Recurring concern
Failure of organisational governance to act on escalated patient-safety concerns
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Request correctionFirst reported 14 Jun 2018•Latest report 8 Feb 2026
What this concern includes
Includes governance or senior-management failures to own, investigate, escalate, monitor or act on known patient-safety signals.
Not included
- Excludes un-escalated clinical deterioration, treatment, staffing, equipment or documentation failures unless the report explicitly identifies a clinical-governance failure to respond to the concern.
- Excludes ordinary complaints or communications that are not framed as patient-safety concerns within a clinical governance or safety-oversight process.
- Excludes failures confined to the delivery of a specific clinical intervention where no governance or oversight response is implicated.
- Excludes concerns about the general quality of care or a service where no escalated safety concern and governance response are identified.
- Reports
- 7
- Individual concerns
- 7
- Date range
- 2018–2026
- Stated actions
- 6
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 further investigate or monitor falsified observation records
This report raised 30 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
Further develop PSIIR support and quality-check tools, including detailed investigation checklists, care-team confirmation and organisational sign-off checks.
Stated by Essex Partnership University 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 concern is factually incorrect because the 2022 inquest concerned a Derwent Centre patient, not a St Aubyn’s Centre patient.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure of clinical governance to respond to escalated serious patient-safety concerns
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.
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
No further action is considered necessary because considerable work has addressed the identified concerns.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to investigate senior staff roles in disputed safety-report decisions
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 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
Operate twice-weekly Executive Review Group oversight of validated moderate-or-above harm incidents, complaints and organisational concerns.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
No further investigation was considered beneficial because significant time had elapsed, relevant disclosures were made, and key senior leaders had left.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust
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Position
The Trust is best placed to respond to concerns about individual staff members.
Stated by NHS Lancashire and South Cumbria Integrated Care Board -
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 Care
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Concerns raised1
Failure to escalate suspension of patient observations through governance processes
This report raised 14 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
Review the Safe and Supportive Observations Policy to clarify escalation when staffing or other constraints challenge observation provision.
Stated by North East London NHS Foundation Trust -
Action
Share the clarified observation-escalation process through leadership meetings, team meetings and individual supervision.
Stated by North East London NHS Foundation 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 Safe and Supportive Observations Policy already prohibits suspending observations; the response limits further work to clarifying escalation.
Stated by North East London NHS Foundation Trust
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Position
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to assure appropriate action following serious crisis-line failings
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
Provide monthly supervisory listening to sampled Crisis Line calls to assess care quality.
Stated by East London NHS Foundation Trust -
Action
Conduct a larger Trust-wide Crisis Line call-quality audit from January 2022.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to produce effective action following Serious Incident 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.
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 act on escalated concerns about insufficient supervision resources
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.
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
Existing enhanced supervision systems, staffing assessments and resource-allocation procedures are considered sufficient to manage staffing after escalation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Position
Short-notice additional staffing responses remain limited by finite resources, temporary-staff fill rates, sickness and absence.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Data last updated 7 September 2026