Significant event log failures
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
38 items
1 source
13 inquiries
Source spread
Where this theme appears
Significant event log failures has been flagged across 1 independent accountability source:
38 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry Recommendations (38)
6 — Encourage drivers to report faults
Recommendation: Drivers should be encouraged to report all actual or suspected faults, whether through formal fault reporting procedures or through CIRAS (paras 14.26, 16.4).
Unknown
45 — Senior officer checks information reaching wing
Recommendation: The senior officer on a wing should ensure that information arriving on the wing about a prisoner is recorded in the wing observation book. Particularly important information should be in red. When coming on duty, staff should read any entries …
Unknown
R12 — Single written channel for serious incident reports
Recommendation: We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved (para 5.14.12)
Words of: Virginia Bottomley, Secretary of State for Health, in a written answer to Richard Spring MP, House of Commons, 2 November 1994
Gov response: Recommendation 12. We recommend that reports of serious untoward incidents to District and Regional Health Authorities should be made in writing and through a single channel which is known to all involved. We will shortly …
Accepted
R11 — Incident report on monitoring alarm failure
Recommendation: We recommend that in the event of failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again (para 5.11.6).
Words of: Virginia Bottomley, Secretary of State for Health, in a written answer to Richard Spring MP, House of Commons, 2 November 1994
Gov response: Recommendation 11. We recommend that in the event of a failure of an alarm on monitoring equipment, an untoward incident report should be completed and the equipment serviced before it is used again. This recommendation …
Response Unclear
R16 — Missed care incident reporting
Recommendation: If a care plan cannot be delivered due to issues, such as staffing shortages, this should be recorded as ‘missed care’ using the Trust’s or organisation’s incident reporting system.
No response yet
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. This recommendation refers to the reporting of patient safety incidents by individuals as opposed to via the ‘standard’ route of uploading incident reports from organisations’ local risk management systems. It is predicated …
Accepted in part
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. Reporting of patient safety incidents involving severe harm and death is already mandatory nationally under the Care Quality Commission regulations and these incidents are actively reviewed by NHS England as well as …
Accepted in part
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 …
Words of: UK Government (Cabinet Office), UK Government Response to the Covid-19 Inquiry Module 1 Report (CP 1240), January 2025
Gov response: The government agrees that regularly programmed exercises should test pandemic preparedness. A ministerial, national level (Tier 1) exercise has been programmed for 2025 to test the response to a major pandemic. In addition, smaller scale …
Accepted
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. As a minimum, the strategy should: be adaptable; include …
Words of: UK Government (Cabinet Office), UK Government Response to the Covid-19 Inquiry Module 1 Report (CP 1240), January 2025
Gov response: The government agrees with the Inquiry’s insights, and they align with our own reflections. The government is therefore implementing a common strategic approach to preparing for and responding to whole-system civil emergencies, which will form …
Accepted in part
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.
Words of: Department for Business and Trade, Government response to the Post Office Horizon IT Inquiry report (volume 1), 9 October 2025
Gov response: DBT sees clear advantages of the recommendation but recognises that options to improve future delivery of redress will need to be carefully considered and the feasibility of an independent body will need to be properly …
Noted
In progress
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 …
Words of: Department for Business and Trade, Government response to the Post Office Horizon IT Inquiry report (volume 1), 9 October 2025
Gov response: DBT rejects this recommendation as we believe it comes into conflict with the principle of “full and fair” redress set out as we accepted Recommendation 2. DBT’s view is that it would not be fair …
Not accepted
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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 …
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
In progress
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.
Speaker not recorded. Source: Cabinet Office, Manchester Arena Inquiry Recommendations Dashboard (government response status), 14 November 2025
Gov response: Accepted in full
Accepted
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.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted in principle. All serious incidents involving severe harm and death reported by individuals to via the on-line e-form, or any route, are routinely shared with the Care Quality Commission on a weekly basis. The …
Accepted in part
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Unknown
17 — Keep accurate contemporaneous records
Recommendation: We remind shipowners and operators of the importance of the keeping of accurate contemporaneous records and of the importance of ensuring that their standing orders include instructions to that effect and that such instructions should be monitored closely.
Unknown
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').
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-17 — Recording Changes in Accountability
Recommendation: Any change in clinical accountability should be recorded in the notes.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F114 — Complaints handling
Recommendation: Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. A fundamental principle of the current complaints arrangements for handling NHS and adult social care complaints is that a case should be handled according to the needs of that individual case. Investigation should be …
Accepted
F42 — Use of information about compliance by regulator from: Serious untoward incidents
Recommendation: Strategic Health Authorities/their successors should, as a matter of routine, share information on serious untoward incidents with the Care Quality Commission.
Speaker not recorded. Source: Department of Health, Hard Truths: the Journey to Putting Patients First, volume 2 (Cm 8777-II), November 2013
Gov response: Accepted. Information on serious untoward incidents is shared routinely with the Care Quality Commission, and Quality Surveillance Groups have been established to support the sharing of information and intelligence more generally at a local level. …
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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
In progress
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 in part
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
IHRD-70 — Board Meeting Minutes Preservation
Recommendation: Effective measures should be taken to ensure that minutes of board and committee meetings are preserved.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
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 …
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IHRD-32 — SAI Reporting as Disciplinary Offence
Recommendation: Failure to report an SAI should be a disciplinary offence.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
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 …
Words of: Department of Health, Learning not blaming (Cm 9113), government response to the Morecambe Bay Investigation and two other reports, July 2015
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 …
Unknown
IHRD-29 — Record Keeping Audit
Recommendation: Record keeping should be subject to rigorous, routine and regular audit.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
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.
Words of: Mr Swann, Minister of Health, written ministerial statement to the Northern Ireland Assembly, 25 March 2021
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
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 …
Words of: Neil Gray, Cabinet Secretary for Health and Social Care, in a letter to Clare Haughey MSP, Convener of the Health, Social Care and Sport Committee, 17 September 2025
Gov response: On 13 March 2025, I made a statement in parliament, addressing the Interim Report and its recommendations. I accepted all recommendations and committed to provide a future update on progress around the implementation of those …
Accepted
No update 2+ yrs