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
Internal care reviews failing to identify learning and improvements in individual 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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 HallExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Coventry and Warwickshire
Concerns raised2
Reporting system failing to identify substantive patient safety issues
Reporting system failing to address substantive 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.
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
Develop and embed Patient Safety Incident Response Framework arrangements with external consultancy, local-system collaboration, staff training, a PSIRF Plan and Policy, and senior-leader assurance.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2024.
East London
Concerns raised1
Failure of governance systems to identify and reflect upon failings in 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust is responsible for responding to concerns about its failures and explaining what went wrong.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The CQC will determine whether further regulatory action concerning the Trust’s PSIRF and governance is appropriate or necessary.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria
Concerns raised1
Failure to undertake learning or teaching following comparable deaths
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.4
Action
Write an action plan addressing the causes and prevention of missed aortic dissection diagnoses.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
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 TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
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 TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 July 2024.
Action
Include aortic dissection in the August induction programme for new doctors.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 July 2024.
Warwickshire
Concerns raised1
Failure to specify and disseminate learning from the DOAC pausing incident
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.5
Action
Review the Report and consider whether learning should be shared across Midlands integrated care boards.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 8 August 2024.
Action
Share the report with Agilio Software for awareness.
Stated by National Institute for Health and Care ExcellenceStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Present the incident and related learning at the cardiology Grand Round.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Action
Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 8 August 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Leicester City and South Leicestershire
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 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
Require an independent third party to conduct investigations under the Death and Serious Incidents Policy.
Stated by United Children's Services (United HealthStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
North Wales (East and Central)
Concerns raised1
Lack of assurance regarding changes and learning from identified matters
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.2
Action
Develop a detailed action plan responding to the investigation findings.
Stated by Betsi Cadwaladr University LHBStated plannedThe respondent said that this action was planned when they made their response on 25 January 2024.
Action
Form the Quality Systems Group to provide integrated oversight of quality systems and user feedback.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 25 January 2024.
Berkshire
Concerns raised1
Failure to conduct or require learning reviews of inspection-related concerns
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.2
Action
Appoint an independent expert to lead and publish recommendations from a learning review of the response to Ruth Perry’s death.
Stated by OfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Define when future learning reviews will be commissioned, who will conduct them, how they will operate, and how lessons will be disseminated.
Stated by OfstedStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Black Country
Concerns raised1
Failure of the ambulance service to implement collective learning from identified ECG training gaps
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.
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 CPD education on STEMI care, ECGs, ACS guidance and ambulance quality indicators.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Deliver ECG recognition and advanced life support sessions with Zoll Medical.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Deliver evening ECG and resuscitation-skills education sessions, including sessions alongside Zoll Medical.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Deliver an in-person CPD event covering ECG signs and recognition.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Publish ACS discharge-on-scene case learning and link staff to ACS educational resources.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Review ECG cases and disseminate the resulting learning through staff briefings and clinical communications.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 November 2023.
Action
Establish a Microsoft Teams channel for publishing ECG case studies and facilitating clinical discussion.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Action
Provide remedial ECG and acute coronary syndrome training to both clinicians through training school.
Stated by West Midlands Ambulance Service University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 November 2023.
Action
Continue monitoring improvements to serious incident management and learning from deaths through ongoing monitoring and engagement.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
At the time of the incident, the individual was employed by WMAS as an associate ambulance practitioner, not acting as a university student.
Stated by University of WolverhamptonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Somerset
Concerns raised1
Failure to learn from and reflect on DVT-related care to change practice
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.
