Recurring concern
Unreliable completion and receipt of incident review reports
- Reports that mention this concern
- 13
- Times this concern has been raised
- 13
- Stated actions linked to this concern
- 14
What this concern includes
Includes failures in the dedicated incident review-report process involving preparation, completion, responsible sign-off, transmission, receipt or tracking of reports needed for safety review and corrective action.
What is not included
- Excludes failures in the underlying incident investigation or the quality of its analysis where completion or receipt of the report is not deficient.
- Excludes generic patient-safety incident reporting, post-incident learning or action implementation failures unless the assertion specifically concerns completion or receipt of an incident review report.
- Excludes ordinary clinical or operational records and reports that are not incident review reports or their directly equivalent safety-review reports.
- Excludes delays caused solely by external legal, coronial or regulatory proceedings when the incident review-report process itself is not deficient.
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 13 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Delays in receipt of provider-led report requests resulting in investigations without all relevant issues known
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- London Borough of Bromley
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
-
London Borough of Bromley
Launch a Prevention and Intervention Service with a dedicated Safeguarding Hub to manage safeguarding referrals, initial information gathering and immediate safety actions.
-
London Borough of Bromley
Review the contents of the Provider Lead Enquiry form.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
London Borough of Bromley
Delays in sharing Provider Lead Enquiry forms are not a wider concern and the incident appears isolated.
-
Concerns raised1
Automated Datix review and approval failing to ensure human identification of patient-safety incidents
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Birmingham NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University Hospitals Birmingham NHS Foundation Trust
Incidents are not automatically approved: every incident receives individual review before closure, although low-harm records are automatically stamped after managerial review.
-
Concerns raised1
Delays and premature sign-off in Trust investigations
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Essex Partnership University 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.2
-
Essex Partnership University NHS Foundation Trust
Refine patient-safety incident processes and reporting templates.
-
Essex Partnership University NHS Foundation Trust
Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
-
Concerns raised1
Delays in completing and sharing investigations into deaths
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Betsi Cadwaladr University LHB
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
-
Betsi Cadwaladr University LHB
Review the incident process to improve incident handling and learning.
-
Betsi Cadwaladr University LHB
Implement rapid learning panels and incident learning panels.
-
Betsi Cadwaladr University LHB
Prioritise overdue investigations and action plans, meeting weekly to resolve remaining work and monitor actions through completion.
-
Concerns raised1
Delays in responsible sign-off of S.I. reports
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Wye Valley NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Wye Valley NHS Trust
Serious incident report completion and closure are jointly owned by the Trust and ICS, with final sign-off assigned to the ICB.
-
Concerns raised1
Delays in completing and providing patient safety incident investigation reports
This report raised 18 other concerns. 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 obtain crucial witness evidence, learn lessons, and adequately oversee SUI report sign-off
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Greater Manchester Mental 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
-
Greater Manchester Mental Health NHS Foundation Trust
Share the Trust review findings with inpatient and CMHT teams through a learning event.
-
Greater Manchester Mental Health NHS Foundation Trust
Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.
-
Greater Manchester Mental Health NHS Foundation Trust
Assign a Patient Safety Practitioner to support and advise serious-incident review teams.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Greater Manchester Mental Health NHS Foundation Trust
The omission of the Responsible Clinician’s interview would not have changed the Serious Incident investigation’s findings.
-
Concerns raised1
Failure to complete a serious incident report on CWB working practices
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- University of Surrey
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
-
University of Surrey
Make internal reviews following future student suicides standard procedure.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
University of Surrey
The University was not required to produce a serious incident report because it is not a regulated healthcare service provider.
-
Concerns raised1
Delays in completing adverse-death review reports
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- East Lancashire Hospitals 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.2
-
East Lancashire Hospitals NHS Trust
Develop a funded cohort of investigators and family liaison officers with allocated time, training and administrative support.
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East Lancashire Hospitals NHS Trust
Introduce weekly Executive review of divisional investigations before SIRI Panel submission.
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Concerns raised1
Delays in receiving incident review reports
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- United Lincolnshire Teaching Hospitals 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
-
United Lincolnshire Teaching Hospitals NHS Trust
Clear the backlog of serious incident reports under oversight from the Medical Director and Director of Nursing.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026