Recurring concern
Failure to ensure clinical governance staff are competent for safety oversight
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Request correctionFirst reported 21 Oct 2019•Latest report 29 Sep 2025
What this concern includes
Includes failures to provide, maintain or verify the knowledge and competence of staff responsible for clinical governance, patient-safety oversight or related governance decisions, including training gaps and failure to understand or apply guidance on safety investigations and governance controls.
Not included
- Excludes competence deficiencies in frontline clinical care, clinical procedures or general staff training where the person is not responsible for clinical governance or patient-safety oversight.
- Excludes deficiencies in the substantive design or operation of a named incident-management, audit or investigation system when staff competence is not the shared unsafe condition.
- Excludes generic organisational governance, leadership or culture concerns where no failure to ensure the competence of clinical governance personnel is identified.
- Reports
- 3
- Individual concerns
- 4
- Date range
- 2019–2025
- Stated actions
- 5
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
Lack of senior governance staff understanding of guidance on patient safety investigation triggers
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
Commission an independent review of governance and PSIRM decision-making for PSIRF learning responses, including PSII criteria and thresholds.
Stated by Barts Health NHS Trust
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Concerns raised2
Insufficiently skilled and trained clinical governance personnel
Untrained clinical governance staff
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 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
Implement a Trust-wide clinical governance reform covering document control, mandatory governance training, oversight restructuring, outcome-focused learning and family-centred care.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust -
Action
Provide training and development where compliance concerns identify gaps in skills, knowledge or behaviours.
Stated by University Hospitals of Morecambe Bay NHS Foundation Trust -
Action
Monitor the impact of clinical-governance recruitment and attend Trust committees to scrutinise and challenge governance practices.
Stated by NHS Lancashire and South Cumbria Integrated Care Board
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
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 of investigation staff to correctly understand and apply the observation policy
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
Develop standard serious-incident-investigation terms of reference requiring assessment against evidence-based practice, NICE guidance, policies and procedures.
Stated by North West Boroughs Healthcare NHS Foundation Trust
Data last updated 7 September 2026