First reported 22 Dec 2014•Latest report 16 Jun 2026
Definition
What this concern includes
Includes dedicated processes for checking, auditing or evaluating the quality of clinical or care records, including paper notes, electronic entries and care notes, where the process is intended to identify shortcomings and support corrective feedback or improvement.
Not included
Excludes failures to create, complete, retain or retrieve records where no record-quality checking or assurance deficiency is identified.
Excludes failures to review clinical records for patient-specific safety issues or retrospective clinical concerns when record-quality assurance is not the shared control.
Excludes generic clinical governance, training or documentation deficiencies unless they directly concern assurance of the quality of clinical or care records.
Excludes substantive care, treatment or record-content failures where no deficiency in the record-quality assurance process is asserted.
Reports
18
Distinct published reports
Individual concerns
20
A report can raise multiple concerns
Date range
2014–2026
First to latest report issue date
Stated actions
30
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.
Department of Health and Social Care3
NHS England3
Care Quality Commission2
East London NHS Foundation Trust2
Appello Careline Limited1
Association of Ambulance Chief Executives1
East Lancashire Hospitals NHS Trust1
Easycare Limited1
Essex Partnership University NHS Foundation Trust1
Family of Gillian McKinlay1
Frimley Health NHS Foundation Trust1
George Eliot Hospital NHS Trust1
Greater Manchester Mental Health NHS Foundation Trust1
Green Range Limited1
Hampshire and Isle of Wight Healthcare NHS Foundation Trust1
NHS trust11
Executive non-departmental public body4
Ministerial department3
Private limited company3
Health and social care service regulator2
Domiciliary care provider1
English metropolitan district council1
Executive agency1
Health professional body1
Health-sector membership body1
Independent healthcare provider1
Integrated care board1
Professional membership body1
Residential care home1
Trade union and professional body1
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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to check and improve the quality of clinical note taking
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 concerns
Each 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.3
Action
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Review training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Current AI and automated call-handling solutions are not sufficiently developed or practicable for EMA call processes.
Stated by South East Coast Ambulance Service NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.
Stated by Appello Careline LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
Stated by TSAOutside remitThe respondent said that this matter was outside its role or authority.
Position
Operational concerns about ambulance care are the responsibility of SECAMB, which is best placed to respond directly.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Nottingham and Nottinghamshire
Concerns raised1
Lack of quality assurance auditing for ED discharge summaries
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Berkshire
Concerns raised1
Failure of records auditing to identify repeated omissions of required information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Stated by Frimley Health NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 December 2025.
Essex
Concerns raised2
Omission of quality and nature audits from observation records auditing
Failure of quality assurance and auditing processes to monitor the quality of observations and engagement documentation
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.6
Action
Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Review and co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 November 2025.
Action
Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Review Tendable audit templates within the wider Trust audit-assurance process.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Action
Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 November 2025.
Inner North London
Concerns raised1
Failure of auditing of nursing and clinical record keeping to produce measurable improvement
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.
Stated by East London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No further action is considered necessary because considerable work has addressed the identified concerns.
Stated by East London NHS Foundation TrustNo action considered necessaryThe respondent said that no further action was needed.
Worcestershire
Concerns raised1
Lack of regular auditing of residents’ records
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
Stated by Green Range LimitedStated completedThe respondent said that this action was complete when they made their response on 3 July 2025.
Inner North London
Concerns raised1
Failure of spot checks to identify and address falsified observation records
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
Action
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
Manchester North
Concerns raised1
Failure to complete management audits of Medication Administration Records for service users receiving medication support
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Audit all service-user MAR sheets and continue regular audits after their return to the office.
Stated by EasyCare Ltd (trading name: EVOLVEStated completedThe respondent said that this action was complete when they made their response on 28 June 2024.
South Yorkshire (Western)
Concerns raised1
Lack of an audit system to check records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.3
Action
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Warwickshire
Concerns raised1
Insufficient quality assurance of Badgernet entries
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes dedicated processes for checking, auditing or evaluating the quality of clinical or care records, including paper notes, electronic entries and care notes, where the process is intended to identify shortcomings and support corrective feedback or improvement.
