Recurring concern
Failure to identify and address recurring safety issues through organisational learning
- Reports that mention this concern
- 62
- Times this concern has been raised
- 68
- Stated actions linked to this concern
- 163
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 62 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure of the Statutory Notification process to require timely submission of relevant evidence about deaths
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Department of Health and Social Care
Stated actions 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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Care Quality Commission
Promote appropriate reporting of deaths and patient safety incidents through regulatory activities.
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Care Quality Commission
Review notifications guidance to clarify reporting requirements concerning the circumstances of a person’s death.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Department of Health and Social Care
Current NRLS and STEIS reporting processes are considered adequate for the CQC to fulfil its regulatory responsibilities.
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Care Quality Commission
NRLS/STEIS reporting is considered adequate for CQC’s regulatory responsibilities, so a separate direct death-notification requirement is not preferred.
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Care Quality Commission
Changing death-reporting arrangements would require legislative action brought forward by the Department of Health and Social Care.
-
Concerns raised1
Failure to address important learning issues
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- St George'S University Hospitals NHS Foundation Trust
Stated actions 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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St George'S University Hospitals NHS Foundation Trust
Share anonymised learning from Bethan’s death through maternity meetings, governance study days, PROMPT, newsletters, staff forums, and mandatory fetal monitoring and skills training.
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St George'S University Hospitals NHS Foundation Trust
Provide yearly staff training updates through monthly practice-development training sessions, using the case as a reference for ongoing learning.
-
Concerns raised1
Failure to establish lessons learned by teams involved in care and treatment
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Oxleas NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Oxleas NHS Foundation Trust
Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.
-
Concerns raised1
Failure of NHS Digital to retain and act on previously identified call-handling safety issues
This report raised 20 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- London Ambulance Service NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
London Ambulance Service NHS Trust
Continue participating in ambulance user groups to share data, discuss cases, exchange learning, and support triage-system improvements through feedback mechanisms.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Established NHS Pathways governance systems capture, review and resolve clinical coding issues, including those raised through Prevention of Future Deaths reports.
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Concerns raised1
Failure to engage with other agencies to learn lessons from complex cases
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Birmingham Women'S and Children'S NHS Foundation Trust
- Walsall Borough Council
Stated actions 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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Birmingham Women'S and Children'S NHS Foundation Trust
Continue engaging with other agencies to learn from incidents and improve patient care.
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Walsall Borough Council
Meet regularly with other agencies to identify service improvements.
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Concerns raised1
Lack of processes to review and learn from significant events
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to analyse reviewed cases for common themes and trends
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cwm Taf Morgannwg University Local Health Board
Stated actions 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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Cwm Taf Morgannwg University Local Health Board
Review 43 cases, identify common themes and trends, and incorporate the learning into the overarching maternity action plan.
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Concerns raised1
Failure to share and act on learning from comparable pool deaths
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to learn from previous mistakes
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Sussex NHS Foundation Trust
Stated actions 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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University Hospitals Sussex NHS Foundation Trust
Embed COSHH management in operational meetings and safety huddles, with Food Improvement Group monitoring, governance escalation and organisation-wide communication of learning.
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University Hospitals Sussex NHS Foundation Trust
Deliver and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.
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University Hospitals Sussex NHS Foundation Trust
Discuss the incident at Board and Executive Committee meetings and continue promoting an open culture of learning across the Trust.
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Concerns raised1
Failure of NHS investigations to identify the telephone consultation issue
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026