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.
North London
Concerns raised3
Failure to complete steps in the Haringey Crisis Resolution Team action plan
Delays in completing outstanding action-plan steps
Failure to complete steps in the first action plan
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.
Exeter and Greater Devon
Concerns raised1
Failure to implement the action plan arising from the Root Cause Analysis
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.10
Action
Provide comprehensive assessments and formulate recovery, care and risk plans for people using CRHT services.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Reassess CRHT patients before discharge when increased risks have been identified.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Record all telephone calls received by CRHT teams in clinical records.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Document discharge awareness and routinely consult and inform people and carers about CRHT discharge decisions.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Register both CRHT teams for the Triangle of Care initiative.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Contact people on the day they are discharged from CRHT, using face-to-face or telephone contact according to risk.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Increase OPMH consultant input and provide CRHT teams with direct access to OPMH consultants or named backup.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Have CRHT staff attend weekly Rougemont discharge-planning meetings to improve Adult/OPMH communication.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Develop recovery plans face to face with people using CRHT services whenever safe and practicable.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Action
Consider the wishes and opinions of people receiving services in clinical decision making.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 January 2015.
Wiltshire and Swindon
Concerns raised1
Delays in acting on road safety recommendations
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner South London
Concerns raised1
Failure to complete identified clinical pathway and interagency service improvements
This report raised 5 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
Secure £250,000 funding to pilot a mental-health-specific homeless project linked to an established homeless support scheme.
Stated by South London and Maudsley NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2014.
South Yorkshire (West)
Concerns raised1
Failure to implement recommended strategies to reduce recurrence of plastic obstruction incidents
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Responsibility for medicines and devices, including syringes, rests with the MHRA, which is gathering information on the case.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing manufacturer safety measures, NHS surgical never-event work and revised guidance are considered sufficient to address the concerns and prevent future deaths.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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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.
