Recurring concern

Unreliable reporting of patient-safety incidents

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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
Individual concerns: 52
Date range: 2013–2026
Stated actions: 58

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

3 May2018
Stoke-on-Trent and North Staffordshire
Concerns raised1
1. Delays in reporting falls through the incident reporting 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Disseminate the incident across the General Medicine Department and Medical division and circulate a memo reinforcing accurate, timely Datix reporting.
  Stated by University Hospitals of North Midlands NHS TrustStated completed
AI-generated summary

Kenneth William Horne · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kenneth William Horne suffered two falls at Royal Stoke University Hospital, including one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter, there was no nurse-to-nurse discharge call, and the Transfer of Care form was not up to date. He fell approximately six hours after admission to Leek Moorlands Hospital, sustaining a serious chest wall injury, and later died from sepsis, bronchopneumonia and chest wall injury.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in reporting falls through the incident reporting system
Wider context from the report
“(1) The deceased had 2 falls whilst at the Royal Stoke University Hospital, one on the morning of his transfer to Leek Moorlands Hospital. The falls were not included in the discharge letter. (2) There was no nurse to nurse discharge call between the hospitals. (3) The Transfer of Care form was not up to date. If these matters had been properly dealt with Leek Moorlands Hospital might not have accepted the transfer. He had a fall with serious injury approximately 6 hours after admission to Leek Moorlands Hospital. As a side issue and a matter of concern, communication with the relatives appeared to be poor. No Datix form was completed for the second fall in the Royal Stoke University Hospital until December. ”
Source location
Kenneth William Horne · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Disseminate the incident across the General Medicine Department and Medical division and circulate a memo reinforcing accurate, timely Datix reporting.

Verbatim wording from the response
“4. This incident was already shared widely across the General Medicine Department and Medical division. A Memo has been circulated divisionally to reiterate the importance of accurate and timely datix reporting.”

Source location
2018-0131-Response-by-University-Hospitals-of-North-Midlands-NHS-Trust
Page 2 · response
Published 1 July 2018
Open published response
12 Apr2018
Sunderland
Concerns raised1
1. Failure to report falls
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Deliver falls identification, reporting and management training, coaching and competency assessment to Hebburn Court staff, completing remaining coverage.
  Stated by Hc-One LimitedStated in progress
AI-generated summary

Patricia Ann Heslop · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to report falls
Wider context from the report
“1. The fall was unwitnessed and went unreported. ”
Source location
Patricia Ann Heslop · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver falls identification, reporting and management training, coaching and competency assessment to Hebburn Court staff, completing remaining coverage.

Verbatim wording from the response
“1.6 Following this incident, action has been taken at Hebburn Court to ensure that all staff have the knowledge, skills and tools to identify, record and manage falls to reduce risk and prevent harm. All staff have been reminded of the importance of alerting nursing colleagues and managers to any fall and documenting within the individuals' records. Learning on this has been facilitated by reassignment of the falls prevention module from our award winning online learning platform, Touchstone. In addition staff have received further coaching and assessment of competencies in this area through staff meetings and individual supervision sessions. Training statistics in this area are currently 93.5% of the staff team and plans remain to press for this to increase to 100% by the end of June 2018.”

Source location
2018-0102-Response-by-HC-One
Page 3 · response
Published 17 June 2018
Open published response
11 Apr2018
Nottinghamshire
Concerns raised1
1. Failure to report choking incidents in line with internal policy
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.
AI-generated summary

George Goldby · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to report choking incidents in line with internal policy
Wider context from the report
“(4) The choking incident on 26.12.16 was not reported in line with Stoneyford’s internal policy. ”
Source location
George Goldby · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Mar2018
Manchester West
Concerns raised1
1. Failure of private hospitals to adhere to the same reporting requirements as NHS hospitals
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Peter O’Donnell · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Peter O’Donnell was admitted for an elective right total hip replacement and later developed a chest infection and deteriorated. The report identifies concerns about ineffective communication, irregular observations, inadequate documentation, delayed antibiotics, missed opportunities to escalate care, unclear consultant and junior doctor arrangements, and the absence of transfer protocols for unwell patients. It also raises concerns about private hospitals’ reporting requirements and the reporting of nurses’ retrospective additions to clinical records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of private hospitals to adhere to the same reporting requirements as NHS hospitals
Wider context from the report
“4. Private hospitals should be required to adhere to the same reporting requirements as NHS Hospitals in order to improve the chance of harm to patients being detected. ”
Source location
Peter O’Donnell · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Nov2017
Manchester South
Concerns raised1
1. Internal incident reporting and escalation process depending largely on an individual manager
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 1
1. Action
  Implement a weekly significant-incident reporting form, discuss reported incidents at Care and Quality meetings, and action follow-up through Area Support.
  Stated by Borough Care LtdStated completed
AI-generated summary

Kathleen Smith · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kathleen Smith, who had Alzheimer’s dementia, sustained a hip fracture at her care home on 12 April 2017 after being pushed to the floor by another resident. She underwent surgery, was discharged back to the care home for palliation, and subsequently died. Concerns raised at the inquest included failures to notify her family and the organisation’s corporate risk function, and the lack of audit or review of incidents after the departure of a manager responsible for reporting and escalation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Internal incident reporting and escalation process depending largely on an individual manager
Wider context from the report
“In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing. ”
Source location
Kathleen Smith · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement a weekly significant-incident reporting form, discuss reported incidents at Care and Quality meetings, and action follow-up through Area Support.

Verbatim wording from the response
“I have therefore devised a form that managers must complete on a weekly basis to inform Head of Care of any significant incidents that happen in the home. These incidents are discussed weekly at our Care & Quality meetings and any follow up is actioned by the Area Support for that Home. This form was introduced to all Managers on the 26th October at our monthly Managers meeting and was actioned by the Managers from the following Monday.”

Source location
2017-0397-Response-by-Borough-Care
Page 1 · response
Published 15 February 2018
Open published response
31 Oct2017
Inner North London
Concerns raised1
1. Delays in completing incident reports
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

William Henry BERGMAN · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

William Henry Bergman, who had vascular dementia, was admitted to hospital with pneumonia and died after sustaining a forehead impact while being changed on 19 December 2016. He was later found to have a subdural haematoma and massive intracranial bleed. The principal concern was that the staff nurse treated the injury as minor without requesting immediate observations or medical review, and did not change the management plan when a bruise and lump were later noted.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in completing incident reports
Wider context from the report
“The staff nurse who was called to see Mr Bergman after the accident, quickly formed the opinion that he was fine. Although the medical records were not available for consideration because Barts Health has been unable to locate them, she said that she would not go into detail such as whether he felt sick. She did not ask for immediate general observations, then to be repeated. She did not ask for immediate neurological observations, then to be repeated. She did not ask for a medical review. She said very candidly that she did not consider the possibility of a minor head injury in an elderly person with vascular dementia and liver cirrhosis having the potential for a major consequence. When she noted a bruise (which a family member attending Mr Bergman that day described as being accompanied by a lump) some hours later, she did not change her management plan. She completed a Datix report only the following day, after Mr Bergman’s death. The staff nurse said in court how sorry she was that she had not acted differently, and described her contact with Mr Bergman as career changing. The reason I write to you now is because if one staff nurse responded in this way to a head injury, immediately assuming that it was minor and therefore with minor consequences, then others may behave in the same way. ”
Source location
William Henry BERGMAN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Jul2017
Leicester City and South Leicestershire
Concerns raised1
1. Unclear incident reporting entry and amendment systems
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Margery Annie Astill · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Margery Annie Astill was admitted to the Evington Centre under Section 2 of the Mental Health Act. On 2 September 2016, she collided with another agitated patient, fell, and was diagnosed with unsurvivable head injuries; she died three days later. Concerns included ineffective referral and incident-reporting systems, inadequate communication with family members, and delays in providing first aid after falls. The inquest also found that there was no care plan, the ward was understaffed, and not all patient observations were completed.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unclear incident reporting entry and amendment systems
Wider context from the report
“(1) Diary systems for ensuring referrals to different specialisms were not effective, such as for physiotherapy and the failure of these systems was not identified until the inquest was held. Furthermore, the system for entering and updating/amending incident reporting was unclear and reported incidents were not reviewed by a senior employee in a timely fashion on this occasion. ”
Source location
Margery Annie Astill · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Apr2017
Nottinghamshire
Concerns raised1
1. Limited understanding of the duty to report serious prescribing incidents
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Kimberley Holden · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Kimberley Holden, who had a chronic neurological condition and chronic pain, died from Oxycodone toxicity on 26 November 2014 after a dose significantly higher than intended was prescribed. The concerns included unsafe prescribing of controlled drugs and poorly coordinated management and prescribing between healthcare providers.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Limited understanding of the duty to report serious prescribing incidents
Wider context from the report
“1. The continuing risk of unsafe prescribing of controlled drugs by the Ivy Grove Surgery, and the limited understanding of the duty to report serious prescribing incidents. ”
Source location
Kimberley Holden · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Jul2016
Inner North London
Concerns raised1
1. Unavailability of Datix reporting access for agency nurses
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Enable agency nurses to submit Datix reports by permitting use of the senior nurse’s email address in the reporting system.
  Stated by Barts Health NHS TrustStated completed
Respondent positions 1
1. Position
  Agency nurses can access and submit Datix reports using generic computer log-ins and the senior nurse’s email address.
  Stated by Barts Health NHS TrustDisputes the concern
AI-generated summary

Margaret Emily TUCK · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of Datix reporting access for agency nurses
Wider context from the report
“6. I heard at inquest that agency nurses are unable to input into the trust reporting system (Datix). Bearing in mind that at times 50% of the ward staff are agency nurses, the matron who gave evidence suggested that agency nurses could be given a card similar to that given to locum doctors, so that they would not have to trouble their colleagues to help them make such reports. She was unsure whether this idea was going to be taken forward. ”
Source location
Margaret Emily TUCK · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Enable agency nurses to submit Datix reports by permitting use of the senior nurse’s email address in the reporting system.

Verbatim wording from the response
“6. As with all staff (medical, nursing and allied healthcare professionals), no-one needs a card of any description to log on and write a Datix. All our computers have generic log-ins that are given to all staff that need to access the computers and once logged in they can use the intranet to access the Datix system. The senior nurse on duty has been re-instructed to allow agency nurses to use their email address in the reporting system.”

Source location
2016-0273-Response-by-Barths-Health-NHS-Trust
Page 3 · response
Published 26 July 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Agency nurses can access and submit Datix reports using generic computer log-ins and the senior nurse’s email address.

Verbatim wording from the response
“6. As with all staff (medical, nursing and allied healthcare professionals), no-one needs a card of any description to log on and write a Datix. All our computers have generic log-ins that are given to all staff that need to access the computers and once logged in they can use the intranet to access the Datix system. The senior nurse on duty has been re-instructed to allow agency nurses to use their email address in the reporting system.”

Source location
2016-0273-Response-by-Barths-Health-NHS-Trust
Page 3 · response
Published 26 July 2016
Open published response
8 Jun2016
Gloucestershire
Concerns raised1
1. Failure of staff to report injuries
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mrs Clarke “Betty” · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mrs Clarke “Betty”, also identified as Gwendoline Betty Clarke, sustained multiple fractures and other injuries during a significant incident at her care home on 28 December 2014. She was admitted to hospital, subsequently deteriorated with respiratory failure and sepsis, and died on 31 December 2014; concerns were that staff did not report the injury or promptly escalate her allegation that a member of staff had hurt her.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of staff to report injuries
Wider context from the report
“(1) No member of staff reported the injury that Betty sustained, and (2) No member of staff escalated Betty’s allegations that a member of staff had hurt her until approximately 12 hours after she first made the allegation. ”
Source location
Mrs Clarke “Betty” · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Delays in reporting falls through the incident reporting system

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

Concerns raised1

Failure to report falls

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

Concerns raised1

Failure to report choking incidents in line with internal policy

Concerns raised1

Failure of private hospitals to adhere to the same reporting requirements as NHS hospitals

Concerns raised1

Internal incident reporting and escalation process depending largely on an individual manager

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

Concerns raised1

Delays in completing incident reports

Concerns raised1

Unclear incident reporting entry and amendment systems

Concerns raised1

Limited understanding of the duty to report serious prescribing incidents

Concerns raised1

Unavailability of Datix reporting access for agency nurses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of staff to report injuries

Actions described in response 1

Actions described in response 1

Actions described in response 1

Actions described in response 1

Respondent positions 1