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 to learn from deaths and reflect on occupational health care processes
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.
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
Embed recording of suicidal-ideation frequency and informal team risk advice in the Assessment of Suicide and Self Harm protocol.
Stated by West Yorkshire Police -
Action
Review national oversight, governance and assurance of organisational learning from force activity.
Stated by College of Policing and National Police Chiefs’ Council -
Action
Communicate organisational-learning concerns and outcomes to all forces and continue monitoring implementation of recommendations.
Stated by College of Policing and National Police Chiefs’ Council
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Concerns raised1
Failure to learn from deaths at the earliest opportunity
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.
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
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Action
Review the Trust-wide M&M process, develop terms of reference, consult clinical leads and obtain external review support to identify improvements.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust -
Action
Operate weekly PSIRF Decision Team meetings to select learning methodologies for relevant incidents and deaths.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust -
Action
Review and amend Interventional Radiology governance practice to achieve learning at the earliest opportunity.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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Action
Disseminate haemothorax management learning through trauma scenario training and a one-page incident summary.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust
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
Birmingham Women’s and Children’s NHS Foundation Trust will address concerns about the inadequate mortality and morbidity meeting in its own response.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of a mechanism for learning from deaths during or following Nursing Home admission
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.
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
Existing investigation and learning arrangements are appropriate; no further changes are required beyond measures already discussed at the inquest.
Stated by Springcare and Springcare (Macclesfield) Ltd t/a Henning Hall
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Concerns raised1
Failure to learn from deaths
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
Failure to conduct internal reviews following 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.1
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Action
Develop and implement a procedure requiring Adult Social Care managers to conduct internal reviews after unexpected deaths and identify learning or required policy changes.
Stated by Leicestershire County Council
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Concerns raised1
Failure to act with due reflection and candour during inquests
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.
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
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Action
Ensure senior staff attending inquests are confident addressing PFD issues and receive legal-representative support when giving evidence.
Stated by HM Prison and Probation Service
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Concerns raised1
Inadequate learning from mortality review cases
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 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.1
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Action
Share identified learning with Hospital Medical Directors and Directors of Nursing across the Trust’s hospitals.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Failure to undertake learning or teaching following comparable deaths
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.4
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Action
Write an action plan addressing the causes and prevention of missed aortic dissection diagnoses.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust -
Action
Display an aortic dissection poster with a linked educational video in emergency department clinical and triage areas.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust -
Action
Disseminate the aortic dissection video to medical and nursing staff across emergency, urgent treatment, same-day emergency care and acute medical units, tracking viewings and adding new starters.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust
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Action
Include aortic dissection in the August induction programme for new doctors.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust
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Concerns raised1
Investigation process failing to identify all learning from deaths
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.1
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Action
Require an independent third party to conduct investigations under the Death and Serious Incidents Policy.
Stated by United Children's Services (United Health
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Concerns raised2
Failure to identify un-actioned service-involvement requests in post-death incident reviews
Insufficient learning and corrective action following deaths
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.
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
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Action
Complete the further review and addendum to incorporate newly identified information and issues from the inquest findings.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
Data last updated 7 September 2026