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.
Department of Health and Social Care31
Care Quality Commission21
NHS England20
Betsi Cadwaladr University LHB11
Barking, Havering and Redbridge University Hospitals NHS Trust10
Barts Health NHS Trust8
Greater Manchester Mental Health NHS Foundation Trust8
Pennine Care NHS Foundation Trust7
Essex Partnership University NHS Foundation Trust6
Nottinghamshire Healthcare NHS Foundation Trust5
Tameside and Glossop Integrated Care NHS Foundation Trust5
Tees, Esk and Wear Valleys NHS Foundation Trust5
Health and Safety Executive4
Medicines and Healthcare products Regulatory Agency4
NHS Greater Manchester Integrated Care Board4
NHS trust146
Ministerial department39
Healthcare site27
Executive non-departmental public body21
Health and social care service regulator21
Private limited company20
Local health board14
Integrated care board11
Type not available11
English metropolitan district council8
Police force8
Health professional body6
Health and care professional regulator5
Independent healthcare provider5
Multi-service care provider5
Reports and published responses 244 reports
See individual reports that have raised this concern, and the actions taken in response
Inner North London
Concerns raised1
Failure to include involved registrars’ input in untoward incident investigations
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to test care home employees’ accounts during investigations
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
West Sussex
Concerns raised1
Failure to undertake a serious incident review after a patient death shortly after discharge
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Surrey and Borders Partnership NHS Foundation 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
Surrey and Borders Partnership NHS Foundation Trust
Contact provider organisations early and agree responsibility for reporting and serious-incident investigations.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Surrey and Borders Partnership NHS Foundation Trust
Responsibility for reporting and leading the serious incident investigation was assigned to the lead provider, while the Trust expected to participate.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised3
Inaccuracies in internal investigation reports
Insufficient and perfunctory investigations of patient deaths
Failure to interview key witnesses during investigations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Tameside and Glossop Integrated Care NHS Foundation 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
Tameside and Glossop Integrated Care NHS Foundation Trust
Rewrite and implement the serious incident investigation policy with guidance on reporting, investigation, best practice, system failures and record-keeping standards.
Tameside and Glossop Integrated Care NHS Foundation Trust
Introduce an Executive-led Serious Incident Review Panel to scrutinise investigation reports and action plans and require clinical leads to report changes and learning.
Tameside and Glossop Integrated Care NHS Foundation Trust
Train senior officers across all divisions in root-cause analysis and incident investigation through external facilitation.
Tameside and Glossop Integrated Care NHS Foundation Trust
Require Directors to review each serious incident and assign an investigation level, team and relevant professional advice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Tameside and Glossop Integrated Care NHS Foundation Trust
Existing serious incident processes provide significant assurance that appropriate systems and processes are in place.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Central Lincolnshire
Concerns raised3
Failure to maintain independence between clinical responsibility and SUI investigation
Failure to identify and address inadequacies in an operating surgeon's statement and SUI
Failure to read source statements before signing off an SUI Report
This report raised 9 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.1
United Lincolnshire Teaching Hospitals NHS Trust
Strengthen serious-incident investigations through revised governance processes, independent investigator requirements, weekly senior oversight, external submission and Trust Board reporting.
Surrey
Concerns raised1
Failure of SI reports to consider dehydration as a possible cause of acute renal failure
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Survey and Sussex NHS Healthcare 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
Survey and Sussex NHS Healthcare NHS Trust
Operate a multidisciplinary Serious Incident Review Group meeting fortnightly to review investigations and reports before closure.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Survey and Sussex NHS Healthcare NHS Trust
The Trust disputes that its investigation failed to recognise dehydration as a possible cause of acute kidney injury.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Bedfordshire and Luton
Concerns raised1
Failure to conduct a formal Serious Incident Investigation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
County Durham and Darlington
Concerns raised1
Failure of internal methadone-related death inquiries to draw on external research
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Leicester City and South Leicestershire
Concerns raised1
Failure to produce accurate and reliable investigation reports
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals of Leicester 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.3
University Hospitals of Leicester NHS Trust
Establish named RCA Chairs to oversee investigation scope, team composition, SMART action plans and report sign-off.
University Hospitals of Leicester NHS Trust
Purchase and provide tiered external RCA training for investigation leads, senior safety investigators and RCA Chairs.
University Hospitals of Leicester NHS Trust
Provide senior scrutiny of events causing avoidable death or harm and identify root causes, themes and required safety workstreams.
South and West Cambridgeshire
Concerns raised1
Failure to investigate serious incidents and prevent recurrence
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
North West Anglia NHS Foundation 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
North West Anglia NHS Foundation Trust
Revise the Trust’s Serious Incident process within the wider quality-improvement programme.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.