Recurring concern
Unreliable root cause analysis processes
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Request correctionFirst reported 3 Dec 2013•Latest report 14 May 2024
What this concern includes
Includes failures of the dedicated root cause analysis process, including initiation, investigator competence and training, evidence and stakeholder input, critical analysis, identification of lessons, action planning, completion and confirmation of resulting actions.
Not included
- Excludes generic incident investigation or organisational-learning failures where root cause analysis is not the specifically identified process.
- Excludes failures in implementing safety actions where no root cause analysis or root cause analysis action plan is involved.
- Excludes generic clinician training deficiencies unrelated to undertaking root cause analysis.
- Excludes deficiencies in the underlying clinical or operational process investigated when the root cause analysis process itself is not unsafe.
- Reports
- 26
- Individual concerns
- 27
- Date range
- 2013–2024
- Stated actions
- 56
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
Failure to conduct a sufficient and comprehensive root cause analysis
This report raised 8 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 and use a pressure-ulcer After Action Review template under the Patient Safety Incident Response Framework.
Stated by East Sussex Healthcare 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 RCA was specifically scoped to pressure ulcers, so it did not address other care concerns that were not identified during admission.
Stated by East Sussex Healthcare NHS Trust
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Concerns raised1
Failure to specify and disseminate learning from the DOAC pausing incident
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.5
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Action
Review the Report and consider whether learning should be shared across Midlands integrated care boards.
Stated by NHS England -
Action
Discuss received Prevention of Future Deaths reports through the Regulation 28 Working Group and share their learning nationally and regionally.
Stated by NHS England -
Action
Share the report with Agilio Software for awareness.
Stated by National Institute for Health and Care Excellence
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Action
Present the incident and related learning at the cardiology Grand Round.
Stated by The Trust -
Action
Prioritise Grand Round slots for cases whose formal investigations recommend presentation.
Stated by The 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
Operational responsibility for delivering health services and responding to related concerns lies with NHS England.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to complete BCH Root Cause Analysis recommendations within their target timeframes
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
Continue working with community services to embed action-plan changes and monitor their impact.
Stated by Black Country Healthcare NHS Foundation Trust
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Concerns raised2
Failure to provide critical primary evidence for root cause analysis
Safeguarding investigations undermined by misleading root cause analysis
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.2
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Action
Implement an amended safeguarding policy covering section 42 enquiries, inter-organisational information sharing, Datix evidence uploads, and Executive Assurance Group review of recommendations.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Continue strengthening safeguarding governance and information sharing with external stakeholders, including consideration of all documentation in internal investigations.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Failure of formal investigation learning to address the breadth of identified patient safety issues
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.7
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Action
Review and update the incident reporting and incident and complaints investigation policy in alignment with the NHS England Patient Safety Framework.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Disseminate organisational learning on investigation methodology and responding to people who raise concerns.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Operate bimonthly oversight meetings to triangulate inquests with related investigatory processes and identify status changes or delays.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Action
Develop a cohesive clinical review process for incident investigations, inquest statements and learning-from-deaths reviews before inquests.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Implement the Ulysses Safeguard improvement project to standardise use and increase reporting functionality.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Implement strengthened inquest triage with seven-day clinical review, investigation review, communication and delay monitoring.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Add a full-time clinical staff member to support the strengthened inquest triage and review process.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Insufficient rigour in root cause analyses
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 pharmacy input mandatory in root-cause analyses whenever medication issues are identified, ensuring objective and expert review.
Stated by Northern Care Alliance NHS Foundation Trust
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Concerns raised1
Lack of compulsory root cause analysis training for clinicians
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.4
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Action
Continue providing root cause analysis training for clinicians across the organisation.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Record all staff who complete root cause analysis training in a staff database and select future investigating officers from that list.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Work with HSIB to test and introduce national patient safety incident investigation training.
Stated by NHS England
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Action
Develop a procurement framework enabling providers and commissioners to access quality-assured patient safety incident investigation training.
Stated by NHS England
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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Position
NHS England and Improvement is responsible for responding to concerns about Hospital Trust evaluation, nursing practice, and root-cause-analysis training.
Stated by Medicines and Healthcare products Regulatory Agency
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Position
Existing NHS investigation requirements already require systems-based investigations conducted by appropriately trained investigators, addressing the concern about compulsory root-cause-analysis training.
Stated by NHS England
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Concerns raised1
Lack of compulsory root cause analysis training for clinicians
This report raised 7 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
Continue providing root cause analysis training for clinicians across the organisation.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Record all staff who complete root cause analysis training in a staff database and select future investigating officers from that list.
Stated by University Hospitals of North Midlands NHS Trust -
Action
Pilot the Patient Safety Incident Response Framework to improve systems-based patient safety incident investigations.
Stated by NHS England
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Action
Work with the Healthcare Safety Investigation Branch to test and introduce national patient safety incident investigation training.
Stated by NHS England -
Action
Develop a procurement framework enabling healthcare providers and commissioners to access quality-assured patient safety incident investigation training.
Stated by NHS England
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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Position
Concerns about hospital tube evaluation, clinical response, and root-cause-analysis training are addressed by a separate NHS England and Improvement response.
Stated by Medicines and Healthcare products Regulatory Agency
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Position
Existing NHS investigation frameworks require systems-based investigations by appropriately trained investigators, addressing the concern about root cause analysis training.
Stated by NHS England
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Concerns raised1
Deficient root cause analysis failing to identify and address oxygen-supply monitoring issues
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.
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 of Root Cause Analysis to recognise and investigate care problems
This report raised 8 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
Commission and complete a review of the Trust’s process for managing and investigating serious incidents.
Stated by Oxleas NHS Foundation Trust -
Action
Establish a central Serious Incidents Team to oversee investigations, monitor incidents, ensure follow-up and share learning across the Trust.
Stated by Oxleas NHS Foundation Trust -
Action
Update the Incident Management Policy and Procedures to require investigating panels to consider care, family involvement, safety, equality and other incident issues.
Stated by Oxleas 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
No further investigation is required because the Trust’s revised Root Cause Analysis process is considered thorough and comprehensive.
Stated by Oxleas NHS Foundation Trust
Data last updated 7 September 2026