Recurring concern

Failure to reliably disseminate contextualised safety learning to relevant staff

First to latest report 10 Sep 2013 — 6 Feb 2026

Reports that mention this concern: 24
Times this concern has been raised: 26
Stated actions linked to this concern: 31

What this concern includes

Includes failures in the dedicated dissemination of safety learning from investigations, incidents or events, including inadequate context or narrative, delayed communication, communication limited to directly involved staff, and failure to share learning with relevant wider staff or successor organisations.

What is not included

Excludes failures to investigate or analyse an incident where the learning-dissemination process is not itself deficient.
Excludes failure to implement corrective actions after learning has been reliably communicated.
Excludes generic communication, training or organisational-learning deficiencies without a specific safety-learning dissemination concern.
Excludes routine policy or procedure communication unrelated to learning from a safety investigation, incident or event.

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

Reports about this concern sent to each recipient.

Department of Health and Social Care6

NHS England5

Betsi Cadwaladr University LHB3

Care Quality Commission2

National Institute for Health and Care Excellence2

University Hospitals Sussex NHS Foundation Trust2

Whittington Health NHS Trust2

Association of Ambulance Chief Executives1

Bristol NHS Foundation Trust1

Chief Fire and Rescue Adviser1

DW Fitness First1

East Kent Hospitals University NHS Foundation Trust1

East London NHS Foundation Trust1

East of England Ambulance Service NHS Trust1

Essex Partnership University NHS Foundation Trust1

Reports and published responses 24 reports

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

19 Oct2015
Inner North London
Concerns raised1
1. Failure to notify involved registrars of incident investigation findings
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Vasilis KTORAKIS · 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

Baby Vasilis was born in an extremely poor condition following a long labour at Whittington Hospital on 23 May 2015 and died shortly thereafter. The report identified concerns about the timing of Syntocinon, inadequate recording of a management plan, a registrar’s decision regarding passive descent, and failures to involve staff in the investigation and communicate its findings for learning.

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 notify involved registrars of incident investigation findings
Wider context from the report
“5. Neither the first nor the second registrar was notified of the untoward incident investigation findings, even by the time of inquest, and so the opportunity for them to learn and to improve was lost. This seems to demonstrate a lack of a robust system for learning lessons. ”
Source location
Vasilis KTORAKIS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Apr2015
Nottinghamshire
Concerns raised1
1. Failure to ensure learning from INR dosing events reaches all GPs at the practice
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Doreen Wood · 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

Doreen Wood, who had atrial fibrillation and was taking Warfarin, died on 25 September 2014 from an intracerebral haemorrhage after repeated raised INR results. The report raised concerns that her INR was not checked soon enough and that the surgery’s monitoring system relied on healthcare assistants to volunteer relevant clinical information without routinely using standardised questionnaires.

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 ensure learning from INR dosing events reaches all GPs at the practice
Wider context from the report
“(1) I invite Newgate Street surgery to review their system of INR monitoring, in discussion with Nottinghamshire Healthcare NHS Foundation Trust. (2) Specifically, I invite the surgery to consider the use of standardised questionnaires, and not rely on healthcare assistants to volunteer – or indeed be aware of – relevant clinical information to pass on to the GP when dosing decisions are made. (3) There has been no internal investigation of these matters within the practice, other than a discussion between two of the GPs who treated Mrs Wood. We heard that there are at least six other GPs at the practice who deal with decisions like this on a regular basis. I invite the practice to carry out its own internal investigation, to ensure that the learning from these events includes all GPs at the practice. ”
Source location
Doreen Wood · Prevention of Future Deaths report
Page 3 · concerns
Open source report
3 Dec2013
Inner North London
Concerns raised1
1. Failure to share root cause analysis learning with relevant staff
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
10 Sep2013
Wiltshire and Swindon
Concerns raised1
1. Failure to ensure dissemination of incident-specific lessons to the wider healthcare community
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

David Hackman · 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

David Hackman took up to 32 paracetamol tablets at home and was taken to hospital. After a mental health assessment, he left the Ambulatory Care Unit unnoticed, travelled to a multi-storey car park and jumped from it, dying from multiple traumatic injuries. The concern was how the lessons from this incident had been disseminated to the wider healthcare community, including other Trusts, and whether further action was needed to prevent future deaths.

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 ensure dissemination of incident-specific lessons to the wider healthcare community
Wider context from the report
“At the end of the Inquest I heard evidence as regards the concordance of voluntary arrangements that were established in 2004 and as regards the national reporting and learning service but I am concerned here as regards how this specific incident and in particular its lessons are being disseminated to the wider health care community in England & Wales and in particular other Trusts. I understand the general principle but I would be grateful if you could please specifically explain relevant to this particular incident and the learning exercise that’s been carried out as to how the lessons learned have been communicated and if they have not been communicated to review as to why no action is being taken in that respect with a view to the prevention of future deaths. ”
Source location
David Hackman · 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.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised1

Failure to notify involved registrars of incident investigation findings

Concerns raised1

Failure to ensure learning from INR dosing events reaches all GPs at the practice

Concerns raised1

Failure to share root cause analysis learning with relevant staff

Concerns raised1

Failure to ensure dissemination of incident-specific lessons to the wider healthcare community