Recurring concern
Unreliable completion and receipt of incident review reports
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Request correctionFirst reported 2 Jul 2014•Latest report 30 Jan 2025
What this concern includes
Includes failures in the dedicated incident review-report process involving preparation, completion, responsible sign-off, transmission, receipt or tracking of reports needed for safety review and corrective action.
Not included
- Excludes failures in the underlying incident investigation or the quality of its analysis where completion or receipt of the report is not deficient.
- Excludes generic patient-safety incident reporting, post-incident learning or action implementation failures unless the assertion specifically concerns completion or receipt of an incident review report.
- Excludes ordinary clinical or operational records and reports that are not incident review reports or their directly equivalent safety-review reports.
- Excludes delays caused solely by external legal, coronial or regulatory proceedings when the incident review-report process itself is not deficient.
- Reports
- 13
- Individual concerns
- 13
- Date range
- 2014–2025
- Stated actions
- 14
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
Delays in receipt of provider-led report requests resulting in investigations without all relevant issues known
This report raised 6 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
Launch a Prevention and Intervention Service with a dedicated Safeguarding Hub to manage safeguarding referrals, initial information gathering and immediate safety actions.
Stated by London Borough of Bromley -
Action
Review the contents of the Provider Lead Enquiry form.
Stated by London Borough of Bromley
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
Delays in sharing Provider Lead Enquiry forms are not a wider concern and the incident appears isolated.
Stated by London Borough of Bromley
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Concerns raised1
Automated Datix review and approval failing to ensure human identification of patient-safety incidents
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.1
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Position
Incidents are not automatically approved: every incident receives individual review before closure, although low-harm records are automatically stamped after managerial review.
Stated by University Hospitals Birmingham NHS Foundation Trust
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Concerns raised1
Delays and premature sign-off in Trust investigations
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.2
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Action
Refine patient-safety incident processes and reporting templates.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Update the PSIRF policy to set learning-response timescales, sign-off requirements, safety-action-plan management and organisation-wide learning dissemination.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Delays in completing and sharing investigations into deaths
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.3
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Action
Review the incident process to improve incident handling and learning.
Stated by Betsi Cadwaladr University LHB -
Action
Implement rapid learning panels and incident learning panels.
Stated by Betsi Cadwaladr University LHB -
Action
Prioritise overdue investigations and action plans, meeting weekly to resolve remaining work and monitor actions through completion.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Delays in responsible sign-off of S.I. 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.
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
Serious incident report completion and closure are jointly owned by the Trust and ICS, with final sign-off assigned to the ICB.
Stated by Wye Valley NHS Trust
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Concerns raised1
Delays in completing and providing patient safety incident investigation reports
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.
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 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 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
-
Action
Share the Trust review findings with inpatient and CMHT teams through a learning event.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
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
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 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 Trust
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Concerns raised1
Failure to complete a serious incident report on CWB working practices
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.
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
Make internal reviews following future student suicides standard procedure.
Stated by University of Surrey
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 University was not required to produce a serious incident report because it is not a regulated healthcare service provider.
Stated by University of Surrey
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Concerns raised1
Delays in completing adverse-death review reports
This report raised 16 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
Develop a funded cohort of investigators and family liaison officers with allocated time, training and administrative support.
Stated by East Lancashire Hospitals NHS Trust -
Action
Introduce weekly Executive review of divisional investigations before SIRI Panel submission.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised1
Delays in receiving incident review 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.1
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Action
Clear the backlog of serious incident reports under oversight from the Medical Director and Director of Nursing.
Stated by United Lincolnshire Teaching Hospitals NHS Trust
Data last updated 7 September 2026