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 raised2
Inaccuracies in patient safety incident investigation reports
Delays in completing and providing patient safety incident investigation reports
This report raised 17 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
Factual errors and misinterpretations in SUI investigation reports
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 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
Update the serious-incident information-gathering process to obtain staff statements early and use them in investigations.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Assign a Patient Safety Practitioner to support and advise serious-incident review teams.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Inaccurate and misinterpreted serious untoward incident investigation reports
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 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
Update serious-incident information-gathering procedures to obtain staff statements early and use them in investigations.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Assign a Patient Safety Practitioner to support and advise serious-incident investigation teams.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Share final serious-incident investigation drafts with senior managers and clinical leads for factual checking and approval.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Action
Require post-incident executive review and approval of serious-incident reports before release to families and other stakeholders.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised1
Failure to complete investigation reports within 72 hours of death
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.6
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Action
Review the Trust-wide 72-hour reporting process and analyse report timeliness to identify improvements.
Stated by North London NHS Foundation Trust -
Action
Improve the 72-hour report submission process using quality-improvement methods, with progress monitored through existing executive and quality-safety governance arrangements.
Stated by North London NHS Foundation Trust -
Action
Develop 72-hour reporting process maps for users to improve compliance and reporting quality.
Stated by North London NHS Foundation Trust
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Action
Implement 72-hour reporting through the Datix patient-safety incident reporting system.
Stated by North London NHS Foundation Trust -
Action
Prepare and deliver training for divisional staff on the Datix 72-hour reporting process.
Stated by North London NHS Foundation Trust -
Action
Evaluate the new 72-hour reporting process and the effectiveness of its training, reporting progress to the Quality and Safety Programme Board.
Stated by North London NHS Foundation Trust
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Concerns raised1
Failure to provide the Chief Electrical Officer’s investigation report
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.
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Concerns raised1
Failure to record and identify the authorship of investigation findings
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
Adopt round-table serious-incident investigations to obtain relevant expertise and name the expert in the report.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to ensure Significant Clinical Incident Investigation reports are based on documentary records rather than conflicting assumptions
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
Complete a BMI Root Cause Analysis of the incident and provide the finalised report.
Stated by South Buckinghamshire Hospitals
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
Investigation reports remain in draft format until the Inquest concludes, preventing finalisation while further issues may be identified.
Stated by South Buckinghamshire Hospitals
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Concerns raised1
Inaccuracies in internal investigation reports
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.2
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Action
Rewrite and implement the serious incident investigation policy with guidance on reporting, investigation, best practice, system failures and record-keeping standards.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Introduce an Executive-led Serious Incident Review Panel to scrutinise investigation reports and action plans and require clinical leads to report changes and learning.
Stated by Tameside and Glossop Integrated Care 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
Existing serious incident processes provide significant assurance that appropriate systems and processes are in place.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure of SUI reports to disclose the lack of support for forceps use to disimpact the fetal head
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Failure to communicate known investigation-report shortcomings in a timely manner
Failure to produce accurate and reliable investigation reports
Failure to revisit and correct recognized errors in investigation reports
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.3
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Action
Establish named RCA Chairs to oversee investigation scope, team composition, SMART action plans and report sign-off.
Stated by University Hospitals of Leicester NHS Trust -
Action
Purchase and provide tiered external RCA training for investigation leads, senior safety investigators and RCA Chairs.
Stated by University Hospitals of Leicester NHS Trust -
Action
Provide senior scrutiny of events causing avoidable death or harm and identify root causes, themes and required safety workstreams.
Stated by University Hospitals of Leicester 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
Reopening investigation reports is limited to commissioner feedback supported by compelling evidence, rather than a general reopening system.
Stated by University Hospitals of Leicester NHS Trust
Data last updated 7 September 2026