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
Factual inaccuracies in adverse-incident review summaries
This report raised 16 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
Introduce weekly Executive review of divisional investigations before SIRI Panel submission.
Stated by East Lancashire Hospitals NHS Trust -
Action
Develop and use a Serious Incident investigation pro forma with staged sign-off and links between problems, learning and preventive actions.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised2
Failure of the serious incident investigation to identify why NG tube placement failures were not escalated or referred back to requesting teams
Failure to ensure factual accuracy and evidential support for reported EWS escalation
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to conduct a serious incident investigation after a death
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to properly explain CT scan interpretation errors
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.
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 reporting error raised no fitness-to-practise concerns and posed no material danger to other patients.
Stated by Royal Free London NHS Foundation Trust
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Concerns raised1
Failure of serious incident investigation to determine directly responsible factors
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
Obtain future independent clinical opinions under formal terms of reference.
Stated by East and North Hertfordshire Teaching NHS Trust -
Action
Establish a standard operating procedure for LMNS oversight of serious incident investigations and action plans.
Stated by East and North Hertfordshire Teaching NHS Trust -
Action
Bring the coroner’s report to the attention of the Healthcare Safety Investigation Branch.
Stated by Department of Health and Social Care
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
NHS providers and local health partners are responsible for implementing the Patient Safety Incident Response Framework and supporting standards.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to involve primary care contacts in internal or serious incident reviews
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
Review practices governing GP involvement in Serious Incident Reviews.
Stated by Aneurin Bevan University LHB -
Action
Develop a process and pro forma to share pertinent information and invite GPs routinely to Serious Incident Reviews.
Stated by Aneurin Bevan University LHB -
Action
Use the pro forma to notify GPs of relevant unexpected deaths, request salient information, and invite review participation.
Stated by Aneurin Bevan University LHB
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Action
Liaise with the Primary Care and Community Division after the trial period to review the GP notification process and take forward suggested amendments.
Stated by Aneurin Bevan University LHB
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Concerns raised2
Use of untrained staff to conduct incident investigations
Perfunctory 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.
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
Communicate to Extra Care Scheme managers that they must review investigations conducted by others for adequacy.
Stated by Comfort Call Limited
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
Council assessments and reviews were undertaken by trained, qualified social workers, not untrained staff.
Stated by City of Stoke-on-Trent
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Concerns raised2
Failure to detect incorrect IV morphine dose guidance in incident-report review
Incorrect quotation of hospital IV morphine dose guidelines in Serious Incident reports
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.1
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Action
Establish trained investigating officers and a team-based process for patient safety incident investigations.
Stated by East Suffolk and North Essex NHS Foundation Trust
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Concerns raised1
Lack of guidance for identifying, securing and gathering evidence in clinical incident investigations
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.1
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Action
Use the newly developed First Responder document Trust-wide for every inpatient fall to record the immediate scene and required post-fall information.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Failure of routine clinical governance processes to initiate formal Serious Untoward Incident investigations or similar 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 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
Have senior clinicians undertake Case Review and Lessons Learned reviews for relevant patient-safety concerns.
Stated by Tameside and Glossop Integrated Care 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
Existing incident investigation processes and review were considered sufficient, so a formal serious untoward incident investigation was not undertaken.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Data last updated 7 September 2026