Recurring concern
Failure to reliably disseminate contextualised safety learning to relevant staff
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Request correctionFirst reported 10 Sep 2013•Latest report 6 Feb 2026
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.
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.
- Reports
- 24
- Individual concerns
- 26
- Date range
- 2013–2026
- Stated actions
- 31
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 communicate patient safety investigation findings to treating staff
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.
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
Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
Stated by The Trust
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Concerns raised2
Failure to contextualise learning in staff memoranda
Inadequate sharing of incident learning with uninvolved staff
This report raised 2 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
Develop and test a searchable learning repository, evaluate it with staff, and roll it out across the Health Board.
Stated by Betsi Cadwaladr University LHB -
Action
Lead the Foundations for the Future programme to integrate women’s and neonatal services and improve investigations and learning across them.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Lack of formal consideration and dissemination of learning points
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.6
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Action
Present consolidated learning from the case at St George’s paediatric, paediatric surgery and radiology Clinical Governance meetings.
Stated by St George'S University Hospitals NHS Foundation Trust -
Action
Meet with Epsom St Helier clinical leads to discuss the learning and resulting practice changes.
Stated by St George'S University Hospitals NHS Foundation Trust -
Action
Deliver a dedicated malrotation session at the British Society of Paediatric Radiology meeting.
Stated by St George'S University Hospitals NHS Foundation Trust
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Action
Audit children over one year old who underwent malrotation surgery across four regional centres and present the findings regionally.
Stated by St George'S University Hospitals NHS Foundation Trust -
Action
Share the malrotation audit findings at national paediatric surgery and paediatrics meetings in 2025.
Stated by St George'S University Hospitals NHS Foundation Trust -
Action
Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group and share key learning across the NHS nationally and regionally.
Stated by NHS England
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Concerns raised1
Failure to specify and disseminate learning from the DOAC pausing incident
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.5
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Action
Review the Report and consider whether learning should be shared across Midlands integrated care boards.
Stated by NHS England -
Action
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
Stated by NHS England -
Action
Share the report with Agilio Software for awareness.
Stated by National Institute for Health and Care Excellence
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Action
Present the incident and related learning at the cardiology Grand Round.
Stated by The Trust -
Action
Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
Stated by The 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
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to implement learning from investigations following deaths in custody
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.1
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Action
Require Early Learning Reviews after deaths in custody and ensure resulting recommendations and learning are investigated and implemented.
Stated by Sodexo
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
Sodexo’s death-in-custody learning processes apply only while the prison is under Sodexo’s operational management.
Stated by Sodexo
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Concerns raised1
Failure to adequately share investigation learning with practitioners
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.2
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Action
Develop a new incident process for sharing investigation learning with clinicians.
Stated by Betsi Cadwaladr University LHB -
Action
Implement the new incident process in April 2024.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to incorporate investigation learning into training and alerts
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.
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
Include a case study in the Safety Matters Newsletter covering adrenaline, paediatric airway management and handover communication during critical asthma incidents.
Stated by East of England Ambulance Service NHS Trust
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Concerns raised1
Failure to disseminate institutional learning from unexpected deaths
This report raised 8 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.6
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Action
Discuss HSIB investigation outputs and learning through Intensive Care, Maternity Mortality and Morbidity, and other Trust forums.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Share learning that non-traumatic bilateral pneumothoraces can cause failure to ventilate and cardiac arrest through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists -
Action
Share learning from Teegan’s death through the Safe Anaesthesia Liaison Group network and relevant organisations.
Stated by NHS England
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Action
Ask regional Regulation 28 Working Group members to share learning with Integrated Care Boards for onward dissemination to trusts across England.
Stated by NHS England -
Action
Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group to share learning, identify trends and consider further review or action.
Stated by NHS England -
Action
Share learning that bilateral pneumothoraces can cause cardiac arrest without trauma or thoracic surgery through safety updates, education and events.
Stated by Association Of Anaesthetists (Great Britain & Ireland) and Royal College of Anaesthetists
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
The identified care, evidence-handling, Duty of Candour and investigation concerns fall outside HEE’s current role and statutory responsibilities.
Stated by NHS England
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Concerns raised1
Failure to embed patient-safety learning and convey it to new senior team members
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 provide Trust-wide learning and training from serious incidents
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026