Recurring concern

Inadequate safety incident investigations

First to latest report 13 Dec 2008 — 25 Jun 2026

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.

Reports and published responses 244 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    STEPHANIE DANIELS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to conduct prompt, thorough and independent investigations of serious patient deaths

    Wider context from the report

    “1. Internal NHS SUI Investigation v Independent Investigation I am concerned that a death such as this of either a detained or voluntary patient (where Article 2 is arguably engaged) requires a prompt, thorough and robust investigation to be completed as soon as possible. Deficiencies in systems, protocols, policies, record keeping and individual actions need to be identified quickly and remedial action taken. This cannot wait for an inquest which may not take place for many months. This was not the first case of a poor or incomplete SUI investigation. The court was aware of and invited submissions about the recent case of R (Antoniou) v Central and North West London NHS Foundation Trust and others [2013] EWHC 3055 (Admin). In this case there were significant errors and omissions in the SUI investigation. Important witnesses were not interviewed. The delay in finding the deceased a bed was not a central issue and no specific findings were made about it. The medication recording errors had not been noted and had the deceased been injected with PRN Haloperidol for severe agitation, then she should have been subject to physical observations for a continuous period of time immediately afterwards, as well as other steps in compliance with the Trust’s Rapid Tranquilisation Policy. It is accepted that SUI investigations are important and hope to learn lessons quickly to be implemented. Whilst the current law indicated that it is not a requirement for there to be an independent investigation at that stage, it is a matter of concern that very significant failures in the investigative process have occurred. The Trust investigation did not reveal at all the allegation of the commencement of discreet continuous observations on the morning of 24th March. This is not the first time that the Trust SUI investigations have been found to be flawed and I have experience of other Trusts’ investigations also being significantly flawed. In conclusion in this sort of case I am concerned that without appropriately speedy and thorough independent investigation commissioned by the NHS Trust involved, flawed SUI investigation reports may continue to be produced. This is a policy decision for the NHS but I strongly urge consideration of this. ”

    Source location

    STEPHANIE DANIELS · Prevention of Future Deaths report
    Page 10 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Review the SIRI policy to consider independent investigation of complex cases and identify a suitable investigation resource.

    Verbatim wording from the response

    “Following the concerns raised in your report about the Serious Untoward Incident the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases. The Trust will also develop further guidance for investigators regarding the learning from this case. As part of the review, the Trust will look at identifying a resource to carry out such independent investigations.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 1 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop guidance for SIRI investigators or chairs on learning from cases and defining investigation scope.

    Verbatim wording from the response

    “Following the concerns raised in your report about the Serious Untoward Incident the Trust will be reviewing the Serious Incident Requiring Investigation (SIRI) policy to consider the engagement of an independent investigator in complex cases. The Trust will also develop further guidance for investigators regarding the learning from this case. As part of the review, the Trust will look at identifying a resource to carry out such independent investigations.”

    Source location

    2013-0353-Response-by-Manchester-Mental-Health-NHS
    Page 1 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operate the revised governance process and monthly Citywide Patient Safety Committee to review serious incidents and other patient-safety concerns.

    Verbatim wording from the response

    “A revised governance process has been developed within the Citywide Commissioning, Quality and Safeguarding Team and the Trust now attends an established Citywide Patient Safety Committee. This committee meets monthly and is responsible for the review and monitoring of serious incidents requiring investigation reported at the Trust as well as any other patient safety related issues including those highlighted at inquest via Prevention of Future Death Reports.”

    Source location

    2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
    Page 2 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Scrutinise Trust investigation reports through High Level Investigation Panels and review resulting action plans for SMART actions that reduce recurrence risk.

    Verbatim wording from the response

    “The City Wide Commissioning, Quality and Safeguarding Team are represented at all High Level Investigation Panels (HLIP) held by the Trust. The HLIP’s were established by the Trust in order to allow scrutiny of their investigations and reports. Prior to the HLIP the Trust provides the City Wide Commissioning, Quality and Safeguarding Team with a draft copy of their investigation report. This allows the City Wide Commissioning, Quality and Safeguarding Team representative to review the report and challenge its robustness, contents and findings. Following the HLIP the Trust develops an action plan and the City Wide Commissioning, Quality and Safeguarding Team representative reviews this to ensure that the actions identified are Specific, Measurable, Achievable, Realistic and Time based (SMART) to reduce the likelihood of a recurrence of the incident.”

    Source location

    2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
    Page 2 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Scrutinise the Trust’s response to the Prevention of Future Deaths report and seek assurance that proposed actions are appropriate, robust and implemented.

    Verbatim wording from the response

    “The Trust's response to the Prevention of Future Deaths Report in this case will be scrutinised by the CCG and assurances will be sought from the Trust in relation to any actions it proposes to take to ensure that they are appropriate and robust and that they are implemented.”

    Source location

    2013-0353-Response-by-Manchester-Clinical-Commissioning-Groups
    Page 2 · response
    Published 13 December 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.

    Verbatim wording from the response

    “As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.”

    Source location

    2013-0353-Response-by-Department-of-Health
    Page 1 · response
    Published 13 December 2013

    Open published response

  2. Inner North London

    AI-generated summary

    John William Wright · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    John William Wright, who had a history of paranoid schizophrenia and COPD, was admitted to hospital with pneumonia and suffered several falls, including a fall that caused a fractured spine and left humerus. He died on 15 April 2013 from recurrent chest infections; the inquest concluded that his death resulted from an accident. Concerns included the lack of investigation into the cause of the fall and uncertainty about whether all relevant staff were trained in falls protocols and recording requirements.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to investigate the causes or potential causes of falls

    Wider context from the report

    “1. There was no investigation of the cause or potential cause of the fall (whether there were any external factors involved – water on the floor, over-cleaning or any other high risk matter) so as to ensure that further falls could be prevented if necessary. Even if it transpired that the cause could not be determined, the fall should have been treated as a Serious Untoward Incident that warranted some kind of investigation. The North Middlesex University Hospital NHS Trust Serious Incident Policy defines as ‘serious’ an ‘Accident while in hospital’ and I consider that such a fall should be considered to be an accident. The policy then details actions that should be taken by staff dependent on the urgency of the incident and the evidence that I was given confirmed that the appropriate electronic records were not made following the incident. 2. It was not at all clear from the evidence whether the training on falls policy and the protocols related to the recording of witnessed falls extended to the doctors as well as nurses and it is clear that, as a fall may be witnessed by any staff member at a hospital, the proper protocols should at least be known even if access to electronic means of recording an incident is limited for reasons of confidentiality. ”

    Source location

    John William Wright · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. South London

    AI-generated summary

    Elsie Gibson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Elsie Gibson, aged 94, slipped from a narrowed pavement while passing an unlicensed scaffold tower in High Street, Bromley, on 4 January 2013. She sustained a fractured hip and died in hospital on 9 January 2013. The concerns included the erection of the scaffold without required formalities and the apparent lack of prompt investigation or enforcement action by the Council after the incident.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in investigating reported incidents involving unlicensed scaffold towers

    Wider context from the report

    “Mrs Gibson was injured when she slipped off the kerb whilst circumventing a narrowed pavement, caused by the erection of an unlicensed scaffold tower, outside premises in High Street Bromley on 4th January 2013. She later died of her injuries. The scaffolding tower was erected without the necessary formalities. When the incident was reported to the Council by the son, it does not appear to have been investigated promptly. I understand that the Council is the Highways Authority and presume that it is for the Council to take all necessary action. The son supplied photographic and other evidence at the inquest. I was told in evidence at the inquest that there is no contemporaneous evidence, in note form or otherwise, of the inspection that did take place. I refer to the evidence given to me by ████████ the Council's Technical Support Team Leader for Environment and Community Services. It seems to me that it would not be unduly difficult to ascertain (whether from Roosters PiriPiri or from the property landlord) who arranged for the erection of the scaffold and then to take appropriate action. However, I understand that no enquiries of that kind have been made and it seemed from evidence given to me that no such action is contemplated. As coroner, I have a duty to the citizens of my area to take appropriate steps to prevent future deaths when there is a continuing risk. If no action is taken it is likely to lead others who might need to erect scaffolding towers to decide that there is no need to seek formal permission because no action is taken by the Highways Authority when others do so without consequences, even in circumstances where passers-by are injured. I invite the Council to reconsider whether there is not an obligation to investigate the incident and to take action against the person(s) who erected the scaffold tower without license and, albeit without intending to do so, caused a passer-by to be injured and to die from those injuries. If no action is taken, others may well believe that they can do as they please without license and not have to face any consequences of their action. If action is taken, and publicity given, it may lead others to adhere to the necessary formalities. ”

    Source location

    Elsie Gibson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Buckinghamshire

    AI-generated summary

    Heather Beatrice Planner · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to procure original patient records during investigations

    Wider context from the report

    “(6) There is a specific concern in Mrs Planner’s case about the robustness of the subsequent Carewatch investigation and any learning that would arise to prevent incidents in the future, since Carewatch had not procured the original paper patient records from Mrs Planner’s home address at any stage during their investigations or prior to the inquest hearing. This may have compromised the ability to assess the accuracy of records to which the individual carers had access, any impact that may have had upon the medication error, or any learning to arise in the context of record keeping and application of medication and care plan requirements by carers. ”

    Source location

    Heather Beatrice Planner · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026