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
Failure to analyse evidence and learn from deaths
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 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
Complete a formal review of Offender Health cases requiring coronial processes and undertake further review where identified.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Action
Introduce two independent investigators to support Offender Health and lead new serious-incident investigations.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
Manchester South
Concerns raised1
Failure to derive all available learning from deaths
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.1
Action
Share Trust-wide learning, including themes concerning military veterans’ experiences navigating mental health services.
Stated by Pennine Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2023.
Norfolk
Concerns raised1
Failure to conduct an internal review following an unexpected resident death
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.6
Action
Report and review incidents and near misses, identifying improvement areas and lessons learned.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Review the Inquest findings and related information to identify remaining themes and trends.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 7 March 2023.
Action
Create a detailed action plan arising from the internal review.
Stated by Priory GroupStated plannedThe respondent said that this action was planned when they made their response on 7 March 2023.
Action
Report all serious incidents through escalation arrangements and coordinate next-day discussions on communication, support and investigations.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Recruit an additional Investigations Officer to support reviews and investigations.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Adopt and embed the Patient Safety Incident Response Framework across Priory Adult Care.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
West Sussex
Concerns raised2
Failure to disseminate institutional learning from unexpected deaths
Failure to investigate potential anaesthetic-related causes of unexpected deaths
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 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.14
Action
Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 January 2023.
Action
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 23 January 2023.
Action
Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Develop and ratify a standard operating procedure defining actions for HSIB investigations and considering parallel local investigation.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 January 2023.
Action
Amend guidance to require a standardised investigation process automatically triggered immediately after a catastrophic event.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Review guidance to identify the need for a standardised investigation process automatically triggered after catastrophic events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated completedThe respondent said that this action was complete when they made their response on 23 January 2023.
Action
Amend guidance to specify a standardised investigation process automatically triggered immediately after catastrophic events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Promote the amended catastrophic-event investigation process to the anaesthesia specialty.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Action
Embed the amended catastrophic-event investigation process through the Royal College of Anaesthetists’ Anaesthesia Clinical Services Accreditation scheme.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of AnaesthetistsStated plannedThe respondent said that this action was planned when they made their response on 23 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
HSIB investigation replaced the need for a parallel local investigation under national guidance, so no concurrent local investigation was required.
Stated by University Hospitals Sussex NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Failure to review deaths and learn lessons before inquest
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.
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
Collate learning from deaths and report it quarterly to the Trust board-level Quality Assurance Meeting.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 November 2022.
Action
Share learning from deaths through Grand Rounds, the Trust-wide Patient Safety newsletter and the monthly Patient Safety Forum.
Stated by Whittington Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 November 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing mortality review meetings and reporting arrangements were considered sufficient to capture and share learning from deaths.
Stated by Whittington Health NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Surrey
Concerns raised1
Lack of reflection and learning following road-related 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Significant reflection and learning occurred following the death, and service improvements were implemented afterward.
Stated by Surrey County CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Failure to investigate and review deaths for learning and implementation of necessary changes
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.
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
Action
Provide the report to Regional Mortality Boards for dissemination to all Integrated Care Boards to support learning from the event.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Request Serious Event Audits from practices and review whether learning points from suicide investigations have been considered.
Stated by NHS Frimley ICBStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Action
Conduct a significant event analysis of the death with clinical staff and review the resulting learning and actions.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Action
Share the significant event analysis findings with practice staff, the CCG and CQC.
Stated by Farnham Park Health Group and Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 19 May 2022.
Action
Discuss unexpected deaths at weekly practice clinical meetings attended by GP clinicians and Partners.
Stated by Farnham Park Health Group and Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 19 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.6
Position
NHS commissioners are responsible for assuring provider serious-incident investigations, overseeing action plans, and closing incidents.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The circumstances were a specific case, not widespread poor care, and the care provided was not unsafe.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further action is currently considered necessary because the provider’s actions are expected to protect service users from harm.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The concerns do not indicate that the doctor poses a patient risk or undermines public confidence in doctors.
Stated by General Medical CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
No further investigation is considered necessary, although the concerns will be shared for discussion during revalidation.
Stated by General Medical CouncilNo action considered necessaryThe respondent said that no further action was needed.
Position
The Practice disputes that the death was not investigated or reviewed, stating that it was discussed promptly and later subjected to significant event analysis.
Stated by Farnham Park Health Group and Recipient name withheldDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Surrey
Concerns raised1
Failure to undertake prompt internal enquiries after sudden unexpected deaths
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.5
Action
Establish the Patient Safety Incident Response Framework to support effective investigation and learning from patient safety incidents.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Add unexpected-death procedures to mandatory basic-life-support induction and annual-update training.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Stated by The Children's TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 May 2022.
Action
Expand simulation training to cover unexpected deaths in addition to medical emergencies and basic life support.
Stated by The Children's TrustStated plannedThe respondent said that this action was planned when they made their response on 17 May 2022.
Sunderland
Concerns raised1
Insufficiently robust review of deaths and lessons to be learnt
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Lack of appropriate investigation and learning from eating disorder deaths
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 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
Convene a stakeholder round table and publish guidance for medical examiners on investigating eating disorder deaths.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 December 2021.
Action
Share case learning through Greater Manchester quality, governance and learning forums.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 31 December 2021.
Action
Monitor key learning and recommendations to ensure they are embedded in practice.
Stated by NHS Greater Manchester Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2021.
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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.
