Recurring concern
Unreliable safety investigation reports and disclosure
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Request correctionFirst reported 18 Sep 2014•Latest report 6 Feb 2026
What this concern includes
Includes failures in formal safety-investigation report provision, disclosure, authorship, version control, correction or transparency where the report itself or its availability is unreliable, including failure to provide a completed report to families or coroners and failure to disclose or clearly attribute investigation findings.
Not included
- Excludes the underlying conduct of the investigation, including evidence gathering or causal analysis, where the report is itself available and the concern is only that the investigation was inadequate.
- Excludes failures to implement corrective actions or organisational learning after a complete and reliable investigation report has been produced.
- Excludes general inquest disclosure, duty-of-candour or court-evidence failures unless they specifically concern the availability, completeness, attribution or transparency of a formal safety investigation report.
- Excludes ordinary clinical-record or administrative-document deficiencies unrelated to a formal safety investigation report.
- Reports
- 20
- Individual concerns
- 23
- Date range
- 2014–2026
- Stated actions
- 27
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 communicate patient safety investigation findings to treating staff
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.
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
Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
Stated by The Trust
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Concerns raised1
Failure to produce timely final reports and interim statements on investigation progress and safety issues
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
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Position
Aircraft accident and serious-incident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.
Stated by Civil Aviation Authority
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Position
The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.
Stated by Civil Aviation Authority -
Position
ICAO’s amended arrangements and public-information encouragement provide adequate assurance without further rights to take over investigations.
Stated by Department for Transport -
Position
Aircraft accident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.
Stated by Civil Aviation Authority -
Position
The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.
Stated by Civil Aviation Authority
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Concerns raised1
Insufficient contextual sharing of investigation findings
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 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 the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Absence of a formal internal post-death investigation report
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.
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 to share and discuss investigation findings and recommendations with relevant prison and healthcare staff
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
Identify relevant staff and share, discuss, and explain investigation findings, learning, and reports with them.
Stated by HM Prison and Probation Service -
Action
Consider investigation recommendations nationally and produce and share learning bulletins across the wider prison estate.
Stated by HM Prison and Probation Service
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Concerns raised1
Delays in completing and providing patient safety investigation reports
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.1
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Action
Track patient safety investigations at the weekly Senior Clinical Leaders patient safety forum.
Stated by County Durham and Darlington NHS Foundation Trust
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Concerns raised1
Delays and premature sign-off in Trust investigations
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.2
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Action
Refine patient-safety incident processes and reporting templates.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to maintain consistent investigation report content
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 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
Introduce a report template identifying the final approved investigation version and distinguishing it from drafts.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Investigation reports containing conflicting evidence
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.
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
Revise and co-design a new incident investigation and action-planning process, including governance review, staff training and planned implementation.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to disclose a critical commissioned expert report to relevant oversight bodies
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026