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
Lack of an effective system for gathering, retaining, reviewing and disclosing investigation material
This report raised 13 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
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing document-retention guidance is considered sufficient to meet coroners’ needs in the vast majority of cases.
Stated by HM Prison and Probation Service
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Position
Overlapping organisations, separate officer statuses, and late Ministry disclosure made admissions without trespassing on inquest evidence difficult.
Stated by Sodexo
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Concerns raised3
Delegation of investigations without terms of reference
Investigation conclusions based on assumptions
Failure to explore all relevant investigation scenarios
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.1
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Action
Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.
Stated by Mills Family Limited
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Concerns raised2
Use of narrowly scoped and time-pressured structured reviews of incidents
Use of incident reviewers with potential conflicts of interest
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
Modify the Structured Judgement Review template to prompt reviewers to identify concerns about the review’s scope or focus.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Require reviewers to confirm before completing a Structured Judgement Review whether they have a conflict of interest.
Stated by Oxford University Hospitals 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 existing Structured Judgement Review process requires whole-record review, allows sufficient time, and enables concerns about care quality to be escalated.
Stated by Oxford University Hospitals NHS Foundation Trust
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Concerns raised1
Failure to conduct adequate investigations of adverse incidents
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
Instruct an external person or organisation to investigate each future death.
Stated by Chiltern Care Services
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Concerns raised1
Failure to conduct internal investigations of care outside safeguarding processes
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.
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
Existing investigation and learning arrangements are appropriate; no further changes are required beyond measures already discussed at the inquest.
Stated by Springcare and Springcare (Macclesfield) Ltd t/a Henning Hall
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Concerns raised1
Lack of internal investigation of serious incidents
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.1
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Action
Complete Structured Judgement Reviews for all patients with identified learning disabilities who die while receiving Trust care.
Stated by NHS Humber Health Partnership
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Trust did not declare a serious incident because harm was not deemed to have been caused by the Trust.
Stated by NHS Humber Health Partnership
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Position
The Humber Steering Group manages the LeDeR action plan across the ICB, while Trust-related actions are monitored through the LeDeR Panel Review Group.
Stated by NHS Humber Health Partnership
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Concerns raised1
Failure of internal investigations to identify deficiencies in handover documents
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
Implement the revised Safety Incident Response Framework for serious-incident investigations.
Stated by Care UK -
Action
Ensure future serious incidents are investigated by an independent Home Manager under the Safety Incident Response Framework.
Stated by Care UK
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Concerns raised1
Failure to obtain accounts from Haematology and blood laboratory staff after a massive haemorrhage
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.1
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Action
Renew MNSI investigation processes so all involved staff receive draft reports and can provide comments through multidisciplinary factual-accuracy review.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Inadequate systems for timely review of patient safety incidents and learning from findings
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
Complete and discuss a full significant event analysis of the case.
Stated by Meanwood Group Practice -
Action
Apply a lower threshold for completing significant event analyses, discussing them weekly and recording and acting on lessons.
Stated by Meanwood Group Practice
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Concerns raised1
Failure of investigations to address relevant clinical issues
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026