Recurring concern

Failure to reliably disseminate contextualised safety learning to relevant staff

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First reported 10 Sep 2013•Latest report 6 Feb 2026

Definition

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

Distinct published reports

Individual concerns
26

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
31

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.

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

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.

  1. Inner North London

    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

  2. Nottinghamshire

    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. 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

  4. Wiltshire and Swindon

    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
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Data last updated 7 September 2026