Recurring concern

Inadequate staff training for clinical and care record keeping

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First reported 16 Jul 2014•Latest report 1 May 2025

Definition

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.

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
12

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
5

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.

NHS England2
Bolton NHS Foundation Trust1
Care UK1
Department of Health and Social Care1
Frimley Health NHS Foundation Trust1
Frimley Park Hospital1
Greater Manchester Mental Health NHS Foundation Trust1
Happy at Home Community Care Services Ltd.1
Manchester University NHS Foundation Trust1
New Park Residential Home1
NHS Greater Manchester Integrated Care Board1
Nottinghamshire Healthcare NHS Foundation Trust1
Nottingham University Hospitals NHS Trust1
Pindy Enterprises Limited1
Rotherham Borough Council1

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.

  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
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Data last updated 7 September 2026