Recurring concern
Failure to implement identified safety actions
- Reports that mention this concern
- 45
- Times this concern has been raised
- 48
- Stated actions linked to this concern
- 80
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 45 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to consider and action falls risk action plan advice
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Avenue House Nursing and Care Home
Stated actions 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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Avenue House Nursing and Care Home
Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
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Concerns raised1
Failure to ensure consideration and implementation of root cause analysis recommendations
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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 implement incident action plans
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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 implement strategies to prevent recurrence of the identified failure
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Wirral University Teaching Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Wirral University Teaching Hospital NHS Foundation Trust
Establish a weekly Serious Incident meeting to review new incidents, report progress, and flag overdue actions.
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Wirral University Teaching Hospital NHS Foundation Trust
Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
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Wirral University Teaching Hospital NHS Foundation Trust
Reduce the haemoglobin delta-check threshold from 25% to 20%.
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Wirral University Teaching Hospital NHS Foundation Trust
Raise the haemoglobin telephone-alert threshold from below 70 g/L to below 75 g/L and audit its operation.
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Concerns raised1
Failure to implement identified highway safety measures
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cumbria County Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Cumbria County Council
Allocate funding to implement the collision study’s safety recommendations in 2017/18.
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Cumbria County Council
Consult the police, Parish Council and County Councillor on proposed high-friction surfacing, road-marking and signage improvements.
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Cumbria County Council
Hold a further police site visit after installing the measures to identify necessary amendments or further improvements.
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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Cumbria County Council
The recommendations were not delayed by insufficient resources; funding had already been allocated for 2016/17 and the following year.
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Concerns raised1
Delays in developing and implementing a safe discharge procedure
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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 implement changes with clear timescales and adequate coverage of identified concerns
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Oxford Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Oxford Health NHS Foundation Trust
Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.
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Oxford Health NHS Foundation Trust
Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.
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Oxford Health NHS Foundation Trust
Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.
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Concerns raised1
Failure to implement previous safety recommendations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- National Offender Management Service Equality, Rights and Decency Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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National Offender Management Service Equality, Rights and Decency Group
Operate a monthly forum chaired by the Deputy Governor to monitor progress on actions responding to death-in-custody recommendations.
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National Offender Management Service Equality, Rights and Decency Group
Maintain a whole-establishment action plan with the health provider and formally monitor and report its progress monthly.
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National Offender Management Service Equality, Rights and Decency Group
Operate a quarterly safer-custody taskforce chaired by the Deputy Director to oversee implementation of the review action plan.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
National Offender Management Service Equality, Rights and Decency Group
Existing prison governance and monitoring processes are considered sufficient to deliver action on HMIP, PPO and Regulation 28 recommendations.
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Concerns raised1
Failure of governance procedures to ensure action plans are followed through
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Herefordshire and Worcestershire Health and Care NHS Trust
Stated actions 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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Herefordshire and Worcestershire Health and Care NHS Trust
Establish an embedded lessons database containing Root Cause Analysis action plans and completion evidence, with Governance Team monitoring.
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Concerns raised1
Failure to implement lessons from previous heat-illness and tracking events
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Ministry of Defence
Stated actions 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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Ministry of Defence
Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
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Ministry of Defence
Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
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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Ministry of Defence
A formal, established process already captures and manages lessons learned, with the Training Governance and Assurance Policy review reinforcing it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026