Recurring concern

Failure to identify and address recurring safety issues through organisational learning

First to latest report 3 Dec 2013 — 20 May 2026

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.

Reports and published responses 62 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Ashley Ponsonby was a detained dual-diagnosis patient who died after injecting illicit drugs on a psychiatric ward. The inquest found amphetamine and paramethoxyamphetamine toxicity as the cause of death, with contributing factors including poor communication, inadequate observations and escalation, failure to recognise toxicity and deterioration, inadequate control of access to illicit drugs, insufficient staff training, and an inadequate emergency response. Concerns included the absence of staff training in managing physical risks from illicit substances, failures to use incident-reporting and risk-register procedures, and the lack of a coherent policy governing cooperation between the Mental Health Trust and police regarding illegal activity.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to use incident reporting and risk-register procedures to identify drug supply or consumption

    Wider context from the report

    “2. There is a concern that the failure to use the Datix and Trust incident reporting policy, as well as the risk register (or other similar procedures available to other Mental Health Trusts), to identify the problem of drug supply and/or consumption, if unremedied may lead to a future death. It is a concern both locally for the Trust, regionally and nationally, that such procedures should be appropriately used so as to prevent a future death. ”

    Source location

    ASHLEY CORIN DE WINTER PONSONBY · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  2. Inner North London

    AI-generated summary

    Agostino COSTA · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Agostino Costa died after an accidental fall in hospital on 12 May 2013, which hastened death from terminal disease. The principal concerns were staff confusion about falls-risk classification and management, inadequate training for a junior doctor, limited sharing of the hospital root cause analysis, and non-mandatory attendance at falls-prevention seminars.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to share root cause analysis learning with relevant staff

    Wider context from the report

    “4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls. 5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some. I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff. ”

    Source location

    Agostino COSTA · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026