First reported 16 Dec 2013•Latest report 1 Jun 2026
Definition
What this concern includes
Includes failures of the dedicated patient-safety incident-reporting process, including encouragement and staff understanding, recognition of reportable events, submission of incident or error reports, and systems for entering, updating or amending reports.
Not included
Excludes failures of incident investigation, organisational learning or implementation of corrective actions where the incident-reporting process itself is not deficient.
Excludes generic documentation, training, staffing or communication deficiencies that are not directly tied to reporting patient-safety incidents or unsafe practices.
Excludes professional-regulator reporting duties where the concern is external misconduct reporting rather than the organisational patient-safety incident-reporting process.
Excludes factual descriptions of incidents or under-reporting risk that do not identify an unsafe reporting-process condition.
Reports
46
Distinct published reports
Individual concerns
52
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
58
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.
Department of Health and Social Care7
Care Quality Commission3
Essex Partnership University NHS Foundation Trust3
Betsi Cadwaladr University LHB2
Borough Care Ltd2
East London NHS Foundation Trust2
Hc-One Limited2
NHS England2
Aden Court Care Home1
ADL Plc1
Barking, Havering and Redbridge University Hospitals NHS Trust1
Barts Health NHS Trust1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Capita Business Services Ltd1
Capita PLC1
NHS trust28
Ministerial department9
Integrated care board5
Healthcare site4
Private limited company4
Health and social care service regulator3
Executive non-departmental public body2
Local health board2
Nursing-home operator2
Public limited company2
Type not available2
Company limited by guarantee1
Domiciliary care provider1
Health professional body1
Justice inspectorate1
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.
Essex
Concerns raised1
Failure to report and audit unauthorised Section 17 Leave incidents
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Nottingham City & Nottinghamshire
Concerns raised1
Failure to complete Datix reports promptly after clinical events
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 concerns
Each 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
Action
Strengthen incident-reporting, device-quarantine and evidence-retention policies through governance ratification and publication.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Action
Develop and deliver Trust-wide multiprofessional training on prompt reporting, candour, device quarantine, data preservation and related safety processes.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Action
Disseminate interim incident-response messaging and implement a formal communication plan alongside revised policies and SOPs.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Action
Monitor incident-reporting timeliness and investigate the rationale for reporting delays.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2026.
Essex
Concerns raised3
Failure to report supervision and ligature-risk breaches
Failure to raise Datix incident reports
Inadequate recording of ligature incidents and risks
This report raised 28 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Implement Trust-wide incident-reporting improvements covering form revisions, risk-assessment prompts, change communications, reporter feedback and completion of key fields.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Improve CAMHS incident learning through ABC-format Datix records, staff training, action recording and ligature-risk categorisation.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Devon, Plymouth and Torbay
Concerns raised2
Lack of staff training and understanding of responsibility to report and escalate serious clinical incidents
Lack of understanding of when Serious Incident Reports should be made or actioned retrospectively
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 concerns
Each 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.8
Action
Recruit and establish three Care Group Director of Nursing roles to lead governance and support patient safety.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Deliver incident-reporting education and training for clinical staff, including medical staff and new starters.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Implement DCIQ as the Trust incident-reporting system and communicate that all staff may report unexpected or unintended incidents.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Deliver additional community-hospital training and targeted communications reinforcing incident-reporting expectations.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Commence quarterly learning events with incident reporting as a core topic.
Stated by Torbay and South Devon NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 February 2026.
Action
Review structured judgement review scores through care-group governance and executive meetings to determine further patient-safety investigation.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Adopt PSIRF and operate weekly Executive Incident Review Meetings to determine proportionate investigation responses, including retrospective incidents.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
Action
Update and publish the Trust PSIRF policy and plan to reflect new patient-safety insight data.
Stated by Torbay and South Devon NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2026.
South Yorkshire (Eastern)
Concerns raised1
Failure to complete a Datix report following an inpatient fall
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 concerns
Each 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
Action
Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.
Stated by the Rotherham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 June 2025.
Cumbria
Concerns raised1
Failure to report falls or collapses on the ward
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 concerns
Each 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
Action
Deliver refresher incident-reporting training to AMU nursing staff covering falls, collapses, unwitnessed incidents and reporting thresholds.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
FRAMP falls assessments were completed and updated appropriately; the identified failure concerned documenting and applying mitigating controls.
Stated by North Cumbria Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Cornwall and Isles of Scilly
Concerns raised1
Failure to report errors through the OUH Incident Reporting process
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 concerns
Each 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
Action
Feed back to the Sarcoma team the importance of reporting all patient safety incidents, including no-harm incidents.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Send a Trust-wide safety message emphasising reporting all patient safety incidents, including no-harm incidents.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Action
Report and investigate the incident under the Patient Safety Incident Response Framework.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Lancashire and Blackburn with Darwen
Concerns raised1
Failure to notify external and internal patient-safety bodies of serious incidents
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 concerns
Each 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
Action
Enhance engagement with level 3 centres to improve handover of maternity events and concerns relevant to external reporting.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Evaluate the operating effectiveness and consistency of serious-incident controls following PSIRF adoption.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Maintain contractual oversight and scrutiny of the Trust’s patient-safety-event reporting, challenging unexpected variation.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Operate a regional procedure for escalating serious maternity patient-safety incidents to regional and national NHS England teams.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to report a split Hickman catheter through the required incident-reporting process
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 concerns
Each 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
Action
Report the split Hickman catheter incident retrospectively through the Trust’s electronic incident-reporting system.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Cascade immediate and reflective learning from the catheter incident to involved, ward, medical and surgical staff.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Reinforce incident-reporting requirements through ward meetings and Elevate training or refresher training for staff.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Use senior-leader briefings to disseminate incident-reporting expectations, including reporting equipment failures, near misses and no-harm incidents.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Issue a Patient Safety update highlighting incident-reporting requirements and incident-record management.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Birmingham and Solihull
Concerns raised2
Use of Datix templates leading to incorrect or incomplete incident information
Failure to complete and review Datix reports within the required timeframe
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 concerns
Each 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
Action
Update falls-team training to reinforce incident-reporting requirements after a fall.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Templates are not used for incident reports; the post-fall care plan lists required actions, while staff record incident information separately.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures of the dedicated patient-safety incident-reporting process, including encouragement and staff understanding, recognition of reportable events, submission of incident or error reports, and systems for entering, updating or amending reports.
