Recurring concern
Failure to learn from deaths through systematic review
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Request correctionFirst reported 2 Jul 2014•Latest report 20 May 2026
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
- Individual concerns
- 68
- Date range
- 2014–2026
- Stated actions
- 139
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 of the GP practice system to investigate unexpected 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 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 effectively scrutinise the ambulatory care unit following a patient death
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
Delays in learning and implementing lessons from identified concerns
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 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 undertake formal reviews of deaths of people known to the organisation
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.2
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Action
Implement the new Trust-wide Serious Incident Policy for timely investigations and learning.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Complete a local review and contribute to another Trust’s investigation when that Trust leads a Root Cause Analysis.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Failure to learn from deaths and incidents
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.
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
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Action
Amend regulations to require NHS Trusts to summarise published deaths information, learning and resulting actions in Quality Accounts.
Stated by Department of Health and Social Care -
Action
Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Hold organisational briefings in April 2017 to share learning from the Never Events.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to learn from a prior nasogastric tube death
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.
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
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Action
Amend regulations to require NHS Trusts to summarise published deaths information, learning and resulting actions in Quality Accounts.
Stated by Department of Health and Social Care -
Action
Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Hold organisational briefings in April 2017 to share learning from the Never Events.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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Concerns raised1
Lack of independent investigation into deaths following release from private custody providers
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 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 identify relevant safety issues in reviews of deaths
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.3
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Action
Continue highlighting through training and local guidance the importance of inviting relevant agencies and professionals to serious incident reviews.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Send all mental health service commissioners NHS England expectations for commissioned arrangements covering urgent correspondence, clinical risk assessment, shared care, incident learning, and vulnerable patients who miss appointments.
Stated by NHS England -
Action
Record Jake’s death as a significant event and discuss the circumstances fully within the practice.
Stated by Bodmin Road Health Centre
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Concerns raised1
Failure to promptly examine cell bell logs and identify those who heard or answered bells
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
Lack of formal review of safeguarding-related 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 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
Follow and report safeguarding alerts to senior managers and immediately review future deaths involving such alerts.
Stated by the Council -
Action
Complete a detailed review of the circumstances surrounding Mr Warren’s involvement with the Council.
Stated by West Sussex County Council
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
The Council disputes that its review and recommendations were absent, stating they arose from an earlier case review.
Stated by the Council
Data last updated 7 September 2026