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 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.
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
Promote appropriate reporting of deaths and patient safety incidents through regulatory activities.
Stated by Care Quality Commission -
Action
Review notifications guidance to clarify reporting requirements concerning the circumstances of a person’s death.
Stated by Care Quality Commission
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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Position
Current NRLS and STEIS reporting processes are considered adequate for the CQC to fulfil its regulatory responsibilities.
Stated by Department of Health and Social Care
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Position
NRLS/STEIS reporting is considered adequate for CQC’s regulatory responsibilities, so a separate direct death-notification requirement is not preferred.
Stated by Care Quality Commission -
Position
Changing death-reporting arrangements would require legislative action brought forward by the Department of Health and Social Care.
Stated by Care Quality Commission
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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.
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
Share anonymised learning from Bethan’s death through maternity meetings, governance study days, PROMPT, newsletters, staff forums, and mandatory fetal monitoring and skills training.
Stated by St George'S University Hospitals NHS Foundation Trust -
Action
Provide yearly staff training updates through monthly practice-development training sessions, using the case as a reference for ongoing learning.
Stated by St George'S University Hospitals NHS Foundation Trust
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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.
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
Share the root-cause analysis report and investigation learning with the involved team and across the Trust to support reflection by similar teams.
Stated by Oxleas NHS Foundation Trust
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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.
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
Continue participating in ambulance user groups to share data, discuss cases, exchange learning, and support triage-system improvements through feedback mechanisms.
Stated by London Ambulance Service NHS 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
Established NHS Pathways governance systems capture, review and resolve clinical coding issues, including those raised through Prevention of Future Deaths reports.
Stated by Department of Health and Social Care
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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.
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
Continue engaging with other agencies to learn from incidents and improve patient care.
Stated by Birmingham Women'S and Children'S NHS Foundation Trust -
Action
Meet regularly with other agencies to identify service improvements.
Stated by Walsall Borough Council
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
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
Review 43 cases, identify common themes and trends, and incorporate the learning into the overarching maternity action plan.
Stated by Cwm Taf Morgannwg University Local Health Board
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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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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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.
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
Embed COSHH management in operational meetings and safety huddles, with Food Improvement Group monitoring, governance escalation and organisation-wide communication of learning.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Deliver and disseminate an inquest-learning presentation that explains system failures and instructs staff to report COSHH and patient-safety concerns.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Discuss the incident at Board and Executive Committee meetings and continue promoting an open culture of learning across the Trust.
Stated by University Hospitals Sussex NHS Foundation 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.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026