First reported 13 Dec 2008•Latest report 25 Jun 2026
Definition
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
Distinct published reports
Individual concerns
316
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
447
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.
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
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.
Berkshire
Concerns raised2
Failure to document investigations of incidents
Failure to identify care staff involved in incidents
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Derby and Derbyshire
Concerns raised1
Insufficiently robust Trust investigation and review process
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 concerns
Each 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
Action
Use a panel sign-off process to review Mental Health Care Group serious-incident investigations.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Share learning from the preventing-future-deaths report through ongoing serious-incident investigation training.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Continue providing two-day systems-based serious-incident investigation training for investigators.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Action
Deliver six serious-incident quality-assurance training events for investigation report reviewers and approvers during 2023–2024.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Action
Use developed neurodiversity guidance to support investigators in considering individual needs and reasonable adjustments.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Action
Conduct a proactive, objective review of active Trust inquests to identify lessons and improvement themes.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 June 2023.
Essex
Concerns raised2
Failure to involve the deceased patient's family in the Trust investigation
Failure to involve the senior pharmacist in the Trust investigation
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 concerns
Each 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
Action
Share learning about involving pharmacy expertise in clinical review investigations with the Clinical Review Group chair.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
East London
Concerns raised1
Failure of serious incident investigation to address risk-assessment and reporting deficiencies
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Review Serious Incident processes and revisit the adequacy of evidence and learning captured in reports.
Stated by North East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
North Wales (East and Central)
Concerns raised1
Lack of timely completion of internal investigations
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 concerns
Each 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
Action
Re-evaluate the incident process and develop a procedure defining roles and responsibilities.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
Action
Address overdue investigations through weekly improvement and scrutiny meetings with clinical directors.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
Action
Strengthen performance and accountability processes to include overdue investigations.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
Action
Provide local quality governance support to services for managing open and overdue investigations and evidencing completed actions.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Worcestershire
Concerns raised1
Failure of internal investigation coordination and learning from patient-safety incidents
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Berkshire
Concerns raised1
Inadequate immediate investigation of suspected anaphylaxis deaths
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 concerns
Each 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
Action
Consider the report’s concerns about investigating and following up perioperative anaphylaxis when developing specialised allergy service specifications and commissioning policies.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Essex
Concerns raised4
Failure to investigate bath plug storage and control issues
Failure to maintain reliable investigation conclusions when presented with unrequested and uncertain evidence
Failure to scrutinise staff movements and available door logs during investigations
Failure to investigate emergency response and information-sharing concerns
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Use the Patient Safety Incident Response Framework and current response plan to investigate incidents with revised methodology and fuller chronology and triangulation.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The investigation could not analyse access logs in depth because they arrived after the chronology and the applicable framework required completion within 60 days.
Stated by Essex Partnership University NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure of serious incident investigations to interview relevant decision makers and provide feedback
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 concerns
Each 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
Action
Amend the Serious Incident reviewer responsibilities document to require relevant staff to be contacted through Human Resources for review involvement.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 January 2023.
West Sussex
Concerns raised2
Failure to investigate potential anaesthetic-related causes of unexpected deaths
Lack of a robust system to trigger investigations into unexpected deaths
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 concerns
Each 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.9
Action
Develop and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 January 2023.
Action
Amend guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Amend guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Launch the Patient Safety Incident Response Framework for developing and maintaining systems to respond to incidents and improve patient safety.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
HSIB investigation replaced the need for a parallel local investigation under national guidance, so no concurrent local investigation was required.
Stated by University Hospitals Sussex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Where HSIB undertakes a maternity investigation, a separate local patient safety learning response is not required under PSIRF.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
