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.
Inner North London
Concerns raised1
Failure to implement system, training and partnership changes after safeguarding investigation
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.24
Action
Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Offer additional pressure-ulcer care training to care organisations where required.
Stated by Central London Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Share safeguarding escalation learning with relevant staff so similar incidents automatically trigger Trust safeguarding-team escalation and local-authority follow-up.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Embed the practice changes in operational procedures for all community teams.
Stated by Central London Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Share the pressure-ulcer care training proforma with Westminster adult social care to support consistent carer training standards.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Offer additional pressure-ulcer prevention training to care organisations where required.
Stated by Central London Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Share safeguarding learning with staff and introduce automatic internal safeguarding-team escalation for relevant incidents.
Stated by Central London Community Healthcare NHS TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Continue collaborative safeguarding work with system partners to embed improvements in partnership working, discharge planning and holistic, personalised care.
Stated by Central London Community Healthcare NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Embed the practice changes in operational procedures for all community teams by 31 March 2023.
Stated by Central London Community Healthcare NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Hold monthly partnership meetings with CLCH and partners to review progress, share learning, develop joint working, and collaborate on discharge-care improvements.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review mandatory pressure-ulcer management training requirements for care staff.
Stated by Kapital Care (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review policies and procedures addressing the identified safeguarding and care concerns.
Stated by Kapital Care (UK) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Review organisation-wide training needs for all employed care staff.
Stated by Kapital Care (UK) LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022.
Action
Update standard operating procedures with social-worker training, a discharge checklist, and escalation links with community providers.
Stated by Westminster City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Work with Kapital Care to support improvements in care practice, documentation, escalation and communication.
Stated by Westminster City CouncilStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review safeguarding-enquiry recommendations for lessons and improvements across relevant organisations.
Stated by Westminster City CouncilStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Continue embedding discharge and coordinated-care improvements and reviewing practice with whole-person care central to changes.
Stated by Westminster City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Continue working with partner agencies to build on current improvements and incorporate learning from the Safeguarding Adults Review.
Stated by Westminster City CouncilStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Action
Review and improve local processes and staff education to prevent poor patient outcomes and support safe, holistic discharge and community care.
Stated by University College London Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review all policies and procedures following safeguarding and coroner findings.
Stated by Kapital Care (UK) LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022.
Action
Request additional pressure-ulcer management and repositioning training from CNWL Academy.
Stated by Kapital Care (UK) LimitedStated plannedThe respondent said that this action was planned when they made their response on 8 December 2022.
Action
Review mandatory pressure-ulcer management training requirements for care staff.
Stated by Kapital Care (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 December 2022.
Action
Review care-staff training needs across the organisation.
Stated by Kapital Care (UK) LimitedStatus unclearThe respondent did not make the status of this action clear when they made their response on 8 December 2022.
Action
Continue improving procedures by identifying gaps and incorporating further preventative measures.
Stated by Kapital Care (UK) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 8 December 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Improved local processes, staff education and monthly partnership reviews are considered sufficient to address discharge and post-discharge safety concerns.
Stated by University College London Hospitals NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure of internal investigations to identify and address deficiencies in risk assessment and management systems
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.
Avon
Concerns raised1
Failure to identify and disseminate learning from serious incidents
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.2
Action
Establish alternative methods for reviewing and learning from patient-safety events that do not require full investigation.
Stated by Bristol NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 September 2022.
Action
Enhance governance arrangements for learning and improvement from patient-safety incidents.
Stated by Bristol NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
Birmingham and Solihull
Concerns raised1
Failure to learn sufficient lessons from the incident
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
Discuss Regulation 28 reports through the national working group and share learning across NHS national and regional services.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Discuss Regulation 28 reports through the national working group and share relevant learning across national and regional NHS teams.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
West Midlands Police cannot determine or carry out commissioning of the Liaison and Diversion model.
Stated by West Midlands PoliceOutside remitThe respondent said that this matter was outside its role or authority.
Position
Responsibility for reviewing the Root Cause Analysis, experience, training and supervision of Liaison and Diversion practitioners rests with Birmingham and Solihull Mental Health Trust.
Stated by West Midlands PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
West Midlands Police cannot determine or carry out commissioning of the Liaison and Diversion model.
Stated by West Midlands PoliceOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Birmingham and Solihull Mental Health Trust is responsible for the Root Cause Analysis and associated lessons learned.
Stated by West Midlands PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester South
Concerns raised1
Failure of formal investigation learning to address the breadth of identified patient safety issues
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.7
Action
Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Implement the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Add a full-time clinical staff member to support the strengthened inquest triage and review process.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Surrey
Concerns raised1
Failure to accept and embed institutional learning from serious incidents
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
Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across national and regional NHS structures.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Update the Incident Reporting and Investigation, including Duty of Candour Policy, to reflect learning from the investigation.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Action
Establish a learning action group, overseen by the Clinical Governance and Safeguarding Committee, to develop processes and systems addressing the coroner’s concerns.
Stated by The Children's TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Current leadership, governance and practice are considered safe, with no evidence that the reported concerns remain current concerns.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Failure of senior staff to openly consider and learn from adverse care events
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.
Derby and Derbyshire
Concerns raised1
Insufficiently robust internal reviews failing to identify and address important patient safety 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure to share and embed lessons about policing plans across other Force Areas
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.
Sunderland
Concerns raised1
Failure to conduct rapid learning exercises to identify ongoing risks to other residents
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.
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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.
