First reported 2 Jul 2014•Latest report 20 May 2026
Definition
What this concern includes
Includes failures to review, investigate, reflect on or derive and communicate safety lessons from deaths, including the anchor's failure to review restraint-related deaths for licensing and responsibility lessons and failures to reflect on or learn from deaths in other services or settings.
Not included
Excludes deficiencies in the underlying care, restraint, licensing or operational process where no failure of post-death review or learning is identified.
Excludes general incident-investigation deficiencies that concern events other than deaths unless the assertion explicitly connects them to learning from deaths.
Excludes failures to implement a clearly identified safety action after lessons have already been established, where the concern is implementation rather than death review or learning.
Excludes coroner, inquest or regulatory disclosure failures where the unsafe condition is incomplete or late disclosure rather than failure to review deaths for safety learning.
Reports
63
Distinct published reports
Individual concerns
68
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
139
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 Care11
Care Quality Commission8
NHS England8
Nottinghamshire Healthcare NHS Foundation Trust4
Greater Manchester Mental Health NHS Foundation Trust3
HM Prison and Probation Service3
Ministry of Justice3
Pennine Care NHS Foundation Trust3
Priory Group3
College of Policing2
Greater Manchester Police2
Lowdham Grange Prison2
Metropolitan Police Service2
NHS Greater Manchester Integrated Care Board2
North Cumbria Integrated Care NHS Foundation Trust2
NHS trust29
Ministerial department15
Executive non-departmental public body9
Health and social care service regulator8
Healthcare site6
Integrated care board6
Police force6
English county council4
Executive agency4
Independent healthcare provider4
Prison or young offender institution4
Prison operator3
Residential care home3
English metropolitan district council2
Health professional body2
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.
Nottinghamshire
Concerns raised1
Persistent failure to maintain a robust system for learning from deaths
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 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
Introduce a Prevention of Future Deaths meeting to review learning recommendations, raise actions and verify their effective implementation.
Stated by HM Prison and Probation Service and Lowdham Grange PrisonStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Appoint an Inquest and PFD Lead to coordinate PFD responses and oversee implementation and sustainment of learning.
Stated by HM Prison and Probation Service and Lowdham Grange PrisonStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
East London
Concerns raised1
Failure to investigate deaths under the Patient Safety Framework
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
Operate the Coroner’s Case Review Meeting as a formal governance mechanism for multidisciplinary oversight of inquest and coronial cases.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Require multidisciplinary clinical review of relevant coronial cases, including cases involving concerns about diagnosis, deterioration, monitoring, treatment or missed opportunities.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Use multiple review routes, including MDT, mortality, complaints, clinician reflection and CCRM reviews, rather than relying solely on PSIRF.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Action
Clarify in governance arrangements that PSIRF is one learning mechanism and not the Trust’s sole route for reviewing deaths or responding to coronial concerns.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
BHRUT is responsible for responding to the broader concerns raised about Mrs Creegan’s care and the application of PSIRF.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing clinical reviews, mortality review, governance meetings and reflection had identified sufficient learning, so a PSII would not add further learning.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Failure to learn lessons from the death
This report raised 12 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
Hold a post-Inquest debrief with Community and Crisis Response teams to share learning about information sharing.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Share patient-safety learning through the lessons team with clinical and non-clinical staff.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Revise the Section 117 policy to improve care delivery and incorporate learning from the death.
Stated by Essex County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 October 2025.
West Sussex, Brighton and Hove
Concerns raised1
Lack of independent review of deaths for learning and practice change
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Review the serious incident and identify all associated learning and recommendations.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Action
Follow up completion of serious-incident recommendations through enhanced contract quality meetings.
Stated by NHS Surrey and Sussex Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 19 September 2025.
Action
Serve a Contract Performance Notice on Goring Hall Hospital concerning clinical governance, serious-incident learning and quality assurance failures.
Stated by NHS Surrey and Sussex Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 19 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
The ICB is not responsible for investigating serious incidents involving individual patient care.
Stated by NHS Surrey and Sussex Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Position
Providers are responsible for conducting serious incident investigations under the applicable Serious Incident Framework.
Stated by NHS Surrey and Sussex Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The provider’s serious-incident review and ICB scrutiny were considered sufficient; an independent review would be considered only if learning was inadequate.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The Integrated Care Board is responsible for commenting on actions taken following Mr Hankin's death.
Stated by Sussex Medical ChambersRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester North
Concerns raised1
Ineffective learning from deaths of detained patients
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
Participate in the Safeguarding Adult Review and act on learning identified through it.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 September 2025.
Action
Review governance and decision-making around selecting and approving the learning review after the death.
Stated by Pennine Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 September 2025.
Action
Consider and decide whether to change the process for reassessing learning reviews when additional information becomes available.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 1 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust disputes that a further investigation was required because no evidence then linked the death to problems in its care.
Stated by Pennine Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to investigate deaths and learn from work-related events and welfare support
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.2
Action
Review crisis management and death-in-service protocols for employment-linked workplace deaths, including support for affected staff, and implement linked policy changes.
Stated by West Midlands Fire ServiceStated plannedThe respondent said that this action was planned when they made their response on 22 May 2025.
Action
Share learning from the case to improve support for senior officers nationally.
Stated by West Midlands Fire ServiceStated plannedThe respondent said that this action was planned when they made their response on 22 May 2025.
Cambridgeshire and Peterborough
Concerns raised1
Failure of child death review to identify learning across relevant environmental and service factors
This report raised 21 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
Collect, collate and store all child death review forms and associated communications in accordance with data protection requirements.
Stated by Northamptonshire Safeguarding Children PartnershipStated completedThe respondent said that this action was complete when they made their response on 15 April 2025.
Action
Review serious incident and comparable investigation reports to identify service-related modifiable factors and challenge insufficient findings or improvement actions.
Stated by Northamptonshire Safeguarding Children PartnershipStated completedThe respondent said that this action was complete when they made their response on 15 April 2025.
Action
Use a joint decision process to determine when child deaths should be brought to CDOP, informed by completed investigations and inquests.
Stated by Northamptonshire Safeguarding Children PartnershipStated completedThe respondent said that this action was complete when they made their response on 15 April 2025.
Swansea and Neath Port Talbot
Concerns raised1
Failure to identify and learn critical lessons from the death
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.4
Action
Embed recommendations from the commissioned review of Serious Incident Group functions and processes.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2025.
Action
Implement a two-stage Serious Incident Review approval and learning process, including senior clinical scrutiny and a forum to share learning and assign improvement actions.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2025.
Action
Train Serious Incident Investigators in effective review techniques and cascade process-mapping training to the mental health investigation team.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 10 March 2025.
Action
Implement regular investigator-team meetings to reflect on review methods, identify learning themes and consider report feedback.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 10 March 2025.
Inner North London
Concerns raised1
Limited internal review of procedure-related circumstances
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.
Nottinghamshire
Concerns raised1
Failure to embed learning from deaths and monitor safety culture
This report raised 13 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
Establish and operate a Pan Custodial Safety Lead role to embed safety improvements across custodial sites.
Stated by Serco UK & EuropeStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Continue embedding remedial actions operationally and monitor their implementation through the Pan Custodial Safety Lead.
Stated by Serco UK & EuropeStated in progressThe respondent said that this action was in progress when they made their response on 13 February 2025.
Action
Establish enhanced Executive-led oversight and assurance reviews for Offender Health and HMP Lowdham Grange.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Establish a meeting focused on addressing issues raised in Reports to Prevent Future Deaths.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Amend future prison competitions to require culture plans and strengthen safety evaluation and safety-risk responses.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Conduct pre-expiry safety audits at private prisons and share reports and recommendations with responsible HMPPS teams.
Stated by HM Prison and Probation ServiceStated plannedThe respondent said that this action was planned when they made their response on 13 February 2025.
Action
Use Reports to Prevent Future Deaths to identify safety themes and disseminate learning through guidance, bulletins and group safety-lead meetings.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
Action
Ringfence key safety tasks and safer-custody staff against future resourcing pressures.
Stated by SodexoStated completedThe respondent said that this action was complete when they made their response on 13 February 2025.
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Includes failures to review, investigate, reflect on or derive and communicate safety lessons from deaths, including the anchor's failure to review restraint-related deaths for licensing and responsibility lessons and failures to reflect on or learn from deaths in other services or settings.
