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
Flawed investigations failing to identify systemic failures and learning
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.6
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Action
Implement a revised incident management policy and process based on national best practice.
Stated by The Children's Trust -
Action
Strengthen the clinical governance framework to identify recurring themes and trends and support organisational learning.
Stated by The Children's Trust -
Action
Implement the national Patient Safety Incident Response Framework for incident investigations.
Stated by The Children's Trust
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Action
Review all incidents through multidisciplinary panels representing the organisation.
Stated by The Children's Trust -
Action
Apply internal governance oversight to externally commissioned investigations and scrutinise their findings.
Stated by The Children's Trust -
Action
Conduct thematic reviews of serious incidents and use findings to inform staff training and service improvements.
Stated by The Children's Trust
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Concerns raised1
Failure of the death investigation process
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.4
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Action
Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.
Stated by Royal Berkshire NHS Foundation Trust -
Action
Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.
Stated by Royal Berkshire NHS Foundation Trust -
Action
Change General Surgery SJR allocation so a subspecialist conducts the review and a second, preferably external-subspecialty, surgeon reviews and signs it.
Stated by Royal Berkshire NHS Foundation Trust
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Action
Introduce a parallel anaesthetist-led SJR to add an independent anaesthetic perspective and identify learning.
Stated by Royal Berkshire 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 Trust considers its established death investigation processes robust and sufficient to underpin learning and patient safety.
Stated by Royal Berkshire NHS Foundation Trust
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Concerns raised1
Failure to investigate errors to establish why they happened and prevent recurrence
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
Report and investigate the incident under the Patient Safety Incident Response Framework.
Stated by Oxford University Hospitals NHS Foundation Trust
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Concerns raised2
Failure to learn from serious incidents and consider recommendations for future care
Inadequate analysis of serious 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
Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
Stated by University Hospitals Plymouth NHS Trust -
Action
Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
Stated by University Hospitals Plymouth NHS Trust -
Action
Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
Stated by University Hospitals Plymouth NHS Trust
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Action
Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
Stated by University Hospitals Plymouth NHS Trust -
Action
Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
Stated by University Hospitals Plymouth NHS Trust
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Concerns raised1
Lack of assured ongoing funding for MSNI investigations
This report raised 19 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
Nationally led MSNI funding prevents assurance about funding continuing beyond 2027.
Stated by NHS Lancashire and South Cumbria Integrated Care Board
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Concerns raised2
Insufficient scrutiny of witness accounts during investigations
Failure to establish accurate circumstances of falls during 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.
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
Require trained Governance Leads to participate in all internal investigations and ensure witness statements receive managerial or Deputy Director sign-off before finalisation.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Brief Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.
Stated by Northumbria Healthcare NHS Foundation Trust
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Concerns raised1
Failure of internal investigations to verify relevant witness information and clinical address records
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.
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
Provide Meet and Greet workers in community mental health team receptions to verify demographic, contact and accommodation information.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Remind clinical staff to record address and contact-number changes on the service-user demographic record in Rio.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Absence of a formal internal post-death investigation report
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
Inadequate investigation of post-fall incidents
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
Update falls risk assessments within 24 hours and document follow-up in care records.
Stated by Care Home Manager -
Action
Implement root-cause analysis and incident-investigation tools for falls.
Stated by Care Home Manager -
Action
Hold staff meetings reinforcing accurate incident assessment, timely reporting and compliance with policy and guidance.
Stated by Care Home Manager
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Concerns raised2
Limited internal review of procedure-related circumstances
Failure to consider NatSSIPS2 standards in detail during internal review
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