Recurring concern
Failure to incorporate relevant clinical history and diagnoses into care decisions
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Request correctionFirst reported 25 Mar 2014•Latest report 27 May 2026
What this concern includes
Includes failures in clinical assessment or treatment-planning processes to obtain, consider, document or use relevant previous diagnoses, treatment, available records and information from prior care providers when making care decisions.
Not included
- Excludes failures limited to accessing or transferring clinical records when the material unsafe condition is unavailable records rather than failure to incorporate relevant information into the decision.
- Excludes generic documentation deficiencies where no failure to consider relevant clinical history or diagnoses is identified.
- Excludes failures to consider family, carer or advocate views unless they are part of a broader failure to incorporate relevant clinical information into the care decision.
- Excludes condition-specific assessment or treatment pathways where that named condition or system provides the more specific supported boundary.
- Reports
- 33
- Individual concerns
- 35
- Date range
- 2014–2026
- Stated actions
- 50
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 incorporate available clinical information into self-harm risk assessments
This report raised 14 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
Use live RiO records for handovers, daily run-throughs and MDT ward rounds.
Stated by North East London NHS Foundation Trust -
Action
Audit compliance with live-record use and risk-assessment processes.
Stated by North East London 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
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of assessment protocols to require consideration of previous diagnoses, treatment and available care information
This report raised 10 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
Require initial assessments to examine previous diagnoses and treatments in consultation with the service user.
Stated by North London NHS Foundation Trust -
Action
Seek internal and external records of previous engagements and treatments, and incorporate relevant information from service users and permitted supporters into assessment and treatment planning.
Stated by North London NHS Foundation Trust
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Concerns raised1
Inadequate review of evolving diagnoses and relevant diagnostic information
This report raised 11 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 to obtain available laboratory results for treatment planning
This report raised 13 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
Implement automatic transfer of laboratory results into the primary patient record and display them on the Trust-wide system home screen.
Stated by Calderdale and Huddersfield NHS Foundation Trust
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Concerns raised1
Failure to incorporate relevant collateral information and community history in mental disorder assessments
This report raised 1 other concern. 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
Introduce an inpatient–community interface meeting to improve discharge-planning information sharing and communication.
Stated by Pennine Care NHS Foundation Trust -
Action
Introduce a process for arranging and facilitating discharge-planning and ward-round meetings.
Stated by Pennine Care NHS Foundation Trust -
Action
Share the Regulation 28 response with the Aspen Ward consultant psychiatrists’ responsible officer.
Stated by Pennine Care NHS Foundation Trust
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Action
Provide Oldham mental health services with a referral route to the multi-agency Adults with Multiple Complex Needs Meeting.
Stated by Pennine Care NHS Foundation Trust -
Action
Recommend that the Oldham Safeguarding Adult Partnership Board develop a multi-agency mental-capacity protocol.
Stated by Pennine Care 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
The MDT found no acute mental illness or immediate risk and considered an inpatient mental health ward inappropriate for ongoing alcohol-dependence support.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Lack of prompts in admissions assessment tools to ask about previous choking episodes
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
Update the nursing admission proforma to ask whether patients have previously experienced choking episodes during the EPR rollout.
Stated by Northern Care Alliance 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
Existing swallowing questions are considered adequate to manage choking risk despite lacking a specific question about previous choking episodes.
Stated by Northern Care Alliance NHS Foundation Trust
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Concerns raised1
Failure to consider medical records at hospital discharge
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.2
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Action
Share the response at the Divisional Surgery Governance Meeting and discuss the importance of checking medical records during handover completion.
Stated by Oldham Care Organisation -
Action
Share the PFD response at the divisional surgery governance meeting and discuss the importance of fully checking medical records when completing handover communications.
Stated by Oldham Care Organisation
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Concerns raised1
Failure to consider the circumstances of a fall during clinical assessment
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.5
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Action
Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
Stated by Medway NHS Foundation Trust -
Action
Resume the suspended staff teaching and simulated training programme on elderly trauma care.
Stated by Medway NHS Foundation Trust -
Action
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Stated by Medway NHS Foundation Trust
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Action
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Stated by Medway NHS Foundation Trust -
Action
Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
Stated by Medway NHS Foundation Trust
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Concerns raised1
Failure to consider a lower methadone starting dose for patients with liver disease
This report raised 1 other concern. 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
Produce and distribute an educational support pack on hepatic dysfunction and methadone metabolism to clinically involved substance-misuse staff.
Stated by Turning Point -
Action
Develop and roll out a multiple-choice assessment of the educational support pack, with learning monitored through clinical supervision.
Stated by Turning Point -
Action
Host a clinical session on safe opioid-substitute-treatment prescribing for representatives from every service, supporting subsequent local learning cascades.
Stated by Turning Point
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Action
Publish a clinical brief reminding all clinical staff about safe opioid-substitute-treatment prescribing.
Stated by Turning Point
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Concerns raised1
Failure to take and consider relevant patient history before discharge
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026