Recurring concern
Unreliable morbidity and mortality review processes
- Reports that mention this concern
- 18
- Times this concern has been raised
- 19
- Stated actions linked to this concern
- 30
What this concern includes
Includes failures in formal morbidity and mortality review processes, including initiating or scheduling reviews, ensuring relevant departments and specialists contribute, conducting meaningful discussion, recording conclusions and learning, and following through required review discussions or actions.
What is not included
- Excludes general clinical governance, incident investigation or organisational-learning failures where no morbidity and mortality review is identified.
- Excludes failures to implement corrective actions after a morbidity and mortality review has reliably established its findings, unless the review process itself was also deficient.
- Excludes routine clinical meetings, audits and case discussions that are not formal morbidity and mortality reviews.
- Excludes the underlying patient-care failure or death where no deficiency in the morbidity and mortality review process is asserted.
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 18 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to carry out Emergency Department morbidity and mortality reviews
This report raised 4 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 of governance processes to reflect upon sub-optimal practice
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Barts Health NHS Trust
Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
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Barts Health NHS Trust
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
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Barts Health NHS Trust
Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
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Barts Health NHS Trust
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
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Barts Health NHS Trust
Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
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Concerns raised1
Lack of regular morbidity and mortality review of community urology complications
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Care Quality Commission
- Sussex Medical Chambers
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
-
Sussex Medical Chambers
Implement a Managing Clinical Incidents Plan to reinforce policies, strengthen incident reviews, and increase confidence and learning.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Care Quality Commission
Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
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Care Quality Commission
The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
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Concerns raised2
Lack of records of concerns identified at morbidity and mortality or clinical governance meetings
Delays in morbidity and mortality meetings
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Berkshire 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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Royal Berkshire NHS Foundation Trust
Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.
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Royal Berkshire NHS Foundation Trust
Disseminate clinical governance learning through specialty teams, governance leads, mortality surveillance and Trust committees.
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Royal Berkshire NHS Foundation Trust
Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.
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Royal Berkshire NHS Foundation Trust
Store clinical governance discussion notes on a shared drive and provide Legal Services access for future court disclosures.
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Concerns raised1
Uncertainty about learning identified through paediatric mortality review
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Northamptonshire Safeguarding Children Partnership
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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Northamptonshire Safeguarding Children Partnership
Collect, collate and store all child death review forms and associated communications in accordance with data protection requirements.
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Northamptonshire Safeguarding Children Partnership
Review serious incident and comparable investigation reports to identify service-related modifiable factors and challenge insufficient findings or improvement actions.
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Northamptonshire Safeguarding Children Partnership
Use a joint decision process to determine when child deaths should be brought to CDOP, informed by completed investigations and inquests.
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Concerns raised1
Failure of governance processes to identify patient safety incidents through mortality review
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
-
Concerns raised1
Inadequate learning from mortality review cases
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- University Hospitals Birmingham 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.1
-
University Hospitals Birmingham NHS Foundation Trust
Share identified learning with Hospital Medical Directors and Directors of Nursing across the Trust’s hospitals.
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Concerns raised1
Failure to include relevant anaesthetic subject expertise in Structured Mortality Reviews
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Oxford University Hospitals 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
-
Oxford University Hospitals NHS Foundation Trust
Strengthen Structured Mortality Review training, guidance and reporting templates to capture relevant clinicians’ views on concerns about poor care.
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Oxford University Hospitals NHS Foundation Trust
Ensure Mortality Review Groups include appropriate subject-matter expertise and convene wider Learning MDT meetings when needed.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Oxford University Hospitals NHS Foundation Trust
The Mortality Review Process already includes relevant clinical expertise through trained clinicians, consultant review and subject-matter input where necessary.
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Concerns raised1
Inadequacy and siloing of incident reporting and mortality review processes
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
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
-
Barts Health NHS Trust
Implement the Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.
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Barts Health NHS Trust
Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Barts Health NHS Trust
The case was not classified as a serious incident because reviews concluded that care failures did not cause or alter the outcome.
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Department of Health and Social Care
The primarily local concerns are for Barts Health NHS Foundation Trust to address.
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Concerns raised1
Failure of surgical mortality reviews to consider the role of anticoagulation
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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026