First reported 10 Feb 2015•Latest report 1 Aug 2025
Definition
What this concern includes
Includes failures of organisational culture and leadership arrangements that suppress, discourage, dismiss or defensively respond to safety concerns, errors or poor practice, including lack of candour, fear of speaking up, failure to listen independently and failure to support accountable safety learning.
Not included
Excludes generic poor management, bullying, harassment or workplace dissatisfaction where no safety-concern, error-reporting, candour or accountable-response dimension is identified.
Excludes failures confined to a specific complaint, incident investigation, clinical pathway or operational process when organisational safety culture is not itself the shared unsafe condition.
Excludes ordinary disagreement or disputed professional judgement without evidence that the organisational culture suppresses or defensively handles safety concerns.
Excludes generic organisational learning or corrective-action failures where the specific unsafe condition is not an open and accountable culture for raising and addressing safety concerns.
Reports
15
Distinct published reports
Individual concerns
17
A report can raise multiple concerns
Date range
2015–2025
First to latest report issue date
Stated actions
31
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.
Care Quality Commission3
Department of Health and Social Care3
NHS England2
Aneurin Bevan University LHB1
Capital Care Group Limited1
Children's Commissioner for Wales1
Cwm Taf Morgannwg University Local Health Board1
Department for Education1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Grange Clinic1
Gwent Police1
Health and Safety Executive1
Health Services Safety Investigations Body1
HM Prison and Probation Service1
Homerton Healthcare NHS Foundation Trust1
NHS trust7
Ministerial department4
Executive non-departmental public body3
Health and social care service regulator3
Integrated care board2
Local health board2
Police force2
Charity regulator1
Company1
Devolved government1
Domiciliary care provider1
Executive agency1
Prison operator1
Private limited company1
Registered charity1
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.
Worcestershire
Concerns raised1
Failure to provide a working environment that enables staff to question unsafe decisions
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
Provide and disseminate whistleblowing and speak-up policies, escalation contacts, open-door access and shift-based opportunities to raise concerns.
Stated by Capital Care Group LimitedStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing policies, escalation routes and speaking-up practices are considered sufficient to equip staff to raise and escalate concerns.
Stated by Capital Care Group LimitedExisting 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 culture of candour
This report raised 19 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
Embed the Duty of Candour process across the Trust, with standardised letters, family contact arrangements and governance monitoring.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Strengthen cultural leadership through visible executive engagement, leadership safety conversations, behavioural performance assessment and quarterly culture reviews.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Implement immediate changes to the Being Open policy following evidence given at the inquest.
Stated by University Hospitals of Morecambe Bay NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2025.
Action
Monitor the Duty of Candour improvement action plan through continued assurance, committee attendance, external challenge and scrutiny.
Stated by NHS Lancashire and South Cumbria Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Bedfordshire and Luton
Concerns raised3
Culture of poor management and institutional defensiveness
Failure to provide officers with a safe ability to speak out about management
Failure of senior management to listen independently to concerns raised
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
Deliver the Culture programme to build staff confidence to raise concerns and improve managers’ and leaders’ responses.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
Action
Maintain a dedicated Trust and Legitimacy leadership structure and a new directorate to drive cultural transformation and improvement.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Deliver mandatory leadership training covering trauma, wellbeing, supportive leadership and referral mechanisms, including programmes for first-line and senior leaders.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
Action
Strengthen Learning and Development leadership through revised senior leadership, supervision and wellbeing oversight arrangements.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Implement the L&D People Strategy with coordinated wellbeing support, recognition, senior leadership engagement and oversight of professional standards and culture.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Operate the Raising Concerns policy with expanded reporting scope, clearer guidance, defined manager responsibilities and support for people raising concerns.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Operate the public-facing complaints and conduct reporting service with Crimestoppers.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Deliver the Upstander programme to improve staff confidence and capability to challenge inappropriate behaviour and help leaders resolve issues.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 27 June 2024.
Action
Create an L&D strategy and performance function informed by colleagues’ input and suggestions.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 27 June 2024.
North Wales (East and Central)
Concerns raised1
Lack of a culture of candour
This report raised 16 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
Develop and approve a Duty of Candour Policy, with its principles implemented immediately.
Stated by The Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
Action
Publish an annual Safety Report covering learning reviews, lessons learned and actions taken.
Stated by The Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
Action
Publish quarterly progress against the delivery plan and provide ongoing annual Safety Report updates.
Stated by The Scout AssociationStated plannedThe respondent said that this action was planned when they made their response on 26 February 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Department cannot comment on the Scout Association’s internal structure, workings, or implementation of internal policies and procedures.
Stated by Department for EducationOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Scout Association and the Charity Commission are expected to address matters concerning internal operations and charity trustees’ legal duties, respectively.
Stated by Department for EducationRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Gwent
Concerns raised1
Failure of officers to speak up about ABD concerns
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
Review national training for all police officers on Acute Behavioural Disturbance.
Stated by Gwent PoliceStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Introduce and publish a new Acute Behavioural Disturbance learning package through the College Learn system for officers and relevant police staff.
Stated by Gwent PoliceStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Incorporate the Acute Behavioural Disturbance package into mandatory Public and Personal Safety Training and First Aid Training.
Stated by Gwent PoliceStated completedThe respondent said that this action was complete when they made their response on 21 February 2024.
Action
Provide bespoke standalone Acute Behavioural Disturbance training to frontline officers who recently completed mandatory safety and first aid training.
Stated by Gwent PoliceStated plannedThe respondent said that this action was planned when they made their response on 21 February 2024.
Nottinghamshire
Concerns raised1
Lack of a culture of candour and staff reflection after deaths in custody
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.
Inner North London
Concerns raised1
Failure to ensure that midwives’ views and differing opinions about precipitous labour are communicated and addressed
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.5
Action
Formulate escalation processes and criteria enabling midwives to raise concerns about birth plans for patients choosing birth outside guidance.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Assign a senior consultant obstetrician to the homebirth midwifery team and its monthly meetings to support case discussion, collaboration and sharing of learning.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Establish monthly meetings between senior nursing leadership and the homebirth midwifery team to provide a forum for discussing staff concerns.
Stated by Homerton Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 July 2023.
Action
Appoint a new Director of Midwifery to lead ongoing meetings with the homebirth midwifery team and Chief Nurse.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
Action
Remind all Trust staff through the daily live communication that they can confidentially access the Freedom to Speak Up Guardian service.
Stated by Homerton Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 July 2023.
South Yorkshire (Western)
Concerns raised1
Lack of a transparent and candid organisational culture
This report raised 20 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
A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.
Stated by Stars Social Support LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure to maintain a culture in which staff can speak up about errors and poor practice
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
Promote and encourage NHS employers to complete Just and Learning Culture training and accredited learning packages.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 19 November 2020.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The Trust’s Duty of Candour policy and reported compliance, rated Good by the CQC, are considered sufficient arrangements for openness and transparency.
Stated by Department of Health and Social CareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Concerns about the wider NHS culture fall outside the Trust’s ability to comment; its response addresses culture within the Trust and Trafford General Hospital.
Stated by Manchester University NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
South Wales Central
Concerns raised1
Reluctance of mid-ranking midwife staff to challenge labour ward coordinator decisions
This report raised 11 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.2
Action
Implement the organisational development plan and continue multidisciplinary work to improve challenge, openness, culture and team working.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
Action
Implement and operate an escalation policy enabling midwives to contact the on-call Obstetric Consultant and Senior Midwife directly.
Stated by Cwm Taf Morgannwg University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2019.
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Includes failures of organisational culture and leadership arrangements that suppress, discourage, dismiss or defensively respond to safety concerns, errors or poor practice, including lack of candour, fear of speaking up, failure to listen independently and failure to support accountable safety learning.
