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 identify and disseminate learning 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.
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
Establish alternative methods for reviewing and learning from patient-safety events that do not require full investigation.
Stated by Bristol NHS Foundation Trust -
Action
Enhance governance arrangements for learning and improvement from patient-safety incidents.
Stated by Bristol NHS Foundation Trust
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Concerns raised1
Delays in sharing learning from adverse 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.
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
Operate a new serious-incident process with daily review, executive oversight, rapid learning escalation, appointed investigators and senior reviewers.
Stated by Betsi Cadwaladr University LHB -
Action
Develop and operate learning-sharing channels, including a portal, lessons-on-a-page, digital dissemination and monthly learning events.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Lack of a mechanism for disseminating clinical incident information and improving learning from similar events
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
Commission a specialist optometrist or neuro-ophthalmologist to develop training materials on this presentation.
Stated by Specsavers -
Action
Record and disseminate the specialist training through an online webinar or similar mechanism for Company professional staff.
Stated by Specsavers
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Concerns raised1
Failure to share important independent safety reports with staff
This report raised 19 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
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social Care
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Concerns raised1
Lack of national provision for sharing maternity induction-of-labour learning
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.
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 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 disseminate near-miss events
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
Appraise the Trust incident-reporting system and develop preliminary recommendations for improving incident data capture and analysis.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to share learning from events with the new Trust
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.1
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Action
Share the coroner’s report and this response with the board of the new Trust.
Stated by Manchester University NHS Foundation Trust
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Concerns raised1
Failure to disseminate and implement weight-estimation learning and training for clinical staff treating high-risk patients
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.
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Concerns raised2
Lack of effective means to ensure fire and rescue services meet expectations and disseminate national learning
Failure to test whether national learning is received, understood, actioned and embedded
This report raised 13 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