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.
Black Country
Concerns raised1
Failure to establish and implement a service-provider action plan for improving quality and safety
This report raised 10 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
Require the provider to submit an action plan addressing safety concerns and meet with the provider to discuss it.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 4 November 2022.
Action
Follow internal enforcement processes to take appropriate regulatory action and monitor progress against the provider’s action plan.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 4 November 2022.
Action
Implement and monitor an improvement plan addressing care quality and service safety concerns.
Stated by Wolverhampton City CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2022.
Action
Draw up an action plan addressing the three improvement areas identified by the CQC.
Stated by Hibiscus Housing Association LimitedStated completedThe respondent said that this action was complete when they made their response on 4 November 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The CQC did not inspect Hibiscus DCA during the pandemic because of changing priorities.
Stated by Care Quality CommissionUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure of formal investigation learning to address the breadth of identified patient safety issues
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.7
Action
Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 September 2022.
Action
Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Action
Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Implement the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 22 September 2022.
Action
Add a full-time clinical staff member to support the strengthened inquest triage and review process.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 22 September 2022.
Manchester South
Concerns raised1
Lack of a plan to address the known risk-assessment problem
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 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.
Manchester South
Concerns raised1
Lack of a clear strategy to address identified risks
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 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.
West Sussex
Concerns raised1
Failure to establish definitive plans to address junction safety issues
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 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
Undertake a feasibility study and options appraisal for improving the crossing point, including bridge and traffic-light-controlled crossing options.
Stated by West Sussex County CouncilStated in progressThe respondent said that this action was in progress when they made their response on 14 June 2021.
Lancashire and Blackburn with Darwen
Concerns raised1
Inadequacy of the action plan for reducing delays in NG tube insertion and decompression
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.
Blackpool and the Fylde
Concerns raised1
Lack of processes to address omissions of care arising from understaffing
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 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.
South Wales Central
Concerns raised1
Failure of improvement planning to address specific shortcomings in service provision
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 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.
Liverpool and the Wirral
Concerns raised1
Failure of public authorities to address tree safety concerns before a fatal event
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
Set up an online event for relevant local authority officers to raise and discuss the review findings.
Stated by Local Government AssociationStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Action
Publish the event outcomes, anonymised Section 28 report and good practice on tree management and reducing harm on the LGA website.
Stated by Local Government AssociationStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Action
Ask relevant professional networks to share the information with local government officers involved in public parks and environmental services.
Stated by Local Government AssociationStated plannedThe respondent said that this action was planned when they made their response on 1 November 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for spending on parks, including responding to the concern, lies with local authorities.
Stated by Ministry of Housing, Communities and Local GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester City
Concerns raised1
Lack of a specific action plan for failed communication with the patient or family
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 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.1
Position
The assessment and communication arrangements were considered reasonable and proportionate, so no further action was identified.
Stated by Herefordshire and Worcestershire Health and Care NHS TrustNo action considered necessaryThe respondent said that no further action was needed.
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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.
