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. Birmingham and Solihull

    AI-generated summary

    Peter Michael ANZANI · 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

    Peter Michael Anzani died in Birmingham Heartlands Hospital on 23 November 2024 from a pulmonary embolism after being admitted with community-acquired pneumonia. He had a spinal cord injury resulting in tetraplegia and had experienced falls and chest infections. Concerns included inadequate recording of clinical observations, possible staff training issues, and prolonged patient waiting lists linked to staffing and funding difficulties.

    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 adequate staff training

    Wider context from the report

    “1. I considered evidence from a ████████ who indicated at paragraphs 20-21 of his statement, “I did not see any record of his pulse, blood pressure or oxygen saturation. The normal practice is to complete these observations, and I would expect this to be done, especially with him presenting with chest issues. However, I am unable to comment why this was not recorded or confirm that these were carried out. (21) This is a learning point for the department, and I have taken steps to ensure this learning is taken forward by the Trust. I have alerted the Sister in charge of the Spinal Injuries Outpatients’ Department and requested that adequate measures are taken to ensure that all observations made are recorded in the outpatient forms...”. 2. It was unclear whether this was a single one-off event involving human error or indicative of a wider and systemic issue involving a lack of training. There was no evidence before the court that this “learning point” had been actioned or that any adequate steps had been taken to ensure proper and accurate recording of records by staff. 3. There is a real risk of future deaths occurring where staff do not have adequate training and that patient records are not being properly completed. ”

    Source location

    Peter Michael ANZANI · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement a standard operating procedure requiring baseline and higher-risk pre- and post-procedure observations in outpatient clinics.

    Verbatim wording from the response

    “A new Standard Operating Procedure (SOP) has been developed and is in the process of being implemented to provide a clear, visual guide for clinical staff working in outpatient settings. The SOP includes a flowchart to ensure ease of understanding and practical application across all relevant clinics. It outlines mandatory baseline observations for all outpatient appointments. The SOP is scheduled to be approved at the next Patient Safety Meeting on 08 July 2025.”

    Source location

    Response from The Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation Trust
    Page 2 · response
    Published 19 May 2025

    Open published response

  2. Berkshire

    AI-generated summary

    Wendy Ann AFFORD · 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

    Wendy Ann Afford was bedbound and living alone with a package of care before developing worsening pressure damage and an infected pressure ulcer. After hospital treatment and discharge to a care home, her health declined and she died on 15 November 2023. Concerns included inadequate skin-integrity risk assessment and monitoring, incomplete repositioning records, unclear compliance with care plans, insufficient management oversight, and possible inadequate staff training.

    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

    Inadequate training in record keeping

    Wider context from the report

    “5. Given these numerous difficulties there is a concern that care staff are not properly trained in the use of care plans, record keeping and importance of monitoring skin integrity. ”

    Source location

    Wendy Ann AFFORD · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Surrey

    AI-generated summary

    Isabella MCCREADIE · 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

    Isabella McCreadie, aged 90, suffered a fall at home causing fractures, was admitted to hospital and underwent surgery. She developed low haemoglobin, delirium and a hospital-acquired stage 4 pressure sore, and died of pneumonia at home on 6 June 2023. Concerns included insufficient dietetic staffing, pressure-sore care and training, an unprocessed dietary supplement order, and inadequate training for some agency staff using the hospital’s computer system.

    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

    Insufficient training of agency staff to record medical care on the ward computer system

    Wider context from the report

    “4. At the time of the inquest, I was informed during Mrs McCreadie's stay a number of staff were agency staff. I note that the hospital now have more permanent staff in place on the ward than when Mrs McCreadie was on the ward. I remain concerned that agency staff who may still need to be called to assist on the ward may not have sufficient training on the computer system used for recording medical care provided before they are required to do so whilst working on the ward. At the inquest there was evidence that insufficient training had been given and therefore there were inconsistencies in recording of treatment given or needed. I understand permanent staff receive 9 hours of training, whereas agency staff may receive only up to 1 hour of training. ”

    Source location

    Isabella MCCREADIE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Require agency staff to complete online and classroom Epic training, including an end-of-training assessment, before working a Trust shift.

    Verbatim wording from the response

    “Since October 2023 agency staff have been required to complete one hour of online training and 4 hours classroom based Epic training in person before they can work a shift at the Trust.”

    Source location

    Response from Frimley NHS
    Page 5 · response
    Published 6 June 2024

    Open published response

  4. Inner West London

    AI-generated summary

    Valeria Munoz Biggs · 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

    Valeria Munoz Biggs died on 20 September 2019 after jumping in front of a train at Holland Park Underground Station while suffering agitated depression, possibly on the bipolar spectrum. The report identified concerns including underestimation of her suicide risk, inadequate engagement with and support for her family, missed planned visits, delayed psychiatric assessment, insufficient consideration of hospital admission, and treatment not in line with guidance.

    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 staff training in record keeping and updating

    Wider context from the report

    “2. That the Trust staff need training in relation to assessment of suicide risk, how to engage with families and carers, not to use inappropriate personal comment to try and bolster the patient, how to provide support to families and carers, that risk needs to be assessed during the present treatment episode in order to mitigate suicidality at that particular point in time and in record keeping and updating. ”

    Source location

    Valeria Munoz Biggs · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  5. Nottinghamshire

    AI-generated summary

    Rohid SHERGILL · 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

    Rohid Shergill, who had Duchenne’s muscular dystrophy and was fed through a nasogastric tube, died on 14 March 2016 after the tube was inserted into his lung and was used for feeding and medication. The principal concerns included inadequate checking of the tube position, uncertainty about parental understanding of pH testing, insufficient information-sharing between trusts, unclear care coordination, and possible contamination from repeated syringe use.

    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 staff training on information to record in shared care records

    Wider context from the report

    “2. Information-sharing between the two trusts – by way of shared IT and / or the use of shared care folders kept in the family home – with clear training to staff on what information should be recorded there. ”

    Source location

    Rohid SHERGILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Manchester West

    AI-generated summary

    Mollie Bentham · 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

    Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

    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

    Inadequate training of nursing and medical staff in the above information-management processes

    Wider context from the report

    “1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”

    Source location

    Mollie Bentham · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Provide weekly and monthly documentation and record-keeping training for Darley Court staff.

    Verbatim wording from the response

    “Documentation training is also now included in the new weekly training programme, furthermore additional training is being provided on a monthly basis in respect of documentation and record keeping. Monthly documentation audits are now being undertaken to ensure compliance with this action and ensure the quality of record keeping is improved.”

    Source location

    Mollie-Bentham-Response
    Page 2 · response
    Published 30 December 2015

    Open published response

  7. West London

    AI-generated summary

    Margaret O’Brien · 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

    Margaret O’Brien was discovered unresponsive in her bed at the care home where she resided, after showing signs of a cold the previous evening. The substantive concern was an absence of specific, prescribed staff training on carrying out and recording observations of residents.

    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 specific, prescribed staff training on recording observations of residents

    Wider context from the report

    “There appeared to be an absence of specific, prescribed training of staff on how to carry out and record observations of residents. ”

    Source location

    Margaret O’Brien · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Create and introduce a competency-based observation assessment for care and nursing colleagues to complete during induction, covering policy knowledge and recording requirements.

    Verbatim wording from the response

    “The Care UK, RCS Learning & Development function is also looking to create a competency based assessment, which care and nursing colleagues would complete during their induction to the company. This will be aligned to the policy and guidance provided around observation of residents/patients in our care.”

    Source location

    Response from Care UK
    Page 1 · response
    Published 11 December 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Revised observation policy and the proposed induction competency assessment are considered sufficient to address staff training and recording concerns.

    Verbatim wording from the response

    “I trust that you will accept that the actions taken in revising our observation policy and the proposal to introduce a competency based assessment, for completion at induction, meet your directions in relation to improving our service and specifically in the carrying out and recording of observations.”

    Source location

    Response from Care UK
    Page 2 · response
    Published 11 December 2015

    Open published response

  8. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Janine Eugenie Pierrette KAISER · 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

    Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

    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

    Inadequate staff training in record keeping

    Wider context from the report

    “3. Staff appeared inadequately trained in record keeping. ”

    Source location

    Janine Eugenie Pierrette KAISER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. South Yorkshire (Eastern)

    AI-generated summary

    Phyllis Broomhead · 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

    Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.

    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

    Insufficient staff training in record keeping

    Wider context from the report

    “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to: i. the head injury protocol, how this should be followed and the importance of doing so. ii. record keeping. iii. indicators and triggers to seek social worker input. (2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home. ”

    Source location

    Phyllis Broomhead · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Deliver record-keeping training and review care records through meetings, site visits and remedial-action follow-up.

    Verbatim wording from the response

    “Record keeping and the importance of accurate documentation have always been paramount to RMBC, however further training embedded in training programmes, team meetings, supervisors’ meetings, and site visits are carried out by Regulation Officers. Care Managers and samples of care records are reviewed. From this the Service Manager is informed of any remedial actions that are required.”

    Source location

    2015-0290-Response-by-Rotherham-Borough-Council
    Page 2 · response
    Published 6 July 2015

    Open published response

  10. Manchester West

    AI-generated summary

    Emmeline Hampson · 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

    Emmeline Hampson died in hospital on 6 November 2014 after a fall at her nursing home caused a subdural haematoma and intracerebral bleeding. The concerns included repeated falls without review of her falls risk assessment or referral back to the Falls Service, inadequate procedures and record keeping, shortcomings in alarm audibility and differentiation, and insufficient training of agency staff.

    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 Agency staff training in documentation, record keeping and risk assessment procedures

    Wider context from the report

    “vi. The evidence at the Inquest in relation to the fall on the 29th October 2014 was given by a trained nurse employed by an Agency who did not appear to be familiar with the documentation and record keeping particularly relating to risk assessments and there did not appear to be any training of Agency Staff in relation to those procedures. ”

    Source location

    Emmeline Hampson · Prevention of Future Deaths report
    Page 3 · 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