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 conduct higher-level investigations into patterns of missed observations and falsified records
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
Carry out a thematic review of CAMHS observation-record audits to identify themes and resulting actions.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Conduct a nationally commissioned independent review of patient services, escalation, oversight and staff culture across Greater Manchester Mental Health NHS Foundation Trust.
Stated by NHS England
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
Greater Manchester Mental Health NHS Foundation Trust is responsible for addressing the specific operational changes arising from the concerns.
Stated by NHS England
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Concerns raised2
Lack of a clearly identifiable person responsible for reviewing and investigating health and safety incidents
Failure to investigate near misses when they occur
This report raised 17 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
Direct incident reports to medical and health-and-safety leaders and provide them with joint investigation accountability.
Stated by Capita PLC and Ministry of Defence -
Action
Blood-test candidates identified by the questionnaire as being at high risk of sickle cell trait before they undertake the 2000-metre run.
Stated by Capita PLC and Ministry of Defence -
Action
Operate the Joint Lessons Learnt Panel and Learning Account process to investigate incidents, assign recommendations, disseminate learning and monitor completion.
Stated by Capita PLC and Ministry of Defence
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Concerns raised2
Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses
Failure of Serious Incident Investigations to investigate care and treatment plan deficiencies and make recommendations
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.5
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Action
Accredit the serious incident review process through SIRAN, revising policies, templates and review arrangements to meet best practice.
Stated by Central and North West London NHS Foundation Trust -
Action
Provide RCA methodology training to staff and establish a forum supporting serious-incident reviewers and investigators.
Stated by Central and North West London NHS Foundation Trust -
Action
Create a dedicated serious incident review post in the incident division.
Stated by Central and North West London NHS Foundation Trust
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Action
Introduce Advanced Clinical Practitioners to support care planning, risk management and identification of Care and Treatment Plan deficiencies.
Stated by Central and North West London NHS Foundation Trust -
Action
Implement the Patient Safety Incident Response Framework through a fortnightly working group and human-factors education incorporating learning from this case.
Stated by Central and North West London NHS Foundation Trust
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Concerns raised1
Failure to promptly capture and consider evidence relevant to deaths in custody
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
Draft and update the death-in-custody policy framework to identify relevant staff and prompt early recording of their information.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure of the patient safety investigation to identify omitted falls risk reassessments
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.4
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Action
Conduct a gap analysis against the final national PSIRF guidance to ensure full alignment.
Stated by Bristol NHS Foundation Trust -
Action
Review investigation progress, timelines and rigour through the central Patient Safety Team, escalating concerns where necessary.
Stated by Bristol NHS Foundation Trust -
Action
Reassess investigation support structures and capacity, including considering new posts dedicated to patient safety investigations.
Stated by Bristol NHS Foundation Trust
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Action
Report gap-analysis findings and associated system or process improvements to the Patient Safety and Quality Committees.
Stated by Bristol 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 shortcomings in this investigation are not representative of the Trust’s usual patient safety investigation standards or processes.
Stated by Bristol NHS Foundation Trust
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Concerns raised1
Ineffective investigation of resident deaths
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised4
Failure to obtain timely and adequate evidence during serious incident investigations
Failure to assess workload and staffing levels in serious incident investigations
Failure to ensure serious incident investigations are conducted by suitably trained and experienced investigators
Failure to ensure serious incident investigations are conducted independently
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.3
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Action
Provide the Emergency Department senior nursing team with a memory-capture tool to promote prompt, consistent incident recording and formalise evidence gathering.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Train staff conducting Patient Safety Incident Response Framework reviews, with ongoing support and updating sessions.
Stated by Leeds Teaching Hospitals NHS Trust -
Action
Deliver bespoke Patient Safety Incident Response Framework documentation sessions for Urgent Care senior staff with the Risk Management team.
Stated by Leeds Teaching Hospitals NHS Trust
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 Trust disputes that CPR was delayed for 15 minutes, stating that it began within 30 to 60 seconds of the patient being found.
Stated by Leeds Teaching Hospitals NHS Trust
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Position
A fully independent investigation was not required because the incident was locally investigated under procedures reserving complete independence for serious incidents.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Lack of rigour in RCA investigations of ECO-related incidents
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.2
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Action
Implement the agreed and funded patient-safety investigation model, including a central team of expert investigators and a human-factors specialist.
Stated by Bristol NHS Foundation Trust -
Action
Complete level 3 patient-safety investigation training for seven relevant staff members.
Stated by Bristol NHS Foundation Trust
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Concerns raised4
Failure to obtain timely written accounts and interviews from key staff in serious incident investigations
Failure to include and properly weight family evidence in serious incident investigations
Insufficient organisational learning from serious incident investigations
Failure to properly consider commissioned expert evidence in 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.
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 a memory-capture document in DATIX alongside immediate interviews and written statements, and reinforce its use across teams.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Involve families directly in investigations and include their recollections and concerns, with supporting evidence, in reports.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Reference commissioned expert opinions in investigation reports and record reasons when an opinion is not reconciled with the evidence.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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
HSIB could not support the requested investigation because its northern branch had not yet been established and operations were limited to southern England.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Position
The external expert opinion was not relied upon because it conflicted with subsequently gathered evidence and was considered less informed than staff accounts.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to identify and escalate deaths through governance procedures as serious incidents for 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 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 governance procedures for detecting potential incidents and emphasise internal incident reporting within clinical divisions.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Introduce incident reporting for all new inquests to formalise divisional review and identify previously unreported incidents.
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
Delayed stent removal should largely be addressed through individual NHS trust clinical governance systems, led by trust medical directors.
Stated by British Association of Urological Surgeons
Data last updated 7 September 2026