First reported 17 Dec 2013•Latest report 24 Apr 2026
Definition
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
Distinct published reports
Individual concerns
48
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
80
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.
Betsi Cadwaladr University LHB9
Department of Health and Social Care3
British Transport Police2
Care Quality Commission2
Devon Partnership NHS Trust2
First MTR South Western Trains Limited2
NHS England2
North London NHS Foundation Trust2
Oxford Health NHS Foundation Trust2
United Lincolnshire Teaching Hospitals NHS Trust2
Woodhill Prison2
Avenue House Nursing and Care Home1
Axminster Medical Practice1
Barnet Assist1
Barts Health NHS Trust1
NHS trust22
Local health board9
Ministerial department6
Healthcare site5
Prison or young offender institution3
English unitary authority2
Executive non-departmental public body2
Health and social care service regulator2
London borough council2
Special police force2
Train operating company2
Type not available2
Company1
English county council1
Executive agency1
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.
Birmingham and Solihull
Concerns raised2
Failure to complete BCH Root Cause Analysis recommendations within their target timeframes
Failure to complete the patient-death notification process action within its target timeframe
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 concerns
Each 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.10
Action
Continue working with community services to embed action-plan changes and monitor their impact.
Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Routinely contact BCH after an unexpected adult patient death to check whether BCH knew of the death and had patient involvement.
Stated by Dudley Integrated Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Raise death-notification coordination with the Black Country ICB to explore improved management with primary care colleagues.
Stated by Dudley Integrated Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Engage DIH-managed GP practices to identify further opportunities to improve death-notification processes.
Stated by Dudley Integrated Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Explore with relevant colleagues how full implementation of local medical examiner services could improve death-notification processes.
Stated by Dudley Integrated Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Ensure the immediate death-notification changes are reflected in DIH’s relevant procedural documents.
Stated by Dudley Integrated Health and Care NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Review the implemented changes at regular intervals to ensure they remain embedded.
Stated by Dudley Integrated Health and Care NHS TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Implement an enhanced cross-organisation process for confirming patient deaths and preventing inappropriate post-death correspondence.
Stated by Black Country Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 February 2024.
Action
Work with the local ICB and primary care colleagues to explore improved management of death notifications.
Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Action
Explore opportunities to improve death notification through full implementation of local medical examiner services.
Stated by Black Country Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2024.
Inner North London
Concerns raised1
Failure to take required actions following risk analysis
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North West Wales
Concerns raised1
Delays in identifying and completing proposed actions
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 concerns
Each 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
Revise and co-design a new incident investigation and action-planning process, including governance review, staff training and planned implementation.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 14 September 2023.
Action
Monitor evidence supporting completion of investigation and complaint actions through the divisional governance forum.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Action
Hold weekly coordination meetings between divisional nursing, governance and Healthcare Law leads to strengthen timely submission of reports and action evidence.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 14 September 2023.
Essex
Concerns raised1
Failure to implement learning from Significant Event Analysis
Responses linked to these concerns
Each 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
Disseminate anonymised learning from the consultation concern at a practice meeting.
Stated by Clacton Community PracticesStated completedThe respondent said that this action was complete when they made their response on 22 June 2023.
Action
Complete a retrospective audit of consultations to promote clinician reflection and improve patient care.
Stated by Clacton Community PracticesStated completedThe respondent said that this action was complete when they made their response on 22 June 2023.
Action
Audit at least one consultation for every clinician annually against recognised criteria and send results for discussion with appraisers.
Stated by Clacton Community PracticesStated plannedThe respondent said that this action was planned when they made their response on 22 June 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Risk-assessed signposting and safety-netting by trained non-clinical staff under clinician supervision is considered safe, so no further action is necessary.
Stated by Clacton Community PracticesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
North West Wales
Concerns raised1
Delays in acting on actions arising from death investigations
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 concerns
Each 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
Prioritise overdue investigations and action plans, meeting weekly to resolve remaining work and monitor actions through completion.
Stated by Betsi Cadwaladr University LHBStated in progressThe respondent said that this action was in progress when they made their response on 12 June 2023.
Manchester South
Concerns raised1
Failure to complete identified action plan actions
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 concerns
Each 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
Revisit local support for investigation authors and services to promote active review of action plans and prepare authors to evidence improvements.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 May 2023.
North Wales (East and Central)
Concerns raised1
Failure to complete investigation actions within their required timescales
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 concerns
Each 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
Provide local quality governance support to services for managing open and overdue investigations and evidencing completed actions.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Monitor performance and assure completion of investigation actions through the Patient Safety Team.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Nottinghamshire
Concerns raised1
Failure to have necessary actions in place to address issues identified through the Serious Incident Investigation process
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 concerns
Each 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
Commission and deliver Serious Incident Quality Assurance training to strengthen critical appraisal of investigation reports and SMART, systems-based actions.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 April 2023.
Action
Develop and implement quality improvement plans based on discussion of investigation recommendations.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 April 2023.
North Wales (East and Central)
Concerns raised1
Delays in addressing learning and actions arising from investigations
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to implement Isotretinoin prescribing recommendations
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 concerns
Each 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 the Implementation Working Group’s work to develop the practical arrangements for safely introducing the isotretinoin recommendations.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2023.
Action
Establish and convene an Implementation Working Group to develop the practical implementation of isotretinoin safety recommendations.
Stated by Medicines and Healthcare products Regulatory AgencyStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2023.
Pin
Get email alerts
Request correction
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.
