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.
North Wales (East and Central)
Concerns raised3
Failure to reliably identify matters requiring investigation
Lack of defined and consistently applied criteria for identifying and acting on learning opportunities
Failure to ensure timely learning and action from investigations
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
Lack of an ongoing programme for reinforcing clinical lessons
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
Complete morbidity and mortality discussions in Emergency Department and Acute Medicine to share and learn from the case.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 October 2017.
Action
Use the case in future training programmes for junior clinical staff in Emergency Department and Acute Medicine.
Stated by Stockport NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 October 2017.
Cumbria
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 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
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 CareStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Hold organisational briefings in April 2017 to share learning from the Never Events.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Cumbria
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 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
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 CareStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Contact the deceased patients’ families to obtain personal comments for organisational learning briefings.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2017.
Action
Hold organisational briefings in April 2017 to share learning from the Never Events.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 19 February 2017.
Inner North London
Concerns raised1
Failure of investigations to reflect identified risk issues for further learning
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Coventry
Concerns raised1
Failure to derive wider organisational learning from investigations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Birmingham and Solihull
Concerns raised2
Lack of a clear pathway for communicating safety lessons
Failure to implement lessons from previous heat-illness and tracking events
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.2
Action
Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
Stated by Ministry of DefenceStated plannedThe respondent said that this action was planned when they made their response on 20 July 2015.
Action
Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
Stated by Ministry of DefenceStated plannedThe respondent said that this action was planned when they made their response on 20 July 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A formal, established process already captures and manages lessons learned, with the Training Governance and Assurance Policy review reinforcing it.
Stated by Ministry of DefenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Nottinghamshire
Concerns raised1
Failure to ensure learning from INR dosing events reaches all GPs at the 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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Wiltshire and Swindon
Concerns raised1
Failure to capture recurring component bolt retightening as an issue warranting investigation
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.1
Action
Review component-failure-awareness training and direct inclusion of lessons on fault reporting and experienced diagnosis.
Stated by Ministry of DefenceStated completedThe respondent said that this action was complete when they made their response on 28 April 2015.
North Wales (East and Central)
Concerns raised1
Failure to rectify previously identified patient handover delays
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.9
Action
Use the Ysbyty Gwynedd handover protocol across the Health Board as an interim consistent approach pending formal policy approval.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 September 2014.
Action
Consult on and ratify revised ambulance handover protocols before formal implementation across the Health Board and Trust.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 September 2014.
Action
Implement the revised ambulance handover safety audit across the Health Board and report its results monthly.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2014.
Action
Establish holding areas in each Emergency Department when required to enable safe, timely patient offloading.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2014.
Action
Investigate serious incidents involving both organisations jointly and share the resulting learning.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 September 2014.
Action
Enhance senior clinical, nursing and operational leadership to support Emergency Departments and patient flow.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 September 2014.
Action
Consult on and ratify a North Wales escalation protocol before implementing it across the area.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 12 September 2014.
Action
Issue Medical Director advice supporting joint assessment of ambulance patients at Emergency Department front doors and safe transfer of suitable patients.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated completedThe respondent said that this action was complete when they made their response on 12 September 2014.
Action
Operate cross-organisational escalation arrangements and conference calls to agree joint action plans for ongoing handover delays.
Stated by Betsi Cadwaladr University LHB and Welsh Ambulance Services NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 September 2014.
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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.
