Recurring concern
Failure to implement identified safety actions
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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.
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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.
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
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Action
Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
Stated by Avenue House Nursing and Care Home
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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.
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.
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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.
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.
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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.
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
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Action
Establish a weekly Serious Incident meeting to review new incidents, report progress, and flag overdue actions.
Stated by Wirral University Teaching Hospital NHS Foundation Trust -
Action
Change the laboratory IT system and issue staff instructions on revised standard operating procedures for haemoglobin reporting.
Stated by Wirral University Teaching Hospital NHS Foundation Trust -
Action
Reduce the haemoglobin delta-check threshold from 25% to 20%.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
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Action
Raise the haemoglobin telephone-alert threshold from below 70 g/L to below 75 g/L and audit its operation.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
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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.
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
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Action
Allocate funding to implement the collision study’s safety recommendations in 2017/18.
Stated by Cumbria County Council -
Action
Consult the police, Parish Council and County Councillor on proposed high-friction surfacing, road-marking and signage improvements.
Stated by Cumbria County Council -
Action
Hold a further police site visit after installing the measures to identify necessary amendments or further improvements.
Stated by Cumbria County Council
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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Position
The recommendations were not delayed by insufficient resources; funding had already been allocated for 2016/17 and the following year.
Stated by Cumbria County Council
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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.
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.
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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.
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
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Action
Complete governance approval and implement the amended section 17 leave form, including recording whether copies should be provided and to whom.
Stated by Oxford Health NHS Foundation Trust -
Action
Test the new leave-management SOP on Sapphire ward, review it, and expand implementation across all adult wards.
Stated by Oxford Health NHS Foundation Trust -
Action
Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.
Stated by Oxford Health NHS Foundation Trust
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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.
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
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Action
Operate a monthly forum chaired by the Deputy Governor to monitor progress on actions responding to death-in-custody recommendations.
Stated by National Offender Management Service Equality, Rights and Decency Group -
Action
Maintain a whole-establishment action plan with the health provider and formally monitor and report its progress monthly.
Stated by National Offender Management Service Equality, Rights and Decency Group -
Action
Operate a quarterly safer-custody taskforce chaired by the Deputy Director to oversee implementation of the review action plan.
Stated by National Offender Management Service Equality, Rights and Decency Group
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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Position
Existing prison governance and monitoring processes are considered sufficient to deliver action on HMIP, PPO and Regulation 28 recommendations.
Stated by National Offender Management Service Equality, Rights and Decency Group
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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.
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
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Action
Establish an embedded lessons database containing Root Cause Analysis action plans and completion evidence, with Governance Team monitoring.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
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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.
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
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Action
Reinforce the formal lessons-learning process through the Training Governance and Assurance Policy review and biannual training reviews.
Stated by Ministry of Defence -
Action
Conduct a Service Inquiry into the incident and wider endurance-training safety lessons across Defence.
Stated by Ministry of 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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Position
A formal, established process already captures and manages lessons learned, with the Training Governance and Assurance Policy review reinforcing it.
Stated by Ministry of Defence
Data last updated 7 September 2026