Recurring concern
Failure to identify and address recurring safety issues through organisational learning
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Request correctionFirst reported 3 Dec 2013•Latest report 20 May 2026
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
- Individual concerns
- 68
- Date range
- 2013–2026
- Stated actions
- 163
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 identify proposed changes after a death
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 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
Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Introduce three forms for documenting vascular surgery-related concerns about patient deaths in the Thames Valley.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Maintain the OUH Medical Examiner office to scrutinize all non-Coronial deaths and feed concerns to governance and clinical teams.
Stated by Oxford University Hospitals NHS Foundation Trust
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Action
Update the OUH Mortality Review Policy with an appendix governing cross-system learning responses across the BOB ICB and Frimley.
Stated by Oxford University Hospitals NHS Foundation Trust
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Concerns raised1
Failure to identify and apply learning from falls-related incidents
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 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
Create AcciMap and HFACS analyses to identify broader system factors contributing to the fall.
Stated by Bristol Ambulance EMS
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Concerns raised1
Failure to disseminate and action important learning points
This report raised 9 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
Create and resource a learning team to disseminate learning from probation-involved inquests across the probation service and OMiC model.
Stated by HM Prison and Probation Service -
Action
Operate the Strategic Improvement Operations team to log, assign, monitor and coordinate recommendations from internal and external investigations and audits.
Stated by Home Office -
Action
Share lessons learned from the inquest across Practice Plus Group services.
Stated by Practice Plus Group
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Concerns raised1
Absence of a single point of oversight for deaths involving previous Council involvement
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.3
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Action
Maintain a departmental risk register and management-team oversight of child deaths, serious incidents, significant events, actions and lessons learned.
Stated by Bradford City Council -
Action
Implement Children’s Services Review Guidance, a notification form and coordinated processes to collect information, identify systemic issues, pursue enquiries and make recommendations after a child’s death.
Stated by Bradford City Council -
Action
Implement serious-incident and significant-event guidance, forms and escalation processes requiring service actions, senior review and departmental management-team oversight.
Stated by Bradford City Council
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 oversight, notification and information-sharing processes are considered sufficient to ensure organisational oversight and learning from child deaths.
Stated by Bradford City Council
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Concerns raised1
Failure to accept and learn from identified care concerns
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 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 staff to communicate and manage laundry and medication-room work so resident care, alarm audibility and staff availability are maintained.
Stated by Broadland View Care Home
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Concerns raised1
Failure to learn from a previous Regulation 28 report
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 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
Implement significant changes to clozapine processes and procedures following the August 2020 report.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to analyse evidence and learn from deaths
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 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.2
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Action
Complete a formal review of Offender Health cases requiring coronial processes and undertake further review where identified.
Stated by Nottinghamshire Healthcare NHS Foundation Trust -
Action
Introduce two independent investigators to support Offender Health and lead new serious-incident investigations.
Stated by Nottinghamshire Healthcare NHS Foundation Trust
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Concerns raised1
Failure to identify and address electronic record availability in investigation learning and improvement
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
Consider and discuss the benefits of integrated IT within the investigation report and subsequent action plan.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to address inadequate leave risk assessment and planning through investigation and learning
This report raised 9 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
Hold inpatient learning forums in addition to training meetings to reflect on shared learning, including learning from this case.
Stated by Pennine Care NHS Foundation Trust -
Action
Revisit local support for investigation authors and services to promote active review of action plans and prepare authors to evidence improvements.
Stated by Pennine Care NHS Foundation Trust -
Action
Develop PSIRF implementation arrangements, including updated investigation templates and support for staff completing investigations.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to identify and escalate observation suspension in the 72-hour report
This report raised 14 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
Implement the new PSIRF framework, including panel review and sign-off of all 72-hour reports.
Stated by North East London 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
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
Data last updated 7 September 2026