Significant event log failures
41 items
2 sources
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
Cross-Source Insight
Significant event log failures has been flagged across 2 independent accountability sources:
32 inquiry recs
9 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (32)
IHRD-17 — Recording Changes in Accountability
Recommendation: Any change in clinical accountability should be recorded in the notes.
Gov response: Incorporated into clinical documentation standards.
Accepted
Delivered
IHRD-24 — Blood Test Result Documentation
Recommendation: All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Gov response: Blood test documentation standards updated. Serum sodium recording on fluid balance charts implemented.
Accepted
Delivered
IHRD-29 — Record Keeping Audit
Recommendation: Record keeping should be subject to rigorous, routine and regular audit.
Gov response: Record keeping audit programmes established across Trusts.
Accepted
Delivered
IHRD-31 — SAI Reporting Understanding
Recommendation: Trusts should ensure that all healthcare professionals understand what is expected of them in relation to reporting Serious Adverse Incidents ('SAIs').
Gov response: SAI reporting training provided to healthcare professionals across Trusts.
Accepted
Delivered
IHRD-32 — SAI Reporting as Disciplinary Offence
Recommendation: Failure to report an SAI should be a disciplinary offence.
Gov response: Incorporated into Trust disciplinary policies.
Accepted
Delivered
IHRD-37 — Family Involvement in SAI Investigations
Recommendation: Trusts should seek to maximise the involvement of families in SAI investigations and in particular: (i) Trusts should publish a statement of patient and family rights in relation to all SAI processes including complaints. (ii) Families should be given the …
Gov response: Family involvement protocols established. Guidance issued on meaningful engagement with families throughout investigation processes. Patient Advocacy Service being developed.
Accepted
No update 2+ yrs
IHRD-45 — Post-Mortem Documentation Checklist
Recommendation: Check-list protocols should be developed to specify the documentation to be furnished to the pathologist conducting a hospital post-mortem.
Gov response: Checklist protocols developed for hospital post-mortem documentation.
Accepted
Delivered
IHRD-48 — Mortality Meeting Recording and Audit
Recommendation: The proceedings of mortality meetings should be digitally recorded, the recording securely archived and an annual audit made of proceedings and procedures.
Gov response: Mortality meeting recording and audit procedures implemented.
Accepted
Delivered
IHRD-70 — Board Meeting Minutes Preservation
Recommendation: Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
Gov response: Board and committee meeting minutes preservation procedures strengthened.
Accepted
Delivered
MAI-14 — Improve BTP Major Incident record-making
Recommendation: British Transport Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-152 — Recording equipment for incident commanders
Recommendation: The Home Office, the College of Policing, the National Ambulance Resilience Unit and the Fire Service College should ensure that all those who may be required to take up a command position in the event of a Major Incident are …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-19 — Provide recording equipment to control room personnel
Recommendation: Consideration should also be given by those organisations to the provision of such equipment to key personnel within control rooms.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-33 — Improve GMFRS Major Incident record-making
Recommendation: Greater Manchester Fire and Rescue Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-38 — Improve GMP Major Incident record-making
Recommendation: Greater Manchester Police should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-71 — Improve NWAS Major Incident record-making
Recommendation: North West Ambulance Service should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice.
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
Delivered
MAI-81 — Improve NWFC Major Incident record-making
Recommendation: North West Fire Control should reflect on its approach to record-making during and immediately following a Major Incident, with a view to improving the current practice
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
MAI-84 — Review NWFC incident log information storage
Recommendation: North West Fire Control should review the way it captures and records key information on its incident logs in order to ensure that the information is stored in one place and is readily accessible at all times by those who …
Gov response: The Home Secretary made a written statement to Parliament on 3 November 2022 following publication of Volume 2, acknowledging the findings on emergency response failures and stating the government would work with emergency services to …
Accepted
In progress
CLAR-3 — Remind agencies to keep detailed, accurate records, especially mortuary documentation
Recommendation: We would like to remind all agencies of the importance of keeping detailed and accurate records. Particular attention should be given to the correct documentation of proceedings in the mortuary.
Unknown
F100 — National Patient Safety Agency functions
Recommendation: Individual reports of serious incidents which have not been otherwise reported should be shared with a regulator for investigation, as the receipt of such a report may be evidence that the mandatory system has not been complied with.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F98 — National Patient Safety Agency functions
Recommendation: Reporting to the National Reporting and Learning System of all significant adverse incidents not amounting to serious untoward incidents but involving harm to patients should be mandatory on the part of trusts.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F99 — National Patient Safety Agency functions
Recommendation: The reporting system should be developed to make more information available from this source. Such reports are likely to be more informative than the corporate version where an incident has been properly reported, and invaluable where it has not been.
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
11 — Raise awareness of incident reporting and duty of candour
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should identify and implement a programme to raise awareness of incident reporting, including requirements, benefits and processes. The Trust should also review its policy of openness and honesty in line with …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
12 — Review incident investigation structures
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should review the structures, processes and staff involved in investigating incidents, carrying out root cause analyses, reporting results and disseminating learning from incidents, identifying any residual conflicts of interest and requirements …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
23 — Clear standards for incident reporting in maternity
Recommendation: Clear standards should be drawn up for incident reporting and investigation in maternity services. These should include the mandatory reporting and investigation as serious incidents of maternal deaths, late and intrapartum stillbirths and unexpected neonatal deaths. We believe that there …
Gov response: 23. We accept this recommendation in principle. A new national, Independent Patient Safety Investigation Service will supplement existing practice. 24. The Investigation found that there were a substantial number of missed opportunities to uncover and …
Accepted
25 — Duty to report external investigation findings
Recommendation: We recommend that a duty should be placed on all NHS Boards to report openly the findings of any external investigation into clinical services, governance or other aspects of the operation of the Trust, including prompt notification of relevant external …
Gov response: 43. We accept these recommendations. A new national, Independent Patient Safety Investigation Service will improve local standards of investigation and openness. 44. During the 10-year period in which serious incidents were occurring at Morecambe Bay, …
Accepted
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: Department for Business and Trade rejects this recommendation as it conflicts with the principle of providing "full and fair" redress. Postmasters should retain the choice between continuing with the dispute resolution procedure or transferring to …
Not Accepted
POH-17 — Establish standing public body to administer future redress schemes
Recommendation: As soon as is reasonably practicable, HM Government shall establish a standing public body which shall, when called upon to do so, devise, administer and deliver schemes for providing financial redress to persons who have been wronged by public bodies.
Gov response: Department for Business and Trade acknowledges this recommendation and sees clear advantages in establishing a standing public body for financial redress. However, the government recognises that establishing such an independent redress body requires careful consideration …
Response Unclear
In progress
SHI-4 — Standard form for derogations from guidance
Recommendation: The evidence before the Inquiry from the public sector (including NHSL), and industry, indicated that a standard form of derogation for use throughout the NHS in Scotland would be beneficial. This would ensure that derogations are captured and recorded in …
Gov response: All 11 recommendations accepted by Cabinet Secretary Neil Gray MSP on 13 March 2025.
Accepted
No update 2+ yrs
COVID-M1.4 — UK-wide Civil Emergency Strategy
Recommendation: The UK government and devolved administrations should together introduce a UK-wide whole-system civil emergency strategy (which includes pandemics) to prevent each emergency and also to reduce, control and mitigate its effects. The strategy should: be adaptable; include sections dedicated to …
Gov response: No formal response published by this government.
Accepted in Part
In progress
COVID-M1.6 — Triennial Pandemic Exercises
Recommendation: The UK government and devolved administrations should together hold a UK-wide pandemic response exercise at least every three years. The exercise should: test the UK-wide, cross-government, national and local response to a pandemic at all stages, from the initial outbreak …
Gov response: No formal response published by this government.
Accepted
In progress
PFD Reports (9)
Richard Moss
Concerns: Medical practitioners must manually select an option to alert colleagues about new referral documents, instead of alerts being automatically generated, risking un-actioned referrals.
Responded
Chloe Every
Concerns: The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Responded
Vivien Brunning
Concerns: Critical venous thromboembolism reviews and prescribed daily heparin injections were omitted. Furthermore, a noticed omission was not reported through the Trust's incident system.
Overdue
Eileen Pollard
Concerns: Call bell maintenance records are pre-populated as 'pass', creating a risk that checks are missed or failures aren't recorded, potentially endangering patients if call bells are non-functional.
Overdue
Julie Morrey
Concerns: A severe communication breakdown between hospital departments resulted in a patient being without fluids for over 24 hours, alongside a lack of proactive nursing management and senior clinician review.
Responded
Janet Hall
Concerns: The Emergency Department system, relying on manual transcription of blood results by junior doctors, led to incorrect discharge letters and prevented GPs from effective trend analysis.
Overdue
Matthew Gunn
Concerns: An epileptic event experienced by an employee at work was not officially recorded, raising concerns about incident reporting protocols.
Responded
Thomas Burchell
Concerns: Inadequate and incomplete medical and nursing record-keeping, particularly a poorly maintained seizure chart, failed to accurately document a patient's critical seizure events.
Overdue
Elsie May Treece
Concerns: Hospital staff likely failed to report an incident where a patient fell during transfer, suggesting a need for better training and reminders on the requirement to report all inappropriate incidents.
Response: The Trust has arranged additional incident reporting training for Ward 6 staff and recently linked with a university to raise awareness for student nurses. They clarified that paper-based incident forms …
Responded