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 identify falsified observation records in post-death investigation
This report raised 30 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
Further develop PSIIR support and quality-check tools, including detailed investigation checklists, care-team confirmation and organisational sign-off checks.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Patient safety investigations failing to seek treating staff recollections
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.
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
Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
Stated by The Trust
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Concerns raised3
Failure of the investigation to substantiate the finding that there was no reason to doubt capacity
Failure of the investigation to critically analyse decisions to rescind section and discharge without trialling s17 leave
Failure of the investigation to examine the consequences of no local bed availability for continuity of care
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.4
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Action
Establish and ratify a subject-matter-expert framework, contact process and investigation-team mapping for patient safety investigations.
Stated by Pennine Care NHS Foundation Trust -
Action
Refresh and operate Central Safety Summit terms of reference to oversee appropriate participation in patient safety investigations.
Stated by Pennine Care NHS Foundation Trust -
Action
Subject investigation reports to critical scrutiny through Network Quality and Safety panels, including clinical and lived-experience perspectives.
Stated by Pennine Care NHS Foundation Trust
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Action
Review and develop the repatriation standard operating procedure for consistent, clinically appropriate patient transfers.
Stated by Pennine 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
Using Trust-wide beds rather than waiting for a local bed is considered safer because delayed admission and ward transfers may cause greater harm.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to investigate incidents in accordance with Datix requirements
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.1
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Action
Report identified care concerns through the incident reporting system and provide Duty of Candour, investigation and learning.
Stated by University Hospitals Plymouth NHS Trust
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Concerns raised1
Inadequate investigation of deaths potentially associated with IV feeding
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 investigate what went wrong and why between treating and administration teams
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
Conduct a Patient Safety Incident Investigation into inpatient-to-outpatient referral risks and identify the safest referral system.
Stated by the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Responsibility for making the cardiology referral lay with the medical inpatient team, not gastroenterology, at discharge.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Position
The concerns fall outside NHS England’s role and remit as a commissioner of certain healthcare services.
Stated by NHS England -
Position
Shrewsbury and Telford Hospital NHS Trust is responsible for addressing the concerns raised in the report.
Stated by NHS England
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Concerns raised1
Delays and obstructions in gathering evidence from key witnesses
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.
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
Subject all suspected RAF suicides to immediate fact-finding investigations led by Station Commanders to gather relevant evidence promptly.
Stated by Ministry of Defence -
Action
Incorporate immediate fact-finding investigations for suspected RAF suicides into the RAF Postvention Suicide Response policy.
Stated by Ministry of Defence
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Concerns raised1
Failure to assess serious unwitnessed falls for investigation through the Patient Safety Framework
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
Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Position
Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Position
Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Concerns raised1
Lack of effective internal investigation and organisational learning from safeguarding incidents
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.5
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Action
Complete a Serious Untoward Incident root cause analysis with Human Resources support.
Stated by Harbour Healthcare Ltd. -
Action
Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
Stated by Harbour Healthcare Ltd. -
Action
Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
Stated by Harbour Healthcare Ltd.
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Action
Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
Stated by Harbour Healthcare Ltd. -
Action
Cascade Riverside Court’s inquest outcome and lessons learned across the company.
Stated by Harbour Healthcare Ltd.
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Concerns raised1
Failure to undertake a patient safety framework investigation when concerns and review triggers arise
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
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
Stated by Barts Health NHS Trust
Data last updated 7 September 2026