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 investigate choking-related events and identify safety issues
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
Submit a safeguarding alert to Hartlepool Social Services for further investigation.
Stated by Rossmere Park Care Centre -
Action
Participate in lessons-learned meetings with safeguarding, commissioning, healthcare and police representatives.
Stated by Rossmere Park Care Centre
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
A separate internal investigation was considered inappropriate while CQC had been notified and the Coroner was conducting a full investigation.
Stated by Rossmere Park Care Centre
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Concerns raised1
Lack of post-death investigation reports for student deaths
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.3
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Action
Establish the national Learning from Deaths policy framework to guide investigation, learning and engagement with bereaved families.
Stated by Department for Education and Department of Health and Social Care -
Action
Work with Universities UK during the forthcoming academic year to remind higher education providers about recommending serious incident reviews.
Stated by Department for Education and Department of Health and Social Care -
Action
Oversee serious-incident reviews for qualifying suicides and serious attempted suicides from September 2019.
Stated by University of Bristol
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Concerns raised1
Failure of internal serious incident investigations to identify PEG contraindications
This report raised 9 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 consider the care-record review concern in investigation
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
Introduce Patient Participation Leads and new Clinical Directors to strengthen clinical and service leadership and oversee learning from serious incidents.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to investigate subsequent falls
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.1
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Action
Develop and provide a post-fall protocol flow chart and checklist to guide staff through required actions, documentation and investigation.
Stated by Hc-One Limited
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Concerns raised1
Failure to establish how or why the anticoagulation chart was mislabelled
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inadequate post-incident investigation and organisational learning
This report raised 9 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
Implemented control measures are considered sufficient to resolve the identified falls, wheelchair restraint and investigation concerns.
Stated by Cole Valley Nursing Home
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Concerns raised2
Failure to conduct robust and thorough incident investigations
Failure to assure the adequacy and thoroughness of incident 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of guidance for frontline staff on promptly capturing evidence after falls
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
Run the Safer Mobility Collaborative, including immediate post-fall assessment, staff statements and patient discussions to confirm safety actions.
Stated by Stockport NHS Foundation Trust -
Action
Use thrice-weekly Quality Safety Leadership Summits to monitor falls, confirm investigations have started and verify inclusion of immediate statements.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Insufficient investigation of deaths by NWAS
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 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.
Data last updated 7 September 2026