Recurring concern
Failure of organisational governance to act on escalated patient-safety concerns
- Reports that mention this concern
- 7
- Times this concern has been raised
- 7
- Stated actions linked to this concern
- 6
What this concern includes
Includes governance or senior-management failures to own, investigate, escalate, monitor or act on known patient-safety signals.
What is 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.
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 7 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
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.1
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Essex Partnership University NHS Foundation Trust
Further develop PSIIR support and quality-check tools, including detailed investigation checklists, care-team confirmation and organisational sign-off checks.
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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Essex Partnership University NHS Foundation Trust
The concern is factually incorrect because the 2022 inquest concerned a Derwent Centre patient, not a St Aubyn’s Centre patient.
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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.
Linked response
- 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.1
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East London NHS Foundation Trust
No further action is considered necessary because considerable work has addressed the identified concerns.
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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.
Linked responses
- Department of Health and Social Care
- NHS Lancashire and South Cumbria Integrated Care Board
- University Hospitals of Morecambe Bay 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
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University Hospitals of Morecambe Bay NHS Foundation Trust
Operate twice-weekly Executive Review Group oversight of validated moderate-or-above harm incidents, complaints and organisational concerns.
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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University Hospitals of Morecambe Bay NHS Foundation Trust
No further investigation was considered beneficial because significant time had elapsed, relevant disclosures were made, and key senior leaders had left.
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NHS Lancashire and South Cumbria Integrated Care Board
The Trust is best placed to respond to concerns about individual staff members.
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Department of Health and Social Care
University Hospitals Morecambe Bay NHS Foundation Trust and Lancashire and South Cumbria ICB will address specific changes arising from the report.
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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.
Linked responses
- Department of Health and Social Care
- North East London 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
-
North East London NHS Foundation Trust
Review the Safe and Supportive Observations Policy to clarify escalation when staffing or other constraints challenge observation provision.
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North East London NHS Foundation Trust
Share the clarified observation-escalation process through leadership meetings, team meetings and individual supervision.
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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North East London NHS Foundation Trust
The Safe and Supportive Observations Policy already prohibits suspending observations; the response limits further work to clarifying escalation.
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Department of Health and Social Care
Concerns about care provision and coordination are mainly for the NHS Trust to address.
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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.
Linked response
- East London 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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East London NHS Foundation Trust
Provide monthly supervisory listening to sampled Crisis Line calls to assess care quality.
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East London NHS Foundation Trust
Conduct a larger Trust-wide Crisis Line call-quality audit from January 2022.
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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.
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.
Linked response
- Doncaster and Bassetlaw Teaching Hospitals 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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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Existing enhanced supervision systems, staffing assessments and resource-allocation procedures are considered sufficient to manage staffing after escalation.
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Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
Short-notice additional staffing responses remain limited by finite resources, temporary-staff fill rates, sickness and absence.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026