There were 2 incidents concerning Safeguarding. These involved concerns about vulnerable individuals; however, all cases were appropriately identified and escalated in line with safeguarding procedures. Another 2 incidents related to Premises, highlighting environmental risks such as unsuitable layouts or limited facilities that may affect the safe delivery of care. Finally, 1 incident was attributed to Digital Systems, involving issues with digital tools and system functionality that affected service delivery. Overall, the themes identified provide important insights to inform targeted quality improvement and strengthen patient safety across services. The thematic profile of incidents demonstrates a shift from previous audit cycles. In 2024, prescribing-related issues were the predominant theme, while referral delays were a key concern in 2022/23. Neither of these emerged as dominant themes in the current review. This change suggests that learning from previous incidents has been effectively translated into system improvements and strengthened processes, demonstrating measurable impact from organisational learning. Consistent with previous findings, no individual staff member was associated with multiple incidents across the dataset. This supports a systems-based approach to patient safety, aligned with the principles of a just culture. Harm Profile These findings indicate that most incidents either did not result in harm or were identified and managed before escalation. The “Unknown / Under Investigation / Not Applicable” category is used where a definitive harm rating cannot be assigned at the time of reporting or review. This typically applies in the following situations:
Norfolk Primary Care - Quality Account 2025/26
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