Recurring concern
Unreliable safety investigation reports and disclosure
- Reports that mention this concern
- 20
- Times this concern has been raised
- 23
- Stated actions linked to this concern
- 27
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.
What is 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.
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 20 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
The Trust
Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
-
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.
Linked responses
- Civil Aviation Authority
- Department for Transport
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
-
Civil Aviation Authority
Aircraft accident and serious-incident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.
-
Civil Aviation Authority
The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.
-
Department for Transport
ICAO’s amended arrangements and public-information encouragement provide adequate assurance without further rights to take over investigations.
-
Civil Aviation Authority
Aircraft accident investigation is outside the CAA’s responsibility and falls to the Air Accidents Investigation Branch.
-
Civil Aviation Authority
The Department for Transport will respond separately to report aspects concerning aircraft accident investigation.
-
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.
Linked response
- Betsi Cadwaladr University LHB
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
-
Betsi Cadwaladr University LHB
Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to share and discuss investigation findings and recommendations with relevant prison and healthcare staff
Linked response
- HM Prison and Probation Service
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
-
HM Prison and Probation Service
Identify relevant staff and share, discuss, and explain investigation findings, learning, and reports with them.
-
HM Prison and Probation Service
Consider investigation recommendations nationally and produce and share learning bulletins across the wider prison estate.
-
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.
Linked response
- County Durham and Darlington 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
-
County Durham and Darlington NHS Foundation Trust
Track patient safety investigations at the weekly Senior Clinical Leaders patient safety forum.
-
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.
Linked response
- Essex Partnership University 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
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Essex Partnership University NHS Foundation Trust
Refine patient-safety incident processes and reporting templates.
-
Essex Partnership University NHS Foundation Trust
Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
-
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.
Linked response
- Betsi Cadwaladr University LHB
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
-
Betsi Cadwaladr University LHB
Introduce a report template identifying the final approved investigation version and distinguishing it from drafts.
-
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.
Linked response
- Betsi Cadwaladr University LHB
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
-
Betsi Cadwaladr University LHB
Revise and co-design a new incident investigation and action-planning process, including governance review, staff training and planned implementation.
-
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.
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