First reported 3 Dec 2013•Latest report 20 May 2026
Definition
What this concern includes
Includes failures of reporting, review, investigation or organisational-learning processes to recognise substantive safety issues, retain learning from prior concerns, or ensure that identified recurring issues are addressed across the organisation.
Not included
Excludes failures limited to implementing a specific already-defined safety action where no broader failure of organisational learning or issue recognition is identified.
Excludes failures of a named clinical, operational or safeguarding system where that system itself supplies the more specific parent boundary.
Excludes deficiencies limited to the quality of an individual incident investigation without evidence that safety issues or learning were not identified or addressed more broadly.
Excludes generic governance, culture or management concerns without a direct failure to identify, retain or address substantive safety issues.
Reports
62
Distinct published reports
Individual concerns
68
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
163
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 Care14
NHS England10
Betsi Cadwaladr University LHB4
Care Quality Commission4
Home Office3
Barts Health NHS Trust2
Birmingham and Solihull Mental Health NHS Foundation Trust2
HM Prison and Probation Service2
Ministry of Defence2
Ministry of Justice2
National Institute for Health and Care Excellence2
North Cumbria Integrated Care NHS Foundation Trust2
Nottinghamshire Healthcare NHS Foundation Trust2
Office of the Chief Coroner2
The Children's Trust2
NHS trust37
Ministerial department21
Executive non-departmental public body11
Healthcare site6
Integrated care board5
Local health board5
Health and social care service regulator4
Independent healthcare provider4
Private limited company4
Type not available4
Residential care home3
Clinical commissioning group2
Coronial office2
English metropolitan district council2
Executive agency2
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.
Cheshire
Concerns raised1
Failure of internal investigations to identify important issues in care
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.6
Action
Obtain or access all relevant healthcare records for future patient safety investigations.
Stated by East Cheshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
Action
Introduce a standard MDT review commissioning email template specifying required clinical specialities and professional groups.
Stated by East Cheshire NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 July 2026.
Action
Develop an MDT review quick-reference guide for consistent patient safety reviews.
Stated by East Cheshire NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 July 2026.
Action
Update the MDT review report template with prompts covering clinical referral processes and other key enquiry areas.
Stated by East Cheshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026.
Action
Deliver focused MDT review and After Action Review training through specialty and departmental meetings alongside the established Patient Safety Investigation programme.
Stated by East Cheshire NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 July 2026.
Action
Embed MDT review training as an ongoing resource and support clinical leaders to cascade learning across clinical teams.
Stated by East Cheshire NHS TrustStatus unclearThe respondent did not make the status of this action clear when they made their response on 28 July 2026.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to disseminate learning and address identified concerns nationally
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 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
Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share relevant learning across national and regional NHS services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 2 July 2026.
East London
Concerns raised1
Failure to identify, reflect upon, and remediate sub-optimal practice
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.5
Action
Review the post-fall action plan with nursing teams after every reported fall to ensure appropriate assessments and maintain patient safety.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Discuss every reported fall at weekly Geriatrics Care Group incident reviews, share learning, and assess whether escalation for a wider learning response is required.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Report all Geriatrics Care Group inpatient falls, including serious-harm incidents, to the Quality Governance and Steering Group and record escalation decisions for Trust Board reporting.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Provide continuing Falls Lead communication and support to identify training needs and implement resulting training across the Geriatrics Care Group.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 20 October 2025.
Action
Commence covert observational audits across Geriatrics wards and departments to measure nursing response times to patient call bells and identify delays requiring further action.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 October 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The inpatient falls were considered unpreventable, disputing that further investigation would identify preventable sub-optimal practice.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Because the contributing factors were known and understood, no further investigation or learning response was considered necessary.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
Position
Existing actions to manage the understood fall risk factors were considered sufficient, so no further investigation was required.
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.
Nottinghamshire
Concerns raised1
Lack of detailed organisational understanding of the extent of identified issues
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
Expand clinical audits to mandate reviews of remote and face-to-face paediatric care episodes against clinical guidelines.
Stated by East Midlands Ambulance Service NHS TrustStated completedThe respondent said that this action was complete when they made their response on 29 September 2025.
East London
Concerns raised1
Failure of governance processes to reflect upon sub-optimal practice
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.5
Action
Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 25 September 2025.
Action
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 25 September 2025.
Action
Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 25 September 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner West London
Concerns raised1
Flawed investigations failing to identify systemic failures and learning
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.6
Action
Implement a revised incident management policy and process based on national best practice.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Strengthen the clinical governance framework to identify recurring themes and trends and support organisational learning.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Implement the national Patient Safety Incident Response Framework for incident investigations.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Review all incidents through multidisciplinary panels representing the organisation.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Apply internal governance oversight to externally commissioned investigations and scrutinise their findings.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Conduct thematic reviews of serious incidents and use findings to inform staff training and service improvements.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Cambridgeshire and Peterborough
Concerns raised1
Failure to undertake deep-dive safety audits examining patterns and trends
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.1
Action
Work with the Trust to gain assurance that progress is being made on PSIRF quality improvement initiatives.
Stated by NHS Central East Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 15 April 2025.
Devon, Plymouth and Torbay
Concerns raised1
Failure to learn from serious incidents and consider recommendations for future care
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.5
Action
Recruit two Learning Response Leads and provide them with mandatory training to conduct and support safety reviews.
Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2025.
Action
Recruit two Patient Safety Partners to participate in governance and scrutinise safety investigations and final reports.
Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2025.
Action
Develop and implement a new safety-incident investigation policy incorporating new investigation methods.
Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2025.
Action
Redesign quality-concern governance to support transparent multidisciplinary review and assurance of resulting improvement actions.
Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2025.
Action
Implement the Patient Safety Incident Response Framework process for recording, escalating, commissioning and overseeing system-based safety reviews with patient and family involvement.
Stated by University Hospitals Plymouth NHS TrustStated completedThe respondent said that this action was complete when they made their response on 2 April 2025.
Lancashire and Blackburn with Darwen
Concerns raised3
Failure of harm-only reporting to identify underlying safety problems
Failure to learn from identified safety issues and themes
Inadequate Trust investigations failing to identify safety issues
This report raised 17 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.12
Action
Implement PSIRF through proportionate learning responses, co-produced investigations, and training for staff involved in incident responses.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Conduct regular mortality reviews and triangulation meetings to inform governance, training, resourcing and risk-prevention decisions.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Employ three full-time Learning Response Leads to conduct investigations and oversee the PSIRF process.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Operate maternity governance and reporting forums to review incidents, outcomes, investigations, learning and improvement actions across the system.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Scrutinise patient-safety investigation reports and monitor PSIRF implementation through safety-panel attendance, supportive challenge and review of patient and family engagement.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Operate multidisciplinary daily triage and cross-care-group reviews of concerns, incidents and feedback to support early escalation and coordinated learning.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Implement a Trust-wide clinical governance reform covering document control, mandatory governance training, oversight restructuring, outcome-focused learning and family-centred care.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Review embeddedness of the Kirkup recommendations or successor practices through internal audit.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Ensure actions arising from shared-learning discussions are implemented across the system.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share learning across regional and national NHS services.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Action
Embed enhanced quality assurance for Patient Safety Incident Investigations through a structured clinical governance review process.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Action
Obtain the external audit outcome on PSIRF progress and monitor implementation of any resulting action plan.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 26 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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 of reporting, review, investigation or organisational-learning processes to recognise substantive safety issues, retain learning from prior concerns, or ensure that identified recurring issues are addressed across the organisation.
