First reported 18 Sep 2014•Latest report 6 Jan 2026
Definition
What this concern includes
Includes failures to establish, specify or assure an effective corrective-action or improvement plan addressing identified safety concerns, service shortcomings or incident learning, including the anchor's failure to address specific service-provision shortcomings and comparable absences of meaningful plans in other reports.
Not included
Excludes failures to implement, complete or deliver actions from an already established safety plan where plan formation is not itself deficient.
Excludes inadequate incident investigations where the investigation process, rather than the absence or inadequacy of a resulting improvement plan, is the unsafe condition.
Excludes generic governance, oversight or organisational-learning deficiencies unless the report specifically identifies failure to establish a meaningful plan addressing known safety concerns.
Excludes ordinary service-improvement planning without an identified patient, public or operational safety concern.
Reports
28
Distinct published reports
Individual concerns
28
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
67
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 LHB3
Department of Health and Social Care3
NHS England3
Care Quality Commission2
Essex Partnership University NHS Foundation Trust2
Blackpool Teaching Hospitals NHS Foundation Trust1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
East Lancashire Hospitals NHS Trust1
East London NHS Foundation Trust1
East of England Ambulance Service NHS Trust1
Family of Gillian McKinlay1
Greater Manchester Mental Health NHS Foundation Trust1
Greater Manchester Police1
Health and Safety Executive1
Herefordshire and Worcestershire Health and Care NHS Trust1
NHS trust18
Ministerial department4
Executive non-departmental public body3
Local health board3
English county council2
English metropolitan district council2
Health and social care service regulator2
Domiciliary care provider1
Integrated care board1
Local-government membership body1
Police force1
Private limited company1
Public transport authority1
Registered provider of social housing1
Workplace safety regulator1
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.
Bedfordshire and Luton
Concerns raised1
Absence of an MDT plan to address anti-psychotic depot medication non-concordance
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.3
Action
Reinforce medication non-concordance policies and procedures requiring weekly MDT discussion and comprehensive electronic-record documentation of missed depot injections or adherence concerns.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Embed depot-medication compliance auditing and weekly monitoring, with findings reported through local and Directorate governance and escalated where required.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Action
Formalise MDT risk oversight for medication non-adherence through risk-register inclusion, weekly RAG review, senior multidisciplinary attendance and recording of decisions and responsible clinicians.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 8 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Strengthened medication non-concordance procedures, auditing, monitoring and training are considered sufficient; no further action is required.
Stated by East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Weekly MDT review, risk-register oversight, escalation and documented accountability are considered sufficient; no further action is required.
Stated by East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Lancashire and Blackburn with Darwen
Concerns raised1
Lack of a clear plan to deliver a 24/7 thrombectomy service in Lancashire
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.17
Action
Operate a seven-day mechanical thrombectomy service until 22:00, with the planned transition to full 24/7 provision by 28 February 2026.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 June 2025.
Action
Negotiate and evaluate a sustainable 1-in-8 neurointerventional radiology rota and associated job plans for 24/7 service delivery.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Finalise and agree the 24/7 thrombectomy business case, including required infrastructure and workforce arrangements.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Complete radiographer shift planning and consultation to support 24/7 thrombectomy provision.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Recruit additional Radiology and Anaesthetic staff required to support overnight thrombectomy provision.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Develop operational readiness for overnight theatre and recovery services.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Establish regional mutual-aid arrangements by engaging neighbouring thrombectomy centres and progressing a coordinated support agreement.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Monitor progress against the 24/7 service and regional-aid plans through monthly executive review.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Work with regional stakeholders and clinicians to explore and progress plans for overnight thrombectomy access across Lancashire and South Cumbria.
Stated by Northern Care Alliance NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Continue working with Lancashire Teaching Hospitals to sustain its seven-day thrombectomy service.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Support an options appraisal of regional nighttime thrombectomy models to improve equal access across the North West.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Issue commissioners an urgent recommendation to review North West thrombectomy provision and achieve fully operational 24/7 coverage.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 10 June 2025.
Action
Implement a fully operational 24/7 mechanical thrombectomy service at LTHTR by 28 February 2026.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 10 June 2025.
Action
Evaluate and negotiate the proposed 1-in-8 NIR consultant rota and associated job plans for sustainable 24/7 coverage.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Finalise the business case for 24/7 thrombectomy expansion, including required infrastructure and workforce arrangements.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Complete recruitment and rota development for Anaesthetic, Radiology and Radiography staffing needed for overnight provision.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Action
Develop operational readiness for overnight theatre and recovery services supporting thrombectomy.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 10 June 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
A 24/7 service cannot yet be implemented because NIR rota approval, recruitment, radiographer planning, and overnight theatre and recovery readiness remain incomplete.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Since 1 April 2024, Lancashire and South Cumbria ICB is responsible for commissioning regional stroke thrombectomy services, not NHS England.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
A 24/7 thrombectomy service cannot yet be implemented because the NIR rota, recruitment, staffing and overnight operational arrangements remain incomplete.
Stated by Lancashire Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Failure to translate investigation learning into a concrete plan
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.1
Action
Implement the revised process for managing Formal Incident Review recommendations, with accountable officers and directors developing actions to address identified risks.
Stated by Transport for LondonStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Rutland and North Leicestershire
Concerns raised1
Failure to link identified serious incident failings to action-plan work
This report raised 8 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.
Birmingham and Solihull
Concerns raised1
Inadequate cohesive planning for short-term staffing pressures and longer-term solutions
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.9
Action
Consider all recommendations from the independent upper-GI service review.
Stated by NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
Action
Open the refurbished elective surgical hub at Solihull Hospital, adding six theatres and capacity for 11,500 procedures annually.
Stated by NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
Action
Introduce the NHS Long Term Workforce Plan and Framework 15.
Stated by NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
Action
Complete a high-level diagnostic of current and future workforce demand and supply.
Stated by NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
Action
Operate the 4R’s Workforce Delivery Framework with allocated resources supporting implementation over two years.
Stated by NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
Action
Deliver workforce programmes addressing diagnostic risks, including sustainable staffing, retention, training and workforce-plan foundations.
Stated by NHS Birmingham and Solihull Integrated Care Board and University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 30 April 2024.
Action
Deliver the Long-Term Workforce Plan, expanding domestic education, training and recruitment while improving staff culture, leadership and wellbeing.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
Action
Plan for and provide system support ahead of winter pressures through operational, surge, cross-system and workforce preparedness measures.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 30 April 2024.
Action
Issue national winter-planning guidance to Integrated Care Boards and NHS trusts.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 30 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
NHS England is responsible for delivering the long-term workforce strategy rather than the responding department undertaking further workforce planning.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised1
Inadequacy of the action plan for addressing ambulance response concerns
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
Publish the Delivery Plan for Recovering Urgent and Emergency Care Services.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Implement the Operational Performance and Improvement Plan to improve organisational efficiency and maximise ambulance availability.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Review and update the information sheet provided to families about actions addressing demand challenges.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Commenting on EEAST’s action plan adequacy is outside the respondent’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
EEAST is responsible for addressing the adequacy of its action plan and updating the court.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Lack of a meaningful plan to address identified safety concerns
This report raised 6 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
Implement and monitor an improvement plan addressing clinical-care, risk-assessment, documentation and reflective-practice gaps.
Stated by Oxleas NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 December 2023.
Berkshire
Concerns raised1
Failure to identify proposed changes after a death
This report raised 6 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.4
Action
Discuss and minute clinically concerning, potentially learnable TVVN vascular deaths at quarterly network morbidity and mortality meetings, sharing minutes across the Network.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 November 2023.
Action
Introduce three forms for documenting vascular surgery-related concerns about patient deaths in the Thames Valley.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 November 2023.
Action
Maintain the OUH Medical Examiner office to scrutinize all non-Coronial deaths and feed concerns to governance and clinical teams.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Action
Update the OUH Mortality Review Policy with an appendix governing cross-system learning responses across the BOB ICB and Frimley.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
North West Wales
Concerns raised1
Failure to identify and address electronic record availability in investigation learning and improvement
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
Consider and discuss the benefits of integrated IT within the investigation report and subsequent action plan.
Stated by Betsi Cadwaladr University LHBStated completedThe respondent said that this action was complete when they made their response on 12 June 2023.
Manchester North
Concerns raised1
Failure of Recovery and Discharge Plans to address online medication procurement risks
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures to establish, specify or assure an effective corrective-action or improvement plan addressing identified safety concerns, service shortcomings or incident learning, including the anchor's failure to address specific service-provision shortcomings and comparable absences of meaningful plans in other reports.
