Recurring concern
Unreliable morbidity and mortality review processes
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Request correctionFirst reported 13 Apr 2017•Latest report 14 Oct 2025
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.
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.
- Reports
- 18
- Individual concerns
- 19
- Date range
- 2017–2025
- Stated actions
- 30
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 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.
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 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.
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.5
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Action
Review the case through the Surgical Division’s Morbidity and Mortality process and share the learning.
Stated by Barts Health NHS Trust -
Action
Review all deaths proceeding to Coroner’s inquest at PSERM to ensure Datix capture, multidisciplinary review and an assigned learning response.
Stated by Barts Health NHS Trust -
Action
Expand the Endoscopy Governance Meeting into a bi-monthly joint Surgery and Gastroenterology forum with governance and nursing representation.
Stated by Barts Health NHS Trust
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Action
Embed governance representation within Surgical and Gastroenterology Morbidity and Mortality meetings.
Stated by Barts Health NHS Trust -
Action
Support divisions to improve recording of Morbidity and Mortality discussions, including use of Microsoft Copilot to capture decisions, themes and actions.
Stated by Barts Health NHS Trust
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
CQC will decide whether further action is needed regarding the Trust’s application of PSIRF.
Stated by Department of Health and Social Care
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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.
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
Implement a Managing Clinical Incidents Plan to reinforce policies, strengthen incident reviews, and increase confidence and learning.
Stated by Sussex Medical Chambers
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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Position
Oversight and governance of Integrated Care Boards fall outside the regulatory scope of this respondent.
Stated by Care Quality Commission
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Position
The Integrated Care Board is best placed to address concerns about its oversight, governance and performance.
Stated by Care Quality Commission
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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.
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
Introduce structured forms and meeting documentation to capture concerns, learning, recommendations and actions from morbidity and mortality reviews.
Stated by Royal Berkshire NHS Foundation Trust -
Action
Disseminate clinical governance learning through specialty teams, governance leads, mortality surveillance and Trust committees.
Stated by Royal Berkshire NHS Foundation Trust -
Action
Restructure General Surgery morbidity and mortality reviews to include SJR and PSIRF learning, consultant-led contemporaneous records, escalation of unresolved issues and wider dissemination.
Stated by Royal Berkshire NHS Foundation Trust
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Action
Store clinical governance discussion notes on a shared drive and provide Legal Services access for future court disclosures.
Stated by Royal Berkshire NHS Foundation Trust
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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.
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
Collect, collate and store all child death review forms and associated communications in accordance with data protection requirements.
Stated by Northamptonshire Safeguarding Children Partnership -
Action
Review serious incident and comparable investigation reports to identify service-related modifiable factors and challenge insufficient findings or improvement actions.
Stated by Northamptonshire Safeguarding Children Partnership -
Action
Use a joint decision process to determine when child deaths should be brought to CDOP, informed by completed investigations and inquests.
Stated by Northamptonshire Safeguarding Children Partnership
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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.
Responses linked to these concernsEach 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
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Position
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Stated by Department of Health and Social Care
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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.
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
Share identified learning with Hospital Medical Directors and Directors of Nursing across the Trust’s hospitals.
Stated by University Hospitals Birmingham NHS Foundation Trust
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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.
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
Strengthen Structured Mortality Review training, guidance and reporting templates to capture relevant clinicians’ views on concerns about poor care.
Stated by Oxford University Hospitals NHS Foundation Trust -
Action
Ensure Mortality Review Groups include appropriate subject-matter expertise and convene wider Learning MDT meetings when needed.
Stated by Oxford University Hospitals NHS Foundation Trust
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 Mortality Review Process already includes relevant clinical expertise through trained clinicians, consultant review and subject-matter input where necessary.
Stated by Oxford University Hospitals NHS Foundation Trust
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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.
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
Implement the Patient Safety Incident Response Framework, including reporting, multidisciplinary review and proportionate learning responses for unexpected deaths.
Stated by Barts Health NHS Trust -
Action
Give specialties early sight of inquests to support timely incident reporting, review, learning responses and submission of key documentation.
Stated by Barts Health NHS Trust
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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Position
The case was not classified as a serious incident because reviews concluded that care failures did not cause or alter the outcome.
Stated by Barts Health NHS Trust
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Position
The primarily local concerns are for Barts Health NHS Foundation Trust to address.
Stated by Department of Health and Social Care
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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.
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.
Data last updated 7 September 2026