Recurring concern

Failure to assure the quality of clinical and care records

First to latest report 22 Dec 2014 — 16 Jun 2026

Reports that mention this concern
18
Times this concern has been raised
20
Stated actions linked to this concern
30

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.

What is 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 and published responses 18 reports

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

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Derek Thomas Burt · 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

    Derek Thomas Burt died at home on 15 May 2025 after a spontaneous rupture of an arterio-venous malformation at the back of his right ankle caused severe bleeding. The report raises concerns about communication between the careline service and ambulance services, including failure to pass on key information, delays in escalating the emergency, inadequate recording of information, and the loss of opportunities to provide basic first-aid advice.

    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 check and improve the quality of clinical note taking

    Wider context from the report

    “4) Likewise I heard from the SECAMB CSN that she had carried out an audit of the EMA notes added to their system when speaking to the first careline operator. She did so from a clinical perspective and she discovered missing information that was given but not recorded at all namely: that there had already been 20 minutes of bleeding at the time of the first call (approx. 22:43); Mr Burt was not responding normally/groaning; and Mrs Burt was bedbound therefore could not assist Mr Burt. None of this information was therefore available to the CSN who carried out the clinical review. In addition I heard that the end to end review carried out by SECAMB and focused on the dispatch difficulties that existed on 14 May 2025. I appreciate that the dispatch and clinical review systems were different at that time and have now been changed but I remain concerned that the quality of note taking has not been properly checked and action taken to rectify then make improvements with any individual concerned as well as capturing learning points for others. Here vital information was missing and was needed to ensure an effective clinical review could take place and thereby ensure that the category of call response is accurate. I was told this call had been audited and was found to be 95% compliant. This also calls into question the quality of the call auditing system ”

    Source location

    Derek Thomas Burt · Prevention of Future Deaths report
    Page 5 · 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

    Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.

    Verbatim wording from the response

    “The Trust has also reviewed the audit findings associated with this case. During that review it was identified that documentation quality forms a relatively small component of the current NHS Pathways audit framework. SECAMB has discussed this concern with NHS Pathways, recognising the Coroner's observations regarding the significance of missing or inaccurate information within call records. As the national audit framework is owned and maintained by NHS Pathways, any review of the weighting applied to documentation standards sits within their remit. SECAMB will continue to contribute to discussions and share learning where opportunities for improvement are identified.”

    Source location

    Response from South East Coast Ambulance Service NHS Foundation Trust
    Page 4 · response
    Published 14 August 2026

    Open published response

    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

    Review local assurance processes to identify, escalate and address significant omissions in emergency call records.

    Verbatim wording from the response

    “The learning arising from this case has also informed local discussions regarding the assessment of documentation quality within assurance and audit processes, with a view to ensuring that significant omissions within call records are identified, escalated and addressed through appropriate learning and improvement activity.”

    Source location

    Response from South East Coast Ambulance Service NHS Foundation Trust
    Page 4 · response
    Published 14 August 2026

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    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

    Review training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.

    Verbatim wording from the response

    “Whilst these longer-term technological developments continue to be explored, the Trust has taken immediate action by raising the learning identified through this inquest with the Training Department. A review is underway to determine what enhancements can be made to training, guidance and development processes to further support Emergency Medical Advisors in accurately documenting information obtained during emergency calls. This will be in place by the close of the financial year.”

    Source location

    Response from South East Coast Ambulance Service NHS Foundation Trust
    Page 6 · response
    Published 14 August 2026

    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

    Current AI and automated call-handling solutions are not sufficiently developed or practicable for EMA call processes.

    Verbatim wording from the response

    “The Trust fully recognises that accurate and comprehensive documentation is essential to support effective clinical assessment, review and decision-making throughout a patient's journey. Whilst emerging technology may offer future opportunities to improve the capture of information, SECAMB does not consider that current solutions are sufficiently developed for implementation within Emergency Medical Advisor (EMA) call handling processes at this time.”

    Source location

    Response from South East Coast Ambulance Service NHS Foundation Trust
    Page 5 · response
    Published 14 August 2026

    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

    Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.

    Verbatim wording from the response

    “Concerns 4 and 5 Appello Careline Limited understands that these concerns relate to the ambulance service’s internal processes, including note taking and clinical triage decision-making.”

    Source location

    Response from Appello Careline Operations Director
    Page 4 · response
    Published 14 August 2026

    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

    The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.

    Verbatim wording from the response

    “With respect to the matters of concern in relation to the care of Derek Burt, AACE is not in a position to respond; the specific details relate to and should subsequently be addressed by both Appello and SECAMB.”

    Source location

    Response from Association of Ambulance Chief Executives
    Page 3 · response
    Published 14 August 2026

    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

    Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.

    Verbatim wording from the response

    “TEC Quality response to points 4 and 5:”

    Source location

    Response from Telecare Services Association
    Page 7 · response
    Published 14 August 2026

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    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

    Operational concerns about ambulance care are the responsibility of SECAMB, which is best placed to respond directly.

    Verbatim wording from the response

    “NHS England’s Ambulance Team have reviewed this Report and have advised that the concerns raised relate to operational matters, which are the responsibility of the local ambulance service; SECAMB NHS Foundation Trust, who will be best placed to respond to the concerns raised. We note that SECAMB have also been addressed in your Report and will respond directly to the concerns.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 14 August 2026

    Open published response

  2. Nottingham and Nottinghamshire

    AI-generated summary

    David MARRIOTT · 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

    David Marriott died at City Hospital, Nottingham, on 18 July 2025 from metastatic lung cancer diagnosed in May 2025. The report identified missed opportunities to arrange a follow-up chest x-ray after his February 2024 Emergency Department visit, including failures to follow guidance and to review radiology reports received after discharge. It also raised concerns about inadequate discharge summaries, lack of quality assurance, and failure to provide summaries to patients.

    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 quality assurance auditing for ED discharge summaries

    Wider context from the report

    “3. Poor quality discharge summaries, a failure to have in place a system for quality assurance, and a failure to share summaries with patients I heard evidence of a continuing concern amongst the primary care profession that ED discharge summaries often are not worth the (electronic) paper they are written on. Often, they contain inadequate or insufficient information, like the one in this case which did not make clear the steps required of the GP. Occasionally, discharge summaries do not arrive, or there can be a delay in receiving such. I understand the Trust does not have a quality assurance audit for discharge summaries so there is no data to underpin identification of issues and learning. I am further concerned that ED discharge summaries are not supplied to patients. If the patient is expected to act as a safeguard in proactively managing their care, they need to have the plan in writing. Placing an expectation on unwell patients to remember and recite the verbal plan for follow-up to their GP many weeks later is unrealistic. Again, ED seems to be an outlier in this regard as inpatients always receive a copy of their discharge summary and plan. The same occurs for outpatient appointments when the Consultant letter is copied to both the GP and the patient. The witnesses before me were unclear on whether ED discharge summaries appeared in the NHS patient app. Perhaps this could be clarified? ”

    Source location

    David MARRIOTT · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

  3. Berkshire

    AI-generated summary

    June Violet FINDLAY · 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

    June Violet Findlay fell at home on 23 October 2024, fracturing her hip and wrist, and later died at Thames Hospice on 11 December 2024 after her health deteriorated. Concerns included substantial weight loss and sub-optimal management, monitoring, recording, and auditing of the risk of malnutrition during her hospital admission.

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    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 of records auditing to identify repeated omissions of required information

    Wider context from the report

    “During the course of Mrs Findlay’s 9-10 days at Frimley Park Hospital she lost at least 5.3kg from an already low weight. She had been assessed as being at high risk of malnutrition shortly after her admission. The care planning records were inconsistent about the interventions required and the level of risk. The record keeping of the actual interventions used on a daily basis to address this risk were absent or largely incomplete and I found that the ward staff did not properly follow the dietician’s advice or the care plans. I am concerned that ward staff are not: 1. Properly recognising the risk of malnutrition to patients, even after completing the MUST2 assessments; 2. Correctly utilising care planning tools to address the risks of malnutrition; 3. Properly monitoring and recording the interventions undertaken to address the risk. This places patients at risk due to unclear information and also means that the hospital cannot learn from mistakes or pick up near misses. No evidence was forthcoming from the Trust at inquest that these shortcomings at Frimley Park Hospital had been acted upon despite the court hearing that 100% of the ward staff had received MUST training and records were audited on a monthly basis. This gives rise to a further concern: 4. The auditing of records does not seem to have identified the repeated failures to record required information. ”

    Source location

    June Violet FINDLAY · 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

    Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.

    Verbatim wording from the response

    “Audit – There will be an altered focus on the audit to provide assurance that patients are adequately fed according to their need and that any significant weight loss is appropriately escalated to the Ward Matron to ensure that high risk patients are highlighted and appropriate action is taken and documented in line with the new weight loss SOP.”

    Source location

    Response from Frimley Health NHS Foundation Trust
    Page 4 · response
    Published 3 December 2025

    Open published response

  4. Essex

    AI-generated summary

    Stephen John Neville · 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

    Stephen John Neville, aged 68, was an informal inpatient at Beech Ward for planned ECT after a history of severe treatment-resistant depression, anxiety, agitation, and repeated suicide attempts. He died by hanging while in hospital. The report identified concerns including failures in risk communication and assessment, abrupt medication changes, inadequate therapeutic observations and engagement, insufficient auditing and quality assurance, and failure to mitigate risks associated with an unlocked shower room.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Omission of quality and nature audits from observation records auditing

    Wider context from the report

    “4. The Deputy Director of Quality and Safety (Inpatient and Urgent Care) recognised in her written and oral evidence that the available free text box now included on the electronic version of the records relating to observation and engagement is “not a mandatory field” in the recording process and that: “it appears that at some point the Tendable audits were amended to omit the audits of the quality and nature of the observation records.” ”

    Source location

    Stephen John Neville · Prevention of Future Deaths report
    Page 4 · concerns

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    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 of quality assurance and auditing processes to monitor the quality of observations and engagement documentation

    Wider context from the report

    “5. It remains unclear how (or why) this came about, and I am very concerned that the apparent reliance on staff supervision (as per paragraph 7.1 of the Therapeutic Engagement and Supportive Observation Clinical Guideline (Inpatients)) and staff handovers to rigorously audit the nature and quality of the conduct and recording of therapeutic engagement and supportive observations remains a wholly inadequate mechanism for the purposes of achieving appropriate qualitative compliance monitoring. 6. The lacuna identified above gives rise to a real concern regarding the robustness of EPUT quality assurance and auditing processes generally, and particularly in the context of the on-going issues relating to the nature and quality of the conduct by EPUT staff of such critically important observations including the essential therapeutic engagements and interactions, with highly vulnerable inpatients at risk of suicide. This is a concern, I am told, also shared by the Deputy Director quoted above. ”

    Source location

    Stephen John Neville · Prevention of Future Deaths report
    Page 4 · 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

    Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.

    Verbatim wording from the response

    “Response: Reflection has been undertaken on this learning point with key staff including the current Ward Manager and Matron. Staff reflected that audits should be transparent and agreed that it was good practice to acknowledge gaps and take appropriate action in a timely manner. Staff expressed that they would be confident in presenting audits where the findings show gaps and gave recent examples of action taken following audits. The Matron is continuing to work with staff on the importance of accurate audit results and accountability. The matron is also conducting spot checks on audits that consistently report high level compliance as an additional assurance measure.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

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    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

    Review and co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.

    Verbatim wording from the response

    “From a Trust wide learning perspective, a review is already underway of the Trust Tendable audit programme. The current Trust Tendable audit programme has been in place for 12 months and this review was already in progress prior to the inquest. This work will be co-”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 2 · response
    Published 5 November 2025

    Open published response

    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

    Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.

    Verbatim wording from the response

    “Response: In October 2024, EPUT launched a new Quality Assurance Audit Programme across all inpatient areas. This initiative was driven by feedback highlighting issues with previous paper-based audits, including repetitive and duplicated questions across Tendable audits and other checks conducted outside the platform. There was also inconsistency in understanding who should complete audits and when. Ward Managers and Matrons reported limited visibility of audit results and minimal use of findings for quality improvement.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 5 November 2025

    Open published response

    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

    Review Tendable audit templates within the wider Trust audit-assurance process.

    Verbatim wording from the response

    “We have also reviewed the audit templates within our tenable system to ensure the quality of this process is now reviewed as part of the trust wider audit assurance process, this alongside making the commentary box within observation recording a mandatory field has considerably strengthened our trust assurance on this matter.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 4 · response
    Published 5 November 2025

    Open published response

    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 three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.

    Verbatim wording from the response

    “Building on this review, further enhancements were introduced following inquest-related reflections. In November 2025, three new Oxevision audits were implemented to strengthen oversight of observation and therapeutic engagement, incorporating both staff and patient feedback:”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 5 November 2025

    Open published response

    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

    Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.

    Verbatim wording from the response

    “The Trust has since strengthened the reporting of results from audits; with results discussed at the monthly care unit Quality & Safety Meetings and this is supported by the implementation of a Quality & Safety dashboard utilising Power BI (Power BI is a business intelligence tool developed by Microsoft that transforms raw data into visual insights allowing organisations to make data-driven decisions). The dashboard provides the Trust with a range of information, from an overall perspective of results as an organisation.”

    Source location

    Response from Essex Partnership NHS Foundation Trust
    Page 3 · response
    Published 5 November 2025

    Open published response

  5. Inner North London

    AI-generated summary

    Name not published · 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

    ████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.

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    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 of auditing of nursing and clinical record keeping to produce measurable improvement

    Wider context from the report

    “3) Auditing of record keeping The Trust’s evidence regarding auditing nursing / clinical records provided little, if any, reassurance that the system in place is bringing about a truly measurable or meaningful change. ”

    Source location

    Name not published · 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

    Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.

    Verbatim wording from the response

    “In terms of the Trust’s expectations regarding whether staff should commence the My Safety Plan and Dialog+ documents in the absence of patient engagement, staff are expected to complete the Dialog+ and My Safety Plan within 72 hours of admission; where patients are not able to engage in this process staff will revisit and obtain their input. Staff are also encouraged to obtain collateral information from family, friends and carers. There are weekly case note audits to look at the quality of dialog+ including patients’ views, which provides opportunities for clarity of processes and expectations related to this documentation to be reinforced.”

    Source location

    Response from East London NHS Foundation Trust
    Page 3 · response
    Published 2 December 2025

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    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

    No further action is considered necessary because considerable work has addressed the identified concerns.

    Verbatim wording from the response

    “I have addressed these in turn below. Please note that in respect of Concerns 2, 4, 5, 6, 7 and 8 the Trust entirely acknowledges the reasons for your concerns and has considered them extremely”

    Source location

    Response from East London NHS Foundation Trust
    Page 1 · response
    Published 2 December 2025

    Open published response

  6. Worcestershire

    AI-generated summary

    Vera Fortey · 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

    Vera Fortey suffered an unwitnessed fall at her care home, after which her mobility and condition deteriorated. Her fractured hip was not medically identified for approximately two and a half days, and she later underwent surgery, declined despite treatment, and died in hospital. The principal concerns were inadequate recording of the fall, missed opportunities to obtain medical assessment, insufficient auditing of residents’ records, and inadequate staff familiarity with the care home’s records 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

    Lack of regular auditing of residents’ records

    Wider context from the report

    “4) Although she had only been in post since 13 August 2024, the then care home manager told the inquest that a reason why she may not herself have picked up on the above failings was because at the time of these events, she was still not familiar with the care home’s records system, was unable to scroll through residents’ notes, and was instead just “muddling through”. It therefore appears that insufficiently robust measures are in place at The Willows Care Home to ensure: (a) that staff understand the need to record significant incidents in residents’ records; (b) that a regular auditing procedure is in place to help ensure that residents’ records are being updated properly; and (c) that all staff at the care home ( including managers ) have received training so as to be as familiar with the computerized records system in use there as their role may require. ”

    Source location

    Vera Fortey · 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

    Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.

    Verbatim wording from the response

    “To address the specific items raised in the Regulation 28 Report we drew up an action plan that covered:”

    Source location

    Response from The Willows Care Home
    Page 1 · response
    Published 3 July 2025

    Open published response

  7. Inner North London

    AI-generated summary

    Anna Vivien Elliott · 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

    Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.

    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 of spot checks to identify and address falsified observation records

    Wider context from the report

    “Concern 4 In Anna’s case, observation records were backfilled despite the observations not having been conducted. All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done”. As the spot checks described to me only look at the quality and timings of the written observations, I am not reassured that records are not still being falsified or about how this is being identified and addressed. ”

    Source location

    Anna Vivien Elliott · 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

    Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.

    Verbatim wording from the response

    “19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.”

    Source location

    Response from ELFT
    Page 3 · response
    Published 31 July 2024

    Open published response

    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

    Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.

    Verbatim wording from the response

    “Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.”

    Source location

    Response from ELFT
    Page 8 · response
    Published 31 July 2024

    Open published response

  8. Manchester North

    AI-generated summary

    Norman Leadbeater · 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

    Norman Leadbeater, who had advanced Parkinson’s disease, vascular dementia and presumed liver cancer, developed aspiration pneumonia after being advised to have thickened fluids and died on 14 January 2024. Concerns were identified that his prescribed thickener was not listed on the Medication Administration Record and that his care plan lacked sufficient detail for staff to administer thickened fluids safely and correctly. A recommended audit of medication records had still not been completed four and a half months later, and no completion timescale was provided at the inquest.

    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 complete management audits of Medication Administration Records for service users receiving medication support

    Wider context from the report

    “Mr Leadbeater had been in receipt of domiciliary care from Evolve Services since October 2023. The care included the administration of medication. When a concern was raised that the carers had not been thickening fluids appropriately, the Community Commissioning Team at Bury Council undertook an investigation and found that the prescribed thickener was not listed on the Medication Administration Record (MAR) and that the care plan in place for Mr Leadbeater did not contain sufficient detail for care staff to safely and correctly administer thickened fluids. In February 2024 and following its investigation into the concerns regarding Mr Leadbeater’s care, Bury Council Community Commissioning Team recommended that Evolve Services undertake a number of remedial actions. This included an immediate management audit of MAR for those service-users in receipt of medication support and liaison with GPs and Pharmacists to ensure that the medication listed for each service-user is up to date and accurate. The concern had that four and half months since the recommendation was made, Evolve Services have not yet completed the management audit of MAR for those service users in receipt of medication support. The representative from Evolve Services who attended the inquest was unable to provide the Court with a timescale for completion of this work or the number of service users this affects. ”

    Source location

    Norman Leadbeater · 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

    Audit all service-user MAR sheets and continue regular audits after their return to the office.

    Verbatim wording from the response

    “Since the Section 28 was issued to Evolve, the company have taken many remedial steps to address the content of your letter. The current RM has completed an audit of all MAR sheets for all the service users and the report is attached for your attention. Attachment 1”

    Source location

    Response from Evolve
    Page 2 · response
    Published 28 June 2024

    Open published response

  9. South Yorkshire (Western)

    AI-generated summary

    Gareth Michael Etchells-Heights · 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

    Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate 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 an audit system to check records

    Wider context from the report

    “4. Record Keeping There was a failure generally to keep proper records. It became clear as the evidence progressed that many of the record entries did not accurately or fully reflect the interactions with Gareth. There is no audit system in place to check the records. ”

    Source location

    Gareth Michael Etchells-Heights · 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

    Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.

    Verbatim wording from the response

    “The new discharge template will be completed by the end of June 2024 and the launch of this will be supported by local best practice training by the Directorate Leadership Team. An audit of quality compliance will be incorporated into the existing cycle of biannual record keeping audits. Results from the audits will be reflected and acted through our local ward governance processes.”

    Source location

    Response from Sheffield Health and Social Care
    Page 2 · response
    Published 12 December 2023

    Open published response

    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

    Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.

    Verbatim wording from the response

    “We will request regular reporting on clinical record keeping audits and monitor progress via our Directorate Leadership Teams into the Clinical Quality and Safety Group.”

    Source location

    Response from Sheffield Health and Social Care
    Page 2 · response
    Published 12 December 2023

    Open published response

    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

    Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.

    Verbatim wording from the response

    “In addition to the positive impact of the electronic record implementation this year, we have also commissioned a new clinical record keeping policy and training, which aligned to the quality improvement programme we noted in our letter (3 November), will be rolled out to all staff teams. Built alongside this will be a robust audit programme which will include Trustwide clinical audit and team level audits through supervision and spot check audits as part of our Quality Assurance programme. We anticipate the policy will be completed by May 2024 and the training will commence roll out, alongside a clear communication plan from June 2024.”

    Source location

    Response from Sheffield Health and Social Care
    Page 3 · response
    Published 12 December 2023

    Open published response

  10. Warwickshire

    AI-generated summary

    Eclipse Morrison · 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

    Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery 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

    Insufficient quality assurance of Badgernet entries

    Wider context from the report

    “3. Quality Assessment I am informed that Badgernet can easily identify fields which have not been completed and will prevent a record being closed until the field is completed, but it cannot identify the quality of any such entries. I am told that the quality checks are made on ten sets of notes per month out of an estimated 3,000 records that will be open at any one time. The concern remains that there is insufficient quality assurance in this system. ”

    Source location

    Eclipse Morrison · 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