Recurring concern
Unreliable gathering of witness evidence for formal investigations
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Request correctionFirst reported 29 May 2014•Latest report 6 Feb 2026
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
- Individual concerns
- 19
- Date range
- 2014–2026
- Stated actions
- 34
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
Patient safety investigations failing to seek treating staff recollections
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.
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
Investigations may not obtain every clinician account or provide feedback when staff absence conflicts with timely completion.
Stated by The Trust
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Concerns raised3
Failure to obtain an account from a key hospital-attending colleague
Delays and obstructions in gathering evidence from key witnesses
Delays in providing key witness statements to the Service Inquiry panel
This report raised 5 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
Subject all suspected RAF suicides to immediate fact-finding investigations led by Station Commanders to gather relevant evidence promptly.
Stated by Ministry of Defence -
Action
Incorporate immediate fact-finding investigations for suspected RAF suicides into the RAF Postvention Suicide Response policy.
Stated by Ministry of Defence -
Action
Issue further direction and guidance to avoid delays in providing statements to Service Inquiry panels.
Stated by Ministry of Defence
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Concerns raised1
Failure to identify and preserve the accounts of staff directly involved in errors
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
Embed the Patient Safety Incident Response Framework within Trust processes.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to conduct sufficiently thorough neonatal investigations
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.5
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Action
Implement the Integrated Concerns Policy as a single approach to incident, complaint and mortality reviews and investigations.
Stated by Betsi Cadwaladr University LHB -
Action
Implement a programme for investigating officers.
Stated by Betsi Cadwaladr University LHB -
Action
Direct that investigations across women’s and neonatal services use a single investigation officer.
Stated by Betsi Cadwaladr University LHB
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Action
Direct women’s-services investigations to use the Integrated Concerns Policy framework and templates.
Stated by Betsi Cadwaladr University LHB -
Action
Appoint a quality governance officer to neonatal services to provide specialist investigation and review capacity.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure of internal investigations to verify relevant witness information and clinical address records
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 Meet and Greet workers in community mental health team receptions to verify demographic, contact and accommodation information.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Remind clinical staff to record address and contact-number changes on the service-user demographic record in Rio.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to involve responsible staff in investigations of care failings
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.
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
Introduce the new investigation template directing investigators to involve care staff and escalate concerns about care and treatment to managers.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure of Serious Incident Investigations to investigate missing records and interview relevant witnesses
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.3
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Action
Accredit the serious incident review process through SIRAN, revising policies, templates and review arrangements to meet best practice.
Stated by Central and North West London NHS Foundation Trust -
Action
Provide RCA methodology training to staff and establish a forum supporting serious-incident reviewers and investigators.
Stated by Central and North West London NHS Foundation Trust -
Action
Create a dedicated serious incident review post in the incident division.
Stated by Central and North West London NHS Foundation Trust
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Concerns raised1
Failure to obtain timely and adequate evidence during serious incident investigations
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
Provide the Emergency Department senior nursing team with a memory-capture tool to promote prompt, consistent incident recording and formalise evidence gathering.
Stated by Leeds Teaching Hospitals NHS 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 Trust disputes that CPR was delayed for 15 minutes, stating that it began within 30 to 60 seconds of the patient being found.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Failure to obtain timely written accounts and interviews from key staff in serious incident investigations
This report raised 5 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
Use a memory-capture document in DATIX alongside immediate interviews and written statements, and reinforce its use across teams.
Stated by 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.1
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Position
HSIB could not support the requested investigation because its northern branch had not yet been established and operations were limited to southern England.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure of SUI investigation to obtain evidence from an important witness
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.
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 Trust considers interviewing the Responsible Clinician would not have changed the internal review’s findings.
Stated by Greater Manchester Mental Health NHS Foundation Trust
Data last updated 7 September 2026