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 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.
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
Revise post-death investigations to obtain individual statements from involved care staff and embed findings in roundtable reports.
Stated by University Hospitals Birmingham NHS Foundation Trust
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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.
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
Operate the Learning Review Group to oversee learning responses, PSIRF adherence and development of improvement actions.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Monitor safety actions and improvement plans through the Improvement Oversight Panel, including scheduled three-month progression reviews.
Stated by Barking, Havering and Redbridge University Hospitals NHS 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
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Stated by Department of Health and Social Care
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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.
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
Implement PSIRF-based systems to record, monitor, review and learn from incidents across the Trust.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Implement the incident-response policy requiring a hot debrief or another incident response after relevant incidents.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Revise the Radiology Duty of Candour SOP with assessment procedures and response timeframes for discrepancy and harm-feedback cases.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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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.
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
Complete and present a cluster review of speech-and-language-therapy and swallow-related incidents with an associated action plan.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Implement revised incident-management systems and processes for recording, monitoring, reviewing and learning from patient-safety incidents.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
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.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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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.
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
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.
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
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.
Stated by Barts Health NHS 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 NG tube’s removal was not considered materially relevant to the care issues identified in the internal investigation.
Stated by Barts Health NHS Trust
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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.
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
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.
Stated by Priory Group
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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.
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
Track patient safety investigations at the weekly Senior Clinical Leaders patient safety forum.
Stated by County Durham and Darlington NHS Foundation Trust -
Action
Review and update the patient safety investigation report and action plan to cover the patient’s acute and community care.
Stated by County Durham and Darlington NHS Foundation Trust
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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.
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
Use the Patient Safety Investigation Response Framework with multidisciplinary investigations and centrally allocated investigating officers.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Operate a weekly Incident Oversight Learning Group to review concerning incidents and commission further learning responses where needed.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Require Learning Review Group sign-off with Board Executive attendance for quoracy when approving patient safety investigations.
Stated by Barking, Havering and Redbridge University Hospitals NHS 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 Trust will respond separately to the concerns about care and processes.
Stated by Department of Health and Social Care
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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.
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 a Trust-wide system, templates, guidance, staff engagement, governance, and review prompts for capturing early factual recollections after incidents.
Stated by Sherwood Forest Hospitals NHS Foundation Trust -
Action
Introduce Edinburgh Emergency Medicine STOP 5 hot debriefs to provide immediate team discussion, document learning, and highlight factual-recollection requirements after incidents.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
Data last updated 7 September 2026