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 raised2
Flawed and limited review of serious clinical incidents
Failure to undertake detailed, rigorous and effective investigations of serious clinical 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.
Birmingham and Solihull
Concerns raised1
Failure to investigate accidents and their circumstances
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.2
Action
Conduct daily senior-management incident spot checks, with enhanced governance oversight and escalation of incidents requiring investigation.
Stated by PrimeLife LimitedStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2022.
Action
Develop and disseminate a policy for investigating poor care practice and safeguarding incidents, including statement-taking and evidence correlation.
Stated by PrimeLife LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Incident investigations are undertaken only when the home's practice meets the threshold warranting investigation, with enhanced monitoring supporting escalation when necessary.
Stated by PrimeLife LimitedExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Insufficient process, guidance and oversight for effective post-death investigations
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.20
Action
Consult with national and academic experts about improving Surrey’s child death review process.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Request an independent national review of Surrey’s child death review process.
Stated by NHS Surrey and Sussex Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Implement recommendations arising from the national review of joint agency responses.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Request greater detail from agencies when child death reporting forms contain insufficient information.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Deliver a learning event providing guidance to professionals completing child death reporting forms.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Meet national colleagues to discuss learning from reporting-form completion and improvements to child death review processes.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Raise identified reporting-form and process issues with the National Child Mortality Database for future improvement.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Complete a thematic review of probable suicide deaths among children and young people.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Establish a multi-agency task-and-finish group and develop an action plan addressing thematic-review learning and missed opportunities.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Hold themed child death overview panels on a repeating cycle to identify themes, assess whether learning is embedded and identify ongoing concerns.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Produce and publish thematic national reviews to identify learning for safeguarding practice and system improvement.
Stated by Child Safeguarding Practice Review PanelStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Update practice guidance to place greater emphasis on review quality and learning.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Provide feedback to Safeguarding Partners on review content, quality, learning and national issues.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Work with Safeguarding Partners to streamline and focus local safeguarding practice reviews to improve timeliness and learning.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Publish anonymised examples of high-quality rapid reviews as good-practice exemplars.
Stated by Child Safeguarding Practice Review PanelStated plannedThe respondent said that this action was planned when they made their response on 3 February 2022.
Action
Develop an observatory function providing current data and information on serious safeguarding cases.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Develop a case-tracking system to monitor and report on review progress.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Monitor learning from rapid reviews and local safeguarding practice reviews.
Stated by Child Safeguarding Practice Review PanelStated completedThe respondent said that this action was complete when they made their response on 3 February 2022.
Action
Commission national analyses of learning and review quality, and publish their findings in annual reports.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Action
Conduct case-specific national reviews of the deaths of Arthur Labinjo-Hughes and Star Hobson and of safeguarding children with disabilities and complex health needs in residential settings.
Stated by Child Safeguarding Practice Review PanelStated in progressThe respondent said that this action was in progress when they made their response on 3 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.8
Position
The existing statutory Child Death Review process, including CDOP review after investigations, is relied on to capture all learning from a child’s death.
Stated by NHS Surrey and Sussex Integrated Care BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The local Child Death Review team cannot amend nationally agreed reporting forms, but can raise identified issues with the national database team.
Stated by NHS Surrey and Sussex Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Child Safeguarding Practice Review Panel will respond to Concern 10 and oversee the relevant national safeguarding review.
Stated by Department for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Child death review processes fall outside the Panel’s remit.
Stated by Child Safeguarding Practice Review PanelOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for child death review processes rests with health authorities, the mortality database team and local review partners.
Stated by Child Safeguarding Practice Review PanelRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Safeguarding practice reviews are not intended to investigate the cause or circumstances of a child’s death.
Stated by Child Safeguarding Practice Review PanelOutside remitThe respondent said that this matter was outside its role or authority.
Position
Post-death reviews follow national guidance, which permits proportionate local arrangements; the thematic review was accepted by the National Panel.
Stated by Surrey County CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The local safeguarding partnership determines whether a post-death review is appropriate and how learning should be generated.
Stated by Surrey County CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised2
Lack of appropriate investigation and learning from eating disorder deaths
Failure to conduct incident reviews of referral failures
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.3
Action
Convene a stakeholder round table and publish guidance for medical examiners on investigating eating disorder deaths.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 December 2021.
Action
Share case learning through Greater Manchester quality, governance and learning forums.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 31 December 2021.
Action
Monitor key learning and recommendations to ensure they are embedded in practice.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
Manchester North
Concerns raised1
Insufficient rigour in root cause analyses
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
Make pharmacy input mandatory in root-cause analyses whenever medication issues are identified, ensuring objective and expert review.
Stated by Northern Care Alliance NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 October 2021.
Manchester City
Concerns raised1
Failure of SUI investigation to obtain evidence from an important witness
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust considers interviewing the Responsible Clinician would not have changed the internal review’s findings.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised3
Failure of investigations to challenge false assumptions
Failure of investigation processes to identify themes of concern
Failure of investigations to maintain accurate evidence-based findings
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
Provide systems-based investigation training, mentoring and centralised investigative support for staff conducting serious-incident investigations.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Deliver quality-assurance training for staff approving concise and comprehensive investigation reports.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
Action
Update the Quality Improvement Plan to capture and address identified investigation-quality themes, with a nominated lead monitoring delivery.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 18 October 2021.
Action
Share investigation learning with staff to reinforce the importance of factual accuracy.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 October 2021.
Manchester City
Concerns raised2
Factual errors and misinterpretations in SUI investigation reports
Failure to obtain crucial witness evidence, learn lessons, and adequately oversee SUI report sign-off
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.3
Action
Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Action
Assign a Patient Safety Practitioner to support and advise serious-incident review teams.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Action
Share the Trust review findings with inpatient and CMHT teams through a learning event.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The omission of the Responsible Clinician’s interview would not have changed the Serious Incident investigation’s findings.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester City
Concerns raised2
Inaccurate and misinterpreted serious untoward incident investigation reports
Inadequate oversight of serious untoward incident investigation reports before sign-off
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.4
Action
Update serious-incident information-gathering procedures to obtain staff statements early and use them in investigations.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2021.
Action
Assign a Patient Safety Practitioner to support and advise serious-incident investigation teams.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2021.
Action
Share final serious-incident investigation drafts with senior managers and clinical leads for factual checking and approval.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2021.
Action
Require post-incident executive review and approval of serious-incident reports before release to families and other stakeholders.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2021.
Cornwall and Isles of Scilly
Concerns raised1
Failure to fully investigate reports of dog attacks
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing procedures and operational practice are considered sufficient for appropriately and robustly handling reports involving dogs posing a risk of serious harm.
Stated by Devon & Cornwall PoliceExisting 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.
