Recurring concern
Unreliable reporting of patient-safety incidents
- Reports that mention this concern
- 46
- Times this concern has been raised
- 52
- Stated actions linked to this concern
- 58
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 46 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- Royal College of Emergency Medicine
Stated actions 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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Royal College of Emergency Medicine
Re-issue a previously published air-embolism case report to raise awareness among members.
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Royal College of Emergency Medicine
Consider providing specific air-embolism recognition and management guidance through the RCEM eLearning platform.
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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.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions 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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Essex Partnership University NHS Foundation Trust
Review the incident sign-off process to improve completion of patient-safety Datix reports.
-
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.
Linked response
- Betsi Cadwaladr University LHB
Stated actions 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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Betsi Cadwaladr University LHB
Raise an incident report for the identified follow-up error.
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Betsi Cadwaladr University LHB
Deliver a revised Datix training programme through recurring team sessions, local training, videos and guidance.
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Betsi Cadwaladr University LHB
Redesign the incident process with services using frontline feedback and Welsh best practice.
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Betsi Cadwaladr University LHB
Review the incident process further with support from the NHS Wales National Executive Quality Team.
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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.
Linked response
- Kettering General Hospital NHS Foundation Trust
Stated actions 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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Kettering General Hospital NHS Foundation Trust
Introduce and roll out Stop the Line across the Trust, incorporating concerns into Datix reporting and daily team huddles.
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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.
Linked response
- Betsi Cadwaladr University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Betsi Cadwaladr University LHB
Undertake a full Health Board incident-process review through staff co-design.
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Betsi Cadwaladr University LHB
Introduce a new incident reporting and investigation process and procedure, including revised investigation training, for April 2024.
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Betsi Cadwaladr University LHB
Deliver revised incident-reporting training and provide staff with accessible how-to guides and videos through the BetsiNet intranet.
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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.
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.
Linked responses
- Department of Health and Social Care
- North East London NHS Foundation Trust
Stated actions 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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North East London NHS Foundation Trust
Review original evidence and assess whether disciplinary action is warranted for inaccurate or misleading records and reports.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Concerns about care provision and coordination are mainly for the NHS Trust to address.
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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.
Linked responses
- Capita PLC
- Ministry of Defence
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Capita PLC and Ministry of Defence
Maintain integrated oversight of parallel accident-reporting systems through shared access, a reporting register, common reporting ownership and monthly tracking.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Capita PLC and Ministry of Defence
Two separate accident-reporting systems must continue because Army and Capita have distinct organisational reporting obligations.
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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.
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.
Linked responses
- NHS England
- Royal Surrey NHS Foundation Trust
- Surrey and Sussex Healthcare NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
-
Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust
The incident occurred at SASH, so RSFT had no Datix incident and relevant letters were held by SASH rather than RSFT.
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Royal Surrey NHS Foundation Trust and Surrey and Sussex Healthcare NHS Trust
Annual mandatory Datix training, governance discussions and appraisal processes provide sufficient awareness of incident-reporting requirements.
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NHS England
Annual mandatory consultant training already covers Datix use and incident reporting, addressing the need for refresher training for hospital doctors.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026