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.
Cambridgeshire and Peterborough
Concerns raised1
Failure to use Serious Incident Reviews and internal investigations to learn lessons from suicide cases
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised1
Failure to review cases and learn lessons through morbidity and mortality or other forums
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
Present the case and learning at a multidisciplinary Grand Round, reminding clinicians to interpret D-Dimers with the recognised screening tool.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 4 February 2021.
Action
Have the Medical Examiner review post-mortem reports and route identified concerns through the Patient Safety and Learning from Deaths programmes.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 February 2021.
Nottinghamshire
Concerns raised1
Failure to conduct robust management review following a 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 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.
Inner North London
Concerns raised1
Failure to review and improve emergency procedures after a serious incident
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.1
Action
Meet Islington Telecare and other Careline providers to review and standardise information forms and procedures, incorporating learning from the incident.
Stated by Peabody TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The prior review identified no specific procedural or staff failings, and family concerns were not known until the inquest.
Stated by Peabody TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Nottinghamshire
Concerns raised1
Lack of robust initial critical analysis 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 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.9
Action
Deliver training and awareness seminars for maternity and paediatric staff on Medical Examiner information requirements.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 December 2020.
Action
Revise the Child Death Review and Medical Examiner referral form to identify all professionals involved in antenatal and postnatal care.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 December 2020.
Action
Contact bereaved families through the Medical Examiner Service and update bereavement booklets with relevant contact details.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 December 2020.
Action
Establish early multidisciplinary review meetings within five working days of child deaths to gather clinical information and parents’ views.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 December 2020.
Action
Review and strengthen maternity multidisciplinary case review meetings by promoting inclusivity, midwives’ voices and parents’ views.
Stated by Nottingham University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 1 December 2020.
Action
Update incident escalation reports with broader contextual review prompts, care-quality ratings and Serious Incident definitions.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2020.
Action
Build and use a digital application consolidating data sources to identify potential high-risk cases for Serious Incident investigation.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2020.
Action
Pilot live Perinatal Mortality Review Tool information to inform maternity case review discussions before all inputs are available.
Stated by Nottingham University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 1 December 2020.
Action
Classify unexpected early-term neonatal deaths and intrapartum term stillbirths as Serious Incidents, subject to stated exclusions.
Stated by Nottingham University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 1 December 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Serious Incident investigation excludes babies on identified life-limiting-condition pathways unless a deviation requires further investigation.
Stated by Nottingham University Hospitals NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
West London
Concerns raised1
Failure to undertake effective individual and collective reflection and learning
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 anonymised learning from Bethan’s death through maternity meetings, governance study days, PROMPT, newsletters, staff forums, and mandatory fetal monitoring and skills training.
Stated by St George'S University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 September 2020.
Manchester City
Concerns raised1
Failures in the post-death investigation process
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.
Nottinghamshire
Concerns raised1
Lack of processes to review and learn from significant events
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.
Teesside and Hartlepool
Concerns raised1
Failure to investigate choking-related events and identify safety issues
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.2
Action
Submit a safeguarding alert to Hartlepool Social Services for further investigation.
Stated by Rossmere Park Care CentreStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
Action
Participate in lessons-learned meetings with safeguarding, commissioning, healthcare and police representatives.
Stated by Rossmere Park Care CentreStated completedThe respondent said that this action was complete when they made their response on 2 August 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A separate internal investigation was considered inappropriate while CQC had been notified and the Coroner was conducting a full investigation.
Stated by Rossmere Park Care CentreExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Avon
Concerns raised1
Lack of post-death investigation reports for student deaths
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.3
Action
Establish the national Learning from Deaths policy framework to guide investigation, learning and engagement with bereaved families.
Stated by Department for Education and Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 28 July 2019.
Action
Work with Universities UK during the forthcoming academic year to remind higher education providers about recommending serious incident reviews.
Stated by Department for Education and Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 28 July 2019.
Action
Oversee serious-incident reviews for qualifying suicides and serious attempted suicides from September 2019.
Stated by University of BristolStated plannedThe respondent said that this action was planned when they made their response on 28 July 2019.
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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.
