Recurring concern
Inadequate safety incident investigations
- Reports that mention this concern
- 244
- Times this concern has been raised
- 316
- Stated actions linked to this concern
- 447
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 244 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to conduct adequate and candid investigations of serious clinical events
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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 of the GP practice system to investigate unexpected deaths
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring 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
Inaccuracies in serious incident reviews affecting process validity
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring 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 investigate repeated falls
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring 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 of the serious incident report to fulfil its learning and accuracy obligations
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Epsom and St Helier University Hospitals NHS Trust
Stated actions 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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Epsom and St Helier University Hospitals NHS Trust
Prepare and provide a supplemental Root Cause Analysis report addressing the concerns and learning points from the inquest.
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Concerns raised1
Delays in concluding serious incident investigations and reviews
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Betsi Cadwaladr University LHB
Stated actions 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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Betsi Cadwaladr University LHB
Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.
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Betsi Cadwaladr University LHB
Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.
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Betsi Cadwaladr University LHB
Implement a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.
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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Betsi Cadwaladr University LHB
Legal advice was required before the investigation report could be signed off, delaying completion.
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Concerns raised1
Failure to include the responsible care coordinator in the investigation
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring 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 obtain timely witness statements after falls
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Hc-One Limited
Stated actions 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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Hc-One Limited
Monitor incident-investigation reporting quality and provide refreshed investigation-management training to Home Managers and Area Team Managers.
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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Hc-One Limited
Contrary to the report, witness information was obtained during the initial and subsequent internal investigations.
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Concerns raised1
Failure to carry out an internal investigation after serious failures
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- United Lincolnshire Teaching Hospitals NHS Trust
Stated actions 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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United Lincolnshire Teaching Hospitals NHS Trust
Commence a serious incident investigation to review the care provided.
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United Lincolnshire Teaching Hospitals NHS Trust
Improve the serious incident process, including Trust-wide investigation training and governance oversight.
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United Lincolnshire Teaching Hospitals NHS Trust
Maintain an Interim Director of Governance role leading the serious incident process improvement project.
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United Lincolnshire Teaching Hospitals NHS Trust
Establish the new Risk Manager post to support serious incident process improvement.
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Concerns raised1
Lack of internal investigation or Serious Incident Review following a prisoner death
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026