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 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.
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 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.
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
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.
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 investigate repeated falls
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
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.
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
Prepare and provide a supplemental Root Cause Analysis report addressing the concerns and learning points from the inquest.
Stated by Epsom and St Helier University Hospitals NHS Trust
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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.
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
Revise the serious-incident investigation model, pairing Corporate Concerns Team staff with catastrophic-incident investigators and expanding staff training capacity.
Stated by Betsi Cadwaladr University LHB -
Action
Introduce a weekly Incident Review Meeting to review recent incidents, monitor delayed investigations, and drive investigations and action plans to completion.
Stated by Betsi Cadwaladr University LHB -
Action
Implement a project-management approach for comprehensive investigations, including completion milestones agreed with the designated Chair.
Stated by Betsi Cadwaladr University LHB
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
Legal advice was required before the investigation report could be signed off, delaying completion.
Stated by Betsi Cadwaladr University LHB
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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.
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 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.
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
Monitor incident-investigation reporting quality and provide refreshed investigation-management training to Home Managers and Area Team Managers.
Stated by Hc-One 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
Contrary to the report, witness information was obtained during the initial and subsequent internal investigations.
Stated by Hc-One Limited
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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.
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
Commence a serious incident investigation to review the care provided.
Stated by United Lincolnshire Teaching Hospitals NHS Trust -
Action
Improve the serious incident process, including Trust-wide investigation training and governance oversight.
Stated by United Lincolnshire Teaching Hospitals NHS Trust -
Action
Maintain an Interim Director of Governance role leading the serious incident process improvement project.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
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Action
Establish the new Risk Manager post to support serious incident process improvement.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
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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.
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