Recurring concern

Inadequate staff training for clinical and care record keeping

First to latest report 16 Jul 2014 — 1 May 2025

Reports that mention this concern
12
Times this concern has been raised
12
Stated actions linked to this concern
5

What this concern includes

Includes failures of staff training, induction, refresher provision or competence assurance specifically concerning clinical or care record keeping, including training on record content, accuracy, completeness, timeliness and required recording standards.

What is not included
  • Excludes generic staff training deficiencies not specifically tied to clinical or care record keeping.
  • Excludes deficiencies in the quality, availability or auditing of records where no staff-training failure is identified.
  • Excludes training concerning communication alone unless the report also directly connects it to clinical or care record keeping.
  • Excludes failures in a separately named safety system where record-keeping training is only an incidental component and that system provides the more faithful parent boundary.

Reports and published responses 12 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester City

    AI-generated summary

    Kimberley Lauren Lindfield · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Kimberley Lauren Lindfield, who had a history of mental health problems and self-harm, was admitted to hospital after taking an overdose. While on Ward A10, she was found hanging from a dressing gown cord and died several days later after suffering severe brain damage. The principal concerns were failures to arrange a timely mental health assessment, record and respond to increased self-harm observations and risk information, maintain appropriate clinical management, and ensure staff followed relevant referral policies.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure nursing and clinical staff understand their record-keeping responsibilities

    Wider context from the report

    “4. I am concerned that all UHSM Nursing and Clinical staff should be reminded of their responsibilities for good quality record keeping as an essential part of patient care and that there are periodic audits of record keeping in similar cases to ensure that appropriate standards are being met. ”

    Source location

    Kimberley Lauren Lindfield · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  2. Essex

    AI-generated summary

    Julie Ann Robertson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of formal training in good record-keeping practice

    Wider context from the report

    “2) Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping. ”

    Source location

    Julie Ann Robertson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026