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 Serious Incident Reviews after deaths
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.2
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Action
Commission a multi-agency learning review to identify lessons, improve practice and reduce the likelihood of similar cases.
Stated by Milton Keynes Safeguarding Board -
Action
Undertake the multi-agency learning review, including practitioner engagement, case-report analysis, concern analysis and a practice-improvement report with dissemination recommendations.
Stated by Milton Keynes Safeguarding Board
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Concerns raised1
Incomplete team incident reviews of deaths
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Incident investigation failing to identify deficient post-operative care
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 complete timely and accurate Root Cause Analysis reports
This report raised 15 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.7
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Action
Provide dedicated full-time RCA investigator capacity in the adult mental health directorate.
Stated by Oxford Health NHS Foundation Trust -
Action
Monitor RCA investigation allocation, progress and timeliness weekly, with quarterly reporting to the Board of Directors.
Stated by Oxford Health NHS Foundation Trust -
Action
Survey RCA investigators to assess whether training changes meet their needs.
Stated by Oxford Health NHS Foundation Trust
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Action
Commission an external review of the quality of serious-incident investigations to identify improvements.
Stated by Oxford Health NHS Foundation Trust -
Action
Review RCA investigator training and develop an additional module on involving and working with families.
Stated by Oxford Health NHS Foundation Trust -
Action
Deliver the revised RCA training, including the additional family-involvement module.
Stated by Oxford Health NHS Foundation Trust -
Action
Introduce a standard requiring all investigators to complete refresher RCA training at least every three years.
Stated by Oxford Health 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
The second RCA did not need to revisit immediate actions because the initial review had already identified them and the actions required.
Stated by Oxford Health NHS Foundation Trust
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Concerns raised1
Failure to carry out post-event investigations of overturns
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 patient safety events appropriately
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
Failure of investigations to reflect identified risk issues for further learning
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.
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Concerns raised1
Incomplete investigation of events failing to address trust delay
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.1
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Action
Transfer the legal team into the Governance Directorate to strengthen collaboration with the Clinical Governance Unit and support earlier identification of investigation and witness-evidence deficiencies.
Stated by Sherwood Forest Hospitals NHS Foundation Trust
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Concerns raised3
Lack of transparency in internal investigations of patient care incidents
Lack of independence in internal investigations of patient care incidents
Delays in completing investigations and learning lessons from patient safety 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.
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 out-of-hours medical cover in internal 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.
Data last updated 7 September 2026