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 of post-death investigations to establish why care gaps occurred
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Birmingham 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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University Hospitals Birmingham NHS Foundation Trust
Revise post-death investigations to obtain individual statements from involved care staff and embed findings in roundtable reports.
-
Concerns raised2
Failure of Serious Incident investigations to identify healthcare failings
Failure of governance processes to identify patient safety incidents through mortality review
This report raised 6 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
- 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.2
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Barking, Havering and Redbridge University Hospitals NHS Trust
Operate the Learning Review Group to oversee learning responses, PSIRF adherence and development of improvement actions.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Monitor safety actions and improvement plans through the Improvement Oversight Panel, including scheduled three-month progression reviews.
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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Department of Health and Social Care
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
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Concerns raised1
Significant delays in investigating missed radiology reporting errors
This report raised 3 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.3
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Implement PSIRF-based systems to record, monitor, review and learn from incidents across the Trust.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Implement the incident-response policy requiring a hot debrief or another incident response after relevant incidents.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Revise the Radiology Duty of Candour SOP with assessment procedures and response timeframes for discrepancy and harm-feedback cases.
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Concerns raised1
Delays in undertaking and completing patient safety investigation reviews
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.3
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Complete and present a cluster review of speech-and-language-therapy and swallow-related incidents with an associated action plan.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Implement revised incident-management systems and processes for recording, monitoring, reviewing and learning from patient-safety incidents.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Maintain a dedicated Medicine Care Group Clinical Governance Team to review reported patient-safety events daily, request learning responses and escalate severe or moderate harm events.
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Concerns raised1
Inadequate patient safety incident investigations
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.
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Concerns raised1
Patient safety investigations failing to review evidence relevant to governance and coronial investigations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health 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.1
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Barts Health NHS Trust
Review and update the Bereavement policy to clarify when tubes, lines and devices remain in situ after sudden or unexpected death, including medical examiner involvement.
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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Barts Health NHS Trust
The NG tube’s removal was not considered materially relevant to the care issues identified in the internal investigation.
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Concerns raised1
Failure to investigate nursing staff and determine whether care failures reflect individual or system failure
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Priory Group
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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Priory Group
Conduct separate service-level Team Incident Reviews involving staff involved in care and consolidate findings at a senior-manager joint meeting for cross-service learning.
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Concerns raised3
Delays in completing and providing patient safety investigation reports
Failure of patient safety investigations to comprehensively review anticoagulant omissions across hospital settings
Failure to consider alternative treatment to reduce DVT/PE risk
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- County Durham and Darlington 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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County Durham and Darlington NHS Foundation Trust
Track patient safety investigations at the weekly Senior Clinical Leaders patient safety forum.
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County Durham and Darlington NHS Foundation Trust
Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
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Concerns raised2
Failure of serious incident investigations to identify relevant reviewing clinicians
Unfit serious incident investigation reports
This report raised 7 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
- 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
-
Barking, Havering and Redbridge University Hospitals NHS Trust
Use the Patient Safety Investigation Response Framework with multidisciplinary investigations and centrally allocated investigating officers.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Operate a weekly Incident Oversight Learning Group to review concerning incidents and commission further learning responses where needed.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Require Learning Review Group sign-off with Board Executive attendance for quoracy when approving patient safety investigations.
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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Department of Health and Social Care
The Trust will respond separately to the concerns about care and processes.
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Concerns raised1
Failure to capture early reflective accounts from key staff
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sherwood Forest 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.2
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Sherwood Forest Hospitals NHS Foundation Trust
Implement a Trust-wide system, templates, guidance, staff engagement, governance, and review prompts for capturing early factual recollections after incidents.
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Sherwood Forest Hospitals NHS Foundation Trust
Introduce Edinburgh Emergency Medicine STOP 5 hot debriefs to provide immediate team discussion, document learning, and highlight factual-recollection requirements after incidents.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026