meetings.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Action
Require investigators to address staff interviews through standard allocation emails and clinical-governance oversight.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Share approved investigation reports with relevant teams and witnesses and support incident-specific learning reflections.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Implement a standardised ward and community meeting governance template incorporating incident data and learning discussions across MHSOP wards.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Complete the PSIRF policy and local patient-safety incident response plan following stakeholder consultation.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Implement PSIRF across the Trust by August 2024.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Failure to undertake full investigations into patient deaths
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.2
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Action
Review incident and complaint processes and create an integrated framework covering incidents, complaints and mortality.
Stated by Betsi Cadwaladr University LHB -
Action
Engage the NHS Wales National Executive quality team to support improvement work on incident and complaint processes.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to complete a timely Fatal Accident Inquiry Panel investigation
This report raised 16 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.5
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Action
Investigate Ben’s death under the Work-related Death Protocol to determine its cause, identify lessons and prevention actions, and take appropriate enforcement action.
Stated by Health and Safety Executive -
Action
Review how the investigation error occurred and identify measures to prevent it recurring.
Stated by Health and Safety Executive -
Action
Commission and complete an independent Fatal Incident Investigation into Ben’s death, then share its findings and learning.
Stated by The Scout Association
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Action
Create and implement a Critical Incident and Investigation Policy, including prompt independent fatality investigations and transparent information sharing.
Stated by The Scout Association -
Action
Designate a senior accountable staff member to lead future fatality investigations and liaise with statutory agencies.
Stated by The Scout Association
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Department cannot comment on the Scout Association’s internal structure, workings, or implementation of internal policies and procedures.
Stated by Department for Education
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Position
The Scout Association and the Charity Commission are expected to address matters concerning internal operations and charity trustees’ legal duties, respectively.
Stated by Department for Education
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Concerns raised2
Unclear and potentially inaccurate Early Learning Review investigation methodology
Poor quality Early Learning Review failing to identify safety issues and learning
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.
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.6
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Action
Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.
Stated by Sodexo -
Action
Issue and use national guidance and a standard template to improve the consistency and quality of Early Learning Reviews.
Stated by HM Prison and Probation Service -
Action
Deliver workshops and feedback to Group Safety Leads to improve their Early Learning Review skills, practice and report writing.
Stated by HM Prison and Probation Service
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Action
Monitor Early Learning Review quality and share feedback with Group Safety Leads.
Stated by HM Prison and Probation Service -
Action
Develop a new policy framework that mandates Early Learning Reviews and assigns Prison Group Directors responsibility for checking report quality before sign-off.
Stated by HM Prison and Probation Service -
Action
Issue a revised Early Learning Review standard template and refreshed guidance alongside the new policy framework.
Stated by HM Prison and Probation Service
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
Sodexo’s death-in-custody learning processes apply only while the prison is under Sodexo’s operational management.
Stated by Sodexo
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Concerns raised2
Delays in completing serious incident investigations
Failure to preserve evidence while memories are fresh during serious incident investigations
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.
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 PFD appears to arise from unrelated advice about a future investigation, not outstanding concerns from evidence heard at this inquest.
Stated by Tees, Esk and Wear Valleys NHS Foundation Trust
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Concerns raised2
Delays and premature sign-off in Trust investigations
Failure of investigations to identify and document material issues and limitations
This report raised 9 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
Refine patient-safety incident processes and reporting templates.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Introduce post-incident protocols for collating staff statements and triangulating written evidence with CCTV, Oxevision and body-worn-camera data.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised2
Failure of internal investigations to elicit the circumstances of relevant operational failures
Failure of the SI to consider relevant operational failure issues
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 ambulance investigations to compare attendances and identify learning
This report raised 10 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
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Action
Implement the Patient Safety Improvement Response Framework for developing patient-safety systems and learning from incidents.
Stated by East of England Ambulance Service NHS Trust -
Action
Establish fortnightly Action Setting Group reviews of incident reports to set appropriate actions.
Stated by East of England Ambulance Service NHS Trust
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Concerns raised4
Delays in Trust investigation of serious care concerns
Failure of Trust investigations to identify critical care and treatment findings
Lack of robust critical analysis to deliver timely patient-safety learning
Failure to conduct impartial investigation of clinical decision-making
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
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Action
Rewrite and implement the mortality-review policy for externally identified concerns, including formal notification, committee oversight, Structured Judgement Review, escalation and multidisciplinary review.
Stated by Kettering General Hospital NHS Foundation Trust
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 round table panel concluded that no further action was necessary regarding the concerns about the patient's care.
Stated by Kettering General Hospital NHS Foundation Trust
Data last updated 7 September 2026