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 report poor visibility through a seclusion-room observation panel
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
Failure to complete incident forms
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.5
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Action
Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.
Stated by PrimeLife Limited -
Action
Ensure nursing and care staff read and understand accident, incident and falls-management policies.
Stated by PrimeLife Limited -
Action
Deliver falls-management and head-injury training to nurses, covering observations, documentation, assessments, care planning and falls-risk reduction.
Stated by PrimeLife Limited
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Action
Provide nurses with incident-form completion training and supervision, including body mapping.
Stated by PrimeLife Limited -
Action
Deliver safeguarding training covering reportable incidents, incident reporting and incident auditing, with regional oversight of timely external reporting.
Stated by PrimeLife Limited
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
Training for the clinical lead cannot currently be completed because the clinical lead is on long-term sick leave.
Stated by PrimeLife Limited
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Concerns raised1
Failure to report accidents when they take place
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.
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 report noticed medication omissions through the incident reporting system
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.
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Concerns raised1
Failure to raise incident reports for significant suicide-related information
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
Incorrect quotation of hospital IV morphine dose guidelines in Serious Incident reports
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
Establish trained investigating officers and a team-based process for patient safety incident investigations.
Stated by East Suffolk and North Essex NHS Foundation Trust
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Concerns raised1
Failure to ensure staff awareness of reporting all incidents endangering service users
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.
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Concerns raised1
Failure to make datix referrals for missed medications
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 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 raised2
Failure to encourage reporting of suboptimal and dangerous practices
Failure to identify near-miss events
This report raised 10 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
Deliver and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Appraise the Trust incident-reporting system and develop preliminary recommendations for improving incident data capture and analysis.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to make immediate DATIX incident reports in accordance with hospital protocol
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.
Data last updated 7 September 2026