Significant event log failures
Failure to adequately record, review, and log significant events at clinical meetings, hindering learning and improvement.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
74match
R11 - Incident report on monitoring alarm failure
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).
Matched on
terms: event, failure
Inquiry recommendation
70match
MAI-84 - Review NWFC incident log information storage
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 need it.
Matched on
terms: log
CQC action
69match
Liverpool Walk in Centre
Review the significant event reporting system to ensure staff receive feedback when an incident has been reported.
Matched on
terms: event, significant
Scottish FAI
69match
N
a. There should be greater communication and co-operation between NHST and NHS Grampian (“NHSG”) in relation to the care of patients who are resident in the geographical area of one authority and subject to treatment in a facility run by the other. b. NHSG should make greater efforts to co-operate in Significant Clinical Event Analysis (“SCEA”) inquiries in...
Matched on
terms: event, significant
CQC action
67match
The Peter Gidney Neurodisability Centre
The home was not notifying CQC or the funding authorities of significant events.
Matched on
terms: event, significant
CQC action
67match
Ashbourne House - Torquay
The provider had failed to notify the Commission without delay of all significant events in line with their legal obligations.
Matched on
terms: event, significant
Inquiry recommendation
65match
COVID-M1.4 - UK-wide Civil Emergency Strategy
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 sections dedicated to each potential whole-system civil emergency – for example, one on pandemics with a clear explanation...
Matched on
terms: event, log
CQC action
65match
Moorcroft Medical Centre
Evaluate the changes made to the significant event root cause analysis tool.
Matched on
terms: event, significant
PFD report
61match
Thomas Burchell
The coroner noted inadequate and incomplete medical and nursing record keeping, specifically regarding seizure charts. The report also highlights a need for more robust recording of events when patients develop seizures.
Matched on
terms: event
PFD report
61match
Matthew Gunn
An observed or reported epileptic event involving a Morrison's employee at work was not recorded by the employer.
Matched on
terms: event
PFD report
61match
Eileen Pollard
The document used for daily call bell checks is pre-populated with 'P' for pass, which risks rooms being missed or failures not being accurately recorded, potentially affecting patient safety.
Matched on
terms: failure
Inquiry recommendation
57match
F98 - National Patient Safety Agency functions
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.
Matched on
terms: significant
Inquiry recommendation
57match
MAI-152 - Recording equipment for incident commanders
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 issued with a means to record what they say, hear and see unless there are good reasons why...
Matched on
terms: event
CQC action
57match
West Cumberland Hospital
The trust must ensure that systems and processes are in place to accurately review and categorise patient safety incidents logged by frontline staff.Regulation17(2)(a)(b).
Matched on
terms: log
CQC action
57match
Cumberland Infirmary
The trust must ensure that systems and processes are in place to accurately review and categorise patient safety incidents logged by frontline staff. Regulation 17(1)(2)(a)(b)(e).
Matched on
terms: log
CQC enforcement action
56match
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC identified significant and serious safety concerns during the surgery inspection. These related to safe staffing, escalation when people were deteriorating, record keeping and learning from incidents. Due to these issues, the trust has been told to make significant improvements and was issued a warning notice.
Matched on
terms: significant
Article 2 learning point
55match
Mr North — HMP Whitemoor - LP 8
If it has not already done so, staff at HMP Whitemoor may wish to consider reviewing local procedures for the early notification of significant incidents or events to the Independent Monitoring Board.
Matched on
terms: event, significant
PFD report
53match
Elsie May Treece
The coroner noted an alleged incident where a patient fell was not recorded, raising concerns that staff may not be adequately reporting all inappropriate incidents, even when major harm is not immediately apparent.
Matched on
classifier match
Inquiry recommendation
53match
COVID-M1.6 - Triennial Pandemic Exercises
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 to multiple waves over a number of years; include a broad range of those involved in pandemic preparedness...
Matched on
terms: event
CQC action
53match
Fairglen Residential Home
The provider must inform CQC of notifiable events.
Matched on
terms: event
IMB recommendation
52match
London STHF (2024)
The Board stopped receiving Safer Detention Reports in July 2023 and despite many requests, these have not been forthcoming. This means that we do not have access to the data to enable us to monitor Suicide and Self Harm Warning Forms, Vulnerable Adult Warning Forms and Use of Force. After repeated requests at every Board meeting, we were...
Matched on
terms: event
CQC enforcement action
52match
Warning Notice: Blackpool Teaching Hospitals NHS Foundation Trust
The Care Quality Commission (CQC) issued a warning notice to Blackpool Teaching Hospitals NHS Foundation Trust following an inspection in September and October. The CQC required the trust to make significant improvements regarding assessing and managing risks to patients waiting for care and treatment. The notice also required effective systems and processes for incident management to ensure lessons...
Matched on
terms: significant
CQC enforcement action
52match
Warning Notice: Leeds Teaching Hospitals NHS Trust
Section 29A warning notice covering maternity and neonatal services at Leeds General Infirmary and St James's University Hospital, following unannounced inspections in December 2024 and January 2025. CQC identified breaches relating to learning from incidents, risk management, the safety of the environment, infection prevention and control, medicines management and management processes, and found that neonatal staffing did not...
Matched on
terms: event
PFD report
49match
Julie Morrey
The coroner noted a lack of communication between hospital departments regarding patient responsibility, leading to the patient being without fluids for over 24 hours. Additionally, there was no senior clinician review for 24 hours and a lack of policy for nursing staff to proactively manage her condition.
Matched on
classifier match
PFD report
49match
Vivien Brunning
Venous thromboembolism reviews were not undertaken at 24 and 72 hours post-admission, and prescribed daily heparin injections were omitted. An omission of medication was noticed but not reported through the Trust's incident reporting system.
Matched on
classifier match
PFD report
49match
Chloe Every
Lack of contemporary medical notes, infrequent clinical observations, and a procedure performed without informed consent on an unconscious patient. The report also notes delays in incident reporting and coroner notification, which impacted the investigation.
Matched on
classifier match
CQC enforcement action
49match
Warning Notice: Cambridgeshire and Peterborough NHS Foundation Trust
The CQC inspected an acute ward for adults of working age and psychiatric intensive care unit at Fulbourn Hospital in May. Inspectors found that staff could not observe patients in all parts of the ward, recording of patient observations were poor, records of incidents were missing, and parts of the physical environment were unclean. As a result, CQC...
Matched on
classifier match
CQC action
48match
St Benedict's Hospice
The service MUST ensure staff recognise the use of mechanical or pharmacological as restraint and ensure this is incident reported.
Matched on
terms: log
CQC action
48match
Universal Care - Beaconsfield
The provider failed to ensure it notified us of events it was legally responsible to inform us.
Matched on
terms: event
Committee recommendation
48match
#33 - University Hospitals of Leicester NHS Trust faces significant audit and control weaknesses.
At the time of our evidence session, University Hospitals of Leicester NHS Trust (UHL) had yet to publish its 2021–22 Annual Report and Accounts. UHL’s auditor was not able to obtain sufficient, appropriate evidence upon which to form an opinion for 2019–20, and issued an adverse audit opinion for 2020–21, due to system and control weaknesses resulting in...
Matched on
terms: significant
PFD report
45match
Janet Hall
Concerns were raised about the Emergency Department's system for discharge letters, which relies on junior doctors manually transcribing blood results, leading to an incorrect statement about normal bloods. This process also limits GPs' ability to perform trend analysis.
Matched on
classifier match
PFD report
45match
Richard Moss
Referral documents completed by medical practitioners at the practice only generate an alert to colleagues if manually selected, rather than automatically upon completion of the document.
Matched on
classifier match
Inquiry recommendation
45match
45 - Senior officer checks information reaching wing
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 in the wing observation book made since they were last on duty.
Matched on
classifier match
Inquiry recommendation
45match
R16 - Missed care incident reporting
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.
Matched on
classifier match
Inquiry recommendation
45match
MAI-81 - Improve NWFC Major Incident record-making
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.
Matched on
classifier match
Inquiry recommendation
45match
MAI-71 - Improve NWAS Major Incident record-making
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.
Matched on
classifier match
Inquiry recommendation
45match
MAI-38 - Improve GMP Major Incident record-making
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.
Matched on
classifier match
Inquiry recommendation
45match
MAI-33 - Improve GMFRS Major Incident record-making
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.
Matched on
classifier match
Inquiry recommendation
45match
MAI-19 - Provide recording equipment to control room personnel
Consideration should also be given by those organisations to the provision of such equipment to key personnel within control rooms.
Matched on
classifier match
Inquiry recommendation
45match
MAI-14 - Improve BTP Major Incident record-making
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.
Matched on
classifier match
CQC action
45match
The York Hospital
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Matched on
classifier match
CQC action
45match
Sunderland Royal Hospital
The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Matched on
classifier match
CQC action
45match
South Tyneside District Hospital
The trust must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within inappropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Matched on
classifier match
CQC action
45match
Scarborough Hospital
The service must implement an effective system to identify and report incidents including the severity of harm. The system must ensure incidents are appropriately reported to internal and external systems within appropriate timescales. The system must ensure incidents are effectively reviewed, lessons and actions are identified and shared with staff.
Matched on
classifier match
CQC action
45match
Royal Hallamshire Hospital
The trust must ensure incidents including serious incidents are investigated within an appropriate timescale and improvements are made without delay.
Matched on
classifier match
CQC action
45match
King George Hospital
The service must ensure that the administration of rapid tranquilisation is recorded as an incident in line with national guidance.
Matched on
classifier match
CQC action
45match
Conquest Hospital
The trust SHOULD make sure all incidents are reviewed within 72 hours.
Matched on
classifier match
CQC action
45match
Harrogate District Hospital
The service should complete all relevant documentation when incidents are reviewed.
Matched on
classifier match
Inquiry recommendation
44match
12 - Review incident investigation structures
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 for additional training. The Trust should ensure that robust documentation is used, based on a recognised system, and...
Matched on
classifier match
Inquiry recommendation
44match
F114 - Complaints handling
Comments or complaints which describe events amounting to an adverse or serious untoward incident should trigger an investigation.
Matched on
terms: event