Recurring concern
Failure to implement identified safety actions
Pin
Get email alerts
Request correctionFirst reported 17 Dec 2013•Latest report 24 Apr 2026
What this concern includes
Includes failures to implement, complete or deliver actions arising from incident investigations, root-cause analyses, Trust action plans or other explicit safety action plans, including avoidable delays in completing their outstanding steps.
Not included
- Excludes failures to create or sufficiently specify an action plan where no implementation failure is identified.
- Excludes delays concerning ordinary clinical, infrastructure or administrative tasks that are not identified safety-plan actions.
- Excludes generic organisational, staffing, training, audit or governance deficiencies unless they are explicitly presented as failures to implement identified safety actions.
- Reports
- 45
- Individual concerns
- 48
- Date range
- 2013–2026
- Stated actions
- 80
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.
-
Concerns raised1
Failure to implement and embed identified patient-safety changes swiftly and effectively
This report raised 1 other concern. 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.4
-
Action
Strengthen the pleural procedures policy with senior escalation, competency-based referral routes, and guidance for bleeding risks and coagulopathy.
Stated by Walsall Healthcare NHS Trust -
Action
Operate a formal urgency- and clinical-need-based referral process for transferring patients to specialty wards.
Stated by Walsall Healthcare NHS Trust -
Action
Complete consultation and implementation of the amended specialty-transfer policy, including enhanced review and escalation for patients waiting seven or more days.
Stated by Walsall Healthcare NHS Trust
-
Action
Incorporate incident learning into resident and registrar doctor induction and clinical supervisor discussions.
Stated by Walsall Healthcare NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Existing senior escalation, operational oversight, communication and specialist referral arrangements provide immediate safety controls while longer-term changes are embedded.
Stated by Walsall Healthcare NHS Trust
-
Concerns raised1
Delays in implementing identified safety actions
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.
-
Concerns raised1
Delays in addressing identified cell-safety concerns
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.
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.3
-
Action
Restore ligature-resistant cells to serviceable condition using approved lockable observation hatches.
Stated by HM Prison and Probation Service -
Action
Carry out daily accommodation fabric checks with additional scrutiny for cell damage or deterioration.
Stated by HM Prison and Probation Service -
Action
Remove cells with significant defects from use and document and monitor remedial work until they are serviceable.
Stated by HM Prison and Probation Service
-
Concerns raised1
Delays in implementing appropriate changes following serious clinical incidents
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.3
-
Action
Review governance processes to strengthen oversight and accountability for implementing learning and improvement actions.
Stated by Great Western Hospitals NHS Foundation Trust -
Action
Review outstanding serious-incident investigation actions and monitor them through monthly Maternity Governance meetings.
Stated by Great Western Hospitals NHS Foundation Trust -
Action
Strengthen and embed central tracking and monitoring of serious-incident actions, with prompts, responsibility visibility and progress evidence.
Stated by Great Western Hospitals NHS Foundation Trust
-
Concerns raised1
Failure to implement identified risk-reduction actions
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.1
-
Action
Review improvement actions through executive-chaired Mandated Support meetings reporting to the Executive Management Committee.
Stated by North London NHS Foundation Trust
-
Concerns raised1
Lack of certainty that the pedestrian crossing safety redesign will be implemented
This report raised 1 other concern. 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
-
Action
Continue working with TfL and stakeholders to secure priority implementation of the proposed pedestrian and cyclist crossing safety measures.
Stated by London Borough of Hounslow -
Action
Develop a formal signalised crossing scheme across the A4 and both sections of Jersey Road, with associated highway-layout amendments.
Stated by Transport for London
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
-
Position
The Department does not oversee or consent to TfL’s traffic schemes, including this pedestrian crossing.
Stated by Department for Transport
-
Position
TfL and the London Borough of Hounslow are responsible for implementing the crossing redesign, subject to funding and public consultation.
Stated by Department for Transport -
Position
TfL and the Mayor of London decide, prioritise and approve investment funding for the pedestrian crossing redesign.
Stated by Department for Transport -
Position
DfT consent is not required, and LBH consent is needed only for minor works on its road network.
Stated by Transport for London -
Position
Earlier implementation is constrained by required design, modelling, consultation, governance, contractor mobilisation and funding steps.
Stated by Transport for London
-
Concerns raised1
Failure to implement road safety recommendations at the collision location
This report raised 1 other concern. 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.
-
Concerns raised1
Delays in acting on identified learning and actions
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.4
-
Action
Provide the patient information leaflet at triage in the Ysbyty Glan Clwyd Emergency Department.
Stated by Betsi Cadwaladr University LHB -
Action
Adapt and launch the patient information leaflet in the Ysbyty Wrexham Maelor and Ysbyty Gwynedd Emergency Departments.
Stated by Betsi Cadwaladr University LHB -
Action
Review open action-plan progress and escalate delays through the MHLD Learning and Action Group.
Stated by Betsi Cadwaladr University LHB
-
Action
Conduct rolling Datix audits to verify that divisions record, manage and evidence closure of Learning and Improvement Plan actions.
Stated by Betsi Cadwaladr University LHB
-
Concerns raised1
Failure to implement identified suicide-risk mitigation measures at the train station
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.
-
Concerns raised1
Failure to implement identified actions addressing unsafe neurology practice
This report raised 14 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
-
Action
Continue implementing and monitoring actions from the Serious Incident investigation and neurology improvement action plan.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
Stated by NHS England
Data last updated 7 September 2026