First reported 29 May 2014•Latest report 6 Feb 2026
Definition
What this concern includes
Includes failures to identify relevant witnesses and obtain, document or provide their statements or accounts in time for formal coronial, inquest, service, disciplinary, prosecution or comparable safety investigations.
Not included
Excludes general investigation delays or incomplete investigations where no witness-evidence gathering failure is identified.
Excludes disclosure failures occurring after witness statements or accounts have been reliably obtained, unless the assertion also concerns obtaining the witness evidence itself.
Excludes failures to obtain non-witness documentary, digital or physical evidence unless the assertion also concerns the gathering of witness statements or accounts.
Excludes ordinary clinical, care or employment documentation failures that are not part of gathering evidence for a formal investigation or proceeding.
Reports
17
Distinct published reports
Individual concerns
19
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
34
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.
Department of Health and Social Care3
Betsi Cadwaladr University LHB2
Central and North West London NHS Foundation Trust2
Greater Manchester Mental Health NHS Foundation Trust2
Metropolitan Police Service2
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Droylsden Road Family Practice1
East London NHS Foundation Trust1
Hc-One Limited1
Home Office1
Independent Office for Police Conduct1
Leeds Teaching Hospitals NHS Trust1
Ministry of Defence1
NHS trust11
Ministerial department5
Local health board2
Police force2
Coronial office1
English metropolitan district council1
Executive non-departmental public body1
Healthcare site1
National policing body1
Non-ministerial department1
Police oversight body1
Prison or young offender institution1
Private limited company1
Type not available1
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.
Manchester City
Concerns raised1
Failure to obtain crucial witness evidence, learn lessons, and adequately oversee SUI report sign-off
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.
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
Share the Trust review findings with inpatient and CMHT teams through a learning event.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
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 TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Action
Assign a Patient Safety Practitioner to support and advise serious-incident review teams.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 October 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The omission of the Responsible Clinician’s interview would not have changed the Serious Incident investigation’s findings.
Stated by Greater Manchester Mental Health NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Inner North London
Concerns raised1
Delays in interviewing witnesses to progress disciplinary hearings
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
Roll out Vital Conversations training for line managers as a professional requirement, initially prioritising nursing managers.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 December 2018.
Action
Review the disciplinary policy to clarify which matters warrant full investigation and complete the refreshed policy.
Stated by North London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 December 2018.
Action
Require a specially trained lay staff member to review disciplinary cases and provide assurance or challenge whether a formal hearing is required.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 December 2018.
Action
Strengthen formal disciplinary investigations by emphasising managers’ responsibility to minimise delays and monitoring occupational health and Employee Assist referrals.
Stated by North London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 December 2018.
Action
Add the risks of unnecessary and lengthy disciplinary processes to the HR and OD department risk register and monitor progress.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 17 December 2018.
Inner North London
Concerns raised1
Failure to obtain statements from available witnesses
This report raised 18 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.
Sunderland
Concerns raised1
Failure to obtain timely witness statements after falls
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 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
Monitor incident-investigation reporting quality and provide refreshed investigation-management training to Home Managers and Area Team Managers.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 17 June 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Contrary to the report, witness information was obtained during the initial and subsequent internal investigations.
Stated by Hc-One LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Buckinghamshire
Concerns raised1
Delays in identifying relevant witnesses and providing witness statements for coronial investigations
This report raised 15 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.
Derby and Derbyshire
Concerns raised1
Failure to interview key witnesses during investigations
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 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
Existing serious incident processes provide significant assurance that appropriate systems and processes are in place.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
London (North)
Concerns raised1
Failure to obtain prompt comprehensive statements from all police witnesses to fatal shootings
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.
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.8
Action
Issue draft statutory guidance on obtaining best evidence in death or serious injury matters for consultation.
Stated by Independent Office for Police ConductStated completedThe respondent said that this action was complete when they made their response on 29 May 2014.
Action
Review consultation responses and produce a revised statutory guidance document for submission to the Secretary of State.
Stated by Independent Office for Police ConductStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2014.
Action
Review post-incident procedures in light of issues arising from Mark Duggan’s death.
Stated by National Police Chiefs’ CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2014.
Action
Ensure a senior officer is present while officers prepare initial accounts after a death or serious injury incident.
Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 29 May 2014.
Action
Commission an expert review of research underpinning delayed formal accounts after traumatic firearms incidents.
Stated by National Police Chiefs’ CouncilStated completedThe respondent said that this action was complete when they made their response on 29 May 2014.
Action
Revise the APP to restrict staff association representatives’ pre-account intervention to welfare considerations, working with the College of Policing.
Stated by National Police Chiefs’ CouncilStated plannedThe respondent said that this action was planned when they made their response on 29 May 2014.
Action
Require a senior officer to attend the Post Incident Management suite while officers produce statements, ensuring accounts contain sufficient detail.
Stated by Metropolitan Police ServiceStated completedThe respondent said that this action was complete when they made their response on 29 May 2014.
Action
Work with law firms representing firearms officers to clarify expectations for detailed post-incident accounts.
Stated by Metropolitan Police ServiceStated in progressThe respondent said that this action was in progress when they made their response on 29 May 2014.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Further comment on police witness accounts was deferred because statutory guidance had not been finalised and consultation responses were still under review.
Stated by Independent Office for Police ConductUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The existing APP’s flexible, balanced approach is considered sufficient; wholesale separation of officers is not supported as fit for purpose.
Stated by National Police Chiefs’ CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Separating officers may be operationally, logistically and practically impractical, particularly where numerous witnesses and operational imperatives are involved.
Stated by National Police Chiefs’ CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Taking full statements immediately from officers affected by shock, distress or extreme fatigue was considered counterproductive and of limited forensic value.
Stated by Metropolitan Police ServiceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
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Includes failures to identify relevant witnesses and obtain, document or provide their statements or accounts in time for formal coronial, inquest, service, disciplinary, prosecution or comparable safety investigations.
