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.
Manchester South
Concerns raised1
Failure to identify incident learning from what went wrong
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
Complete a retrospective multidisciplinary learning review of the incident and identify learning from the case.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 September 2022.
Action
Run a monthly organisation-wide incident-reporting focus covering incident identification, reporting, response and learning.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Action
Review the Incident Reporting and Incident and Complaint Investigation Policy against the NHS England Patient Safety Framework.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 September 2022.
Action
Hold a multidisciplinary learning event and share learning from the case to support prevention of harm and improve future patient experience.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 27 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The incident was closed after discussion with the Emergency Department Clinical Director, with no further action identified at that time.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Manchester City
Concerns raised1
Failure of serious incident investigations to obtain relevant information and make additional enquiries
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 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.
Manchester South
Concerns raised1
Failure to conduct prompt, rigorous and effective investigations of clinical 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 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.15
Action
Deliver comprehensive root cause analysis investigation training for relevant clinical and corporate staff.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Maintain a live register of staff who have completed root cause analysis investigation training.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Disseminate a briefing on triangulation and factual accuracy in investigations across the Trust.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Provide the updated investigator toolkit to each root cause analysis investigation team.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Require appropriate Matron review and approval of investigations through the revised Safer Care Assurance Process.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Require review of root cause analysis requests by senior nursing and governance leaders when a patient dies during investigation.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Conduct ongoing local audits to monitor adherence to the complaints and investigation policy.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Require senior divisional review and approval evidence in root cause analysis documents before assurance-panel consideration.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Quality-assess falls-pathway investigations against clinical and nursing records before assurance-panel review.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Implement Trust-wide witness statement training and develop supporting statement templates.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Large-scale comprehensive investigation training was challenging because COVID redeployed governance staff and staff attendance was not mandatory.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Avon
Concerns raised1
Inadequate investigation of incidents
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 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.5
Action
Complete a second significant event analysis using the revised investigation system.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Appoint an independent external GP and appraiser to scrutinise incident records, investigation processes and significant event analyses.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Undertake a root cause analysis with detailed risk assessment to identify safety actions.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Produce and use a new significant event analysis policy and documentation process for future investigations.
Stated by Air Balloon SurgeryStated completedThe respondent said that this action was complete when they made their response on 20 September 2022.
Action
Review the new significant event analysis system at the practice board meeting after its further use in August.
Stated by Air Balloon SurgeryStated plannedThe respondent said that this action was planned when they made their response on 20 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Significant event analysis broadly met CQC requirements; root cause analysis is not specifically required and is not generally used in general practice.
Stated by Air Balloon SurgeryExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Birmingham and Solihull
Concerns raised2
Failure of investigations to examine relevant clinical care and record conclusions and their basis
Failure of serious incident investigations to identify relevant guidance and explain departures from it
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.4
Action
Require investigators to use comprehensive literature and independent evidence reviews and address families’ concerns in investigation reports.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Complete a gap analysis of national patient-safety investigation standards against current practice.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
Action
Develop revised investigation processes, report templates and investigator guidance informed by the standards gap analysis.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 16 September 2022.
Action
Raise investigators’ awareness of Library Services support for searches of clinical guidelines and publications.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 16 September 2022.
East London
Concerns raised1
Failure to investigate unexpected care-impacting events through Serious Incident Investigation
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 concerns
Each 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
Position
The incident did not require a Serious Incident investigation because reviews concluded it was not a Serious Incident matter.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Failure to investigate and review deaths for learning and implementation of necessary changes
This report raised 11 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.5
Action
Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Request Serious Event Audits from practices and review whether learning points from suicide investigations have been considered.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Conduct a significant event analysis of the death with clinical staff and review the resulting learning and actions.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Action
Share the significant event analysis findings with practice staff, the CCG and CQC.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Action
Discuss unexpected deaths at weekly practice clinical meetings attended by GP clinicians and Partners.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The Practice disputes that the death was not investigated or reviewed, stating that it was discussed promptly and later subjected to significant event analysis.
Stated by Farnham Park Health Group and Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised3
Delayed and incomplete serious incident investigations
Lack of openness, transparency and proper investigation of deaths
Failure to undertake prompt internal enquiries after sudden unexpected 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 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.7
Action
Follow up statutory notifications from The Children’s Trust with robust investigations documenting actions taken and improvements made.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Action
Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
Stated by The Children's TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Since 2018, statutory notifications have been followed up with appropriate investigations documenting actions and improvements.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Current leadership, governance and practice are considered safe, with no evidence that the reported concerns remain current concerns.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Failure to investigate wider circumstances of serious 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 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.
Norfolk
Concerns raised5
Failure to investigate the source and nature of a hazardous item after an incident
Inaccuracies in patient safety incident investigation reports
Failure to interview relevant staff during patient safety investigations
Delays in completing and providing patient safety incident investigation reports
Incident investigations failing to establish the sequence of safety-critical events
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Agency staff were not compelled to participate in Trust reviews, preventing interviews with some staff involved in Tracy’s care.
Stated by Norfolk and Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The review panel considered accounts from participating staff and professionals sufficient despite some agency staff not being interviewed.
Stated by Norfolk and Suffolk NHS Foundation TrustExisting 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.
