Recurring concern
Unreliable reporting of patient-safety incidents
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Request correctionFirst reported 16 Dec 2013•Latest report 1 Jun 2026
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
- Individual concerns
- 52
- Date range
- 2013–2026
- Stated actions
- 58
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
Failure to recognise and report air embolism cases
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
Re-issue a previously published air-embolism case report to raise awareness among members.
Stated by Royal College of Emergency Medicine -
Action
Consider providing specific air-embolism recognition and management guidance through the RCEM eLearning platform.
Stated by Royal College of Emergency Medicine
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Concerns raised1
Incomplete incident reporting
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 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
Review the incident sign-off process to improve completion of patient-safety Datix reports.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to raise Datix reports for identified matters
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.4
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Action
Raise an incident report for the identified follow-up error.
Stated by Betsi Cadwaladr University LHB -
Action
Deliver a revised Datix training programme through recurring team sessions, local training, videos and guidance.
Stated by Betsi Cadwaladr University LHB -
Action
Redesign the incident process with services using frontline feedback and Welsh best practice.
Stated by Betsi Cadwaladr University LHB
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Action
Review the incident process further with support from the NHS Wales National Executive Quality Team.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to raise incident reports for serious care concerns
This report raised 5 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
Introduce and roll out Stop the Line across the Trust, incorporating concerns into Datix reporting and daily team huddles.
Stated by Kettering General Hospital NHS Foundation Trust
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Concerns raised1
Failure to ensure staff complete Datix reports when required and know how to complete them
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
Undertake a full Health Board incident-process review through staff co-design.
Stated by Betsi Cadwaladr University LHB -
Action
Introduce a new incident reporting and investigation process and procedure, including revised investigation training, for April 2024.
Stated by Betsi Cadwaladr University LHB -
Action
Deliver revised incident-reporting training and provide staff with accessible how-to guides and videos through the BetsiNet intranet.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to make required Datix incident reports for grade II lesions
This report raised 5 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
Failure to provide accurate emergency-response information in incident reports
This report raised 14 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
Review original evidence and assess whether disciplinary action is warranted for inaccurate or misleading records and reports.
Stated by North East London 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
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised2
Use of parallel incident reporting forms on separate IT systems
Unresolved or unclear functionality problems in the Casper incident reporting system
This report raised 17 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
Maintain integrated oversight of parallel accident-reporting systems through shared access, a reporting register, common reporting ownership and monthly tracking.
Stated by Capita PLC and Ministry of Defence
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
Two separate accident-reporting systems must continue because Army and Capita have distinct organisational reporting obligations.
Stated by Capita PLC and Ministry of Defence
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Concerns raised1
Failure to record the DNACPR error in the incident report
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Insufficient guidance or refresher training for hospital doctors on use of the relevant Datix system
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The incident occurred at SASH, so RSFT had no Datix incident and relevant letters were held by SASH rather than RSFT.
Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust
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Position
Annual mandatory Datix training, governance discussions and appraisal processes provide sufficient awareness of incident-reporting requirements.
Stated by Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust -
Position
Annual mandatory consultant training already covers Datix use and incident reporting, addressing the need for refresher training for hospital doctors.
Stated by NHS England
Data last updated 7 September 2026