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. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Jack FARRINGTON · 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

    Jack Farrington, who had a long history of mental health difficulties and was detained under section 2 of the Mental Health Act, died on 2 January 2020 after running from an emergency department and falling from a road bridge. The report raised concerns about fragmented access to medical records, inadequate handovers and record keeping, insufficient flagging and assessment of absconding and self-harm risks, and the implementation of measures intended to keep him safe.

    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 properly record, store or audit paper observations and records

    Wider context from the report

    “Solent NHS Trust still relies on paper forms for some observations and record keeping within the mental health unit. In Jack’s case these were not scanned and stored which hampered the investigation and inquest. There remains a risk that where paper records are kept information is not properly recorded, stored or audited. ”

    Source location

    Jack FARRINGTON · 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

    Attend inpatient handovers, audit clinical records, and escalate audit outcomes through governance meetings to assure handover quality and accuracy.

    Verbatim wording from the response

    “In order to mitigate the risk that the continued use of the handover outside of SystmOne presents, our Clinical Leadership Team are attending handovers to ensure good quality conversation and accuracy of information handed over and undertaking a quality audit of the clinical records. The outcomes from audits are then presented at the Inpatient Governance Meeting and can be escalated to the Mental Health Service Senior Leadership Team at Integrated Governance Meeting if required.”

    Source location

    Response from Solent NHS Trust
    Page 1 · response
    Published 13 November 2023

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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

    Replace paper-based clinical observation forms with electronic forms feeding directly into SystmOne, including tablet procurement and ward testing.

    Verbatim wording from the response

    “The Mental Health Service continues to record various clinical observations on paper-based forms, which are scanned into SystmOne. This includes therapeutic engagement and observations, physical observations, food and fluid charts. The service is working towards replacing the paper-based forms with an electronic form that feeds directly into SystmOne, and I am pleased to report that work is on track and planned to be implemented by 01st April 2024. The Service’s Clinical Matron has visited departments within Southern Health NHS Foundation Trust to view the system in use and is meeting regularly with Solent NHS Trust Information Specialist to ensure this will be ready to implement on time. This change also involves the procurement of tablets to record the information on, which will be tested in all areas of the wards.”

    Source location

    Response from Solent NHS Trust
    Page 2 · response
    Published 13 November 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

    Provide temporary staff and partner mental health teams with electronic access to document assessments and care plans in Oceano.

    Verbatim wording from the response

    “Within the ED, bank and temporary members of staff are provided with a temporary ICT login, and a login for Oceano allowing for electronic documentation of patient assessment and delivery of care. Our partner organisations, Solent NHS Trust, and Southern Health Foundation Trust mental health teams, also now have access to Oceano allowing them to input their assessments and plan of care directly into the Trust’s ICT system negating the need for paper records.”

    Source location

    Response from Portsmouth Hospitals University NHS Trust
    Page 4 · response
    Published 13 November 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

    Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.

    Verbatim wording from the response

    “The Trust fully agrees that the current hybrid between paper and electronic records creates greater complexity and inefficiency, impacting the ability of the multidisciplinary teams to locate all necessary information for each patient. The ambition of PHU and similar NHS Trusts who have not already done so is to move to a true paper free Electronic Patient Record (EPR). We are working with the Integrated Care Board (ICB) and other Acute Trusts in Hampshire and Isle of Wight to achieve that goal over time.”

    Source location

    Response from Portsmouth Hospitals University NHS Trust
    Page 4 · response
    Published 13 November 2023

    Open published response

  2. Hampshire, Portsmouth and Southampton

    AI-generated summary

    Thomas Victor HUNTLEY · 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

    Thomas Victor Huntley died in HMP Winchester after he was found unresponsive in his cell on 28 May 2020, following a planned act intended to end his life. The inquest identified concerns about missing and inadequately recorded risk information, failures in ACCT documentation and risk assessment, inadequate observations, information sharing between prison and healthcare staff, and ligature risks in cells.

    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 ACCT audits to identify inadequate document completion

    Wider context from the report

    “The second relates to the quality and effectiveness of ACCT audits. We heard evidence that ACCT documents are reviewed annually. The case manager mentioned above advised that he had not received any adverse feedback about the quality of his ACCT documents and no issues with them had been identified. Given the inadequate nature of the ACCT document opened on Mr Huntley and apparent lack of understanding about completing the documents the quality of the audits is brought into question. ”

    Source location

    Thomas Victor HUNTLEY · 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

    Operate an accountability system for ACCT quality assurance, feeding findings back to staff and rectifying serious concerns.

    Verbatim wording from the response

    “assurance checks take place at three main stages. The first takes place within 48 hours from the opening of the ACCT, conducted by the Safety Team, assessing the effectiveness of the immediate steps taken and quality of the documentation. The second check is by the Custodial Manager who checks the ongoing record and the case reviews, ensuring that entries are detailed and meaningful, and whether previously identified actions or identified concerns continue to be taken into account and built on. Following ACCT closure, the Safety Team then review the full ACCT document including the seven day post closure monitoring procedure and the post closure reviews.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 22 November 2023

    Open published response

  3. Manchester South

    AI-generated summary

    James John Jude Booth · 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

    James Booth, who had longstanding mental ill-health and was detained at The Priory, Altrincham, absconded on 7 October 2020 and was found dead on 14 October 2020; the medical cause of death was hanging. The principal concerns were inadequate security of the ward garden, including the fence, inadequate risk assessments, and failures to communicate and document repeated incidents and emerging risk between shifts.

    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 audit and robustly review handover documents

    Wider context from the report

    “Matter Two The evidence showed that there was no appreciation of the emerging pattern of behaviour. A major contributing factor was the lack of exchange and transfer of information at the handover between the consecutive shifts. In particular, the form specifically designed for this with a section for completion – ‘incidents in last 7 days’ which would have provided an information flow through was not completed. Whilst I heard evidence of steps taken to improve information exchange at a higher level than between ward staff (nurses and HCAs) I was very surprised to hear that no audit of these ‘handover documents’ had been carried out. Given the fundamental importance of the exchange of information between each shift and consecutive shifts I am of the opinion that The Priory have not carried out a sufficiently robust review. Until this failure is addressed there is a significant risk of a breakdown in the communication of adverse events across the shift pattern of several days. The risk of a lack of appreciation of an emerging pattern of behaviour remains. ”

    Source location

    James John Jude Booth · 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

    Attend weekly ward shift handovers and check their content, accuracy and detail.

    Verbatim wording from the response

    “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.”

    Source location

    Response from Priory
    Page 1 · response
    Published 27 September 2022

    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

    Monitor handover quality through internal compliance and divisional quality inspections.

    Verbatim wording from the response

    “Both ████████ and the Altrincham Hospital Director of Clinical Services, ████████, will continue to attend shift handovers on each of the wards on at least a weekly basis and continue to check the content, accuracy and detail of those handovers. Your concern and the matter of conducting robust shift handovers has also been raised across the Priory Healthcare portfolio via safety bulletins issued to hospital staff reminding them to ensure that shift handovers make sufficient reference to previous incidents. Our internal compliance team and the divisional quality team have also continued to monitor the quality of handovers during their inspections. Again, where matters of concern have been identified these have been brought to the immediate attention of the hospital SMT.”

    Source location

    Response from Priory
    Page 1 · response
    Published 27 September 2022

    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

    Introduce and trial an electronic handover template that consolidates patient and incident information and enables contemporaneous content audits.

    Verbatim wording from the response

    “Additionally, a detailed handover template is being introduced across the Priory Healthcare sites (and this is currently being trialled on Rivendell ward at Altrincham in response to your Regulation 28 report). The handover template has the capacity to download information from different applications including the electronic patient record (CareNotes) and the incident reporting system (Datix). This will give a detailed picture of the patient’s current health and”

    Source location

    Response from Priory
    Page 1 · response
    Published 27 September 2022

    Open published response

  4. Lancashire and Blackburn with Darwen

    AI-generated summary

    Gillian McKinlay · 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

    Gillian McKinlay, aged 68, was admitted to Royal Blackburn Hospital on 23 April 2018 with a provisional diagnosis of small bowel obstruction. A nasogastric tube requested by clinicians was not sited before her death four hours later, and the Coroner considered this contributed to the death. Concerns included unclear responsibility for patients in the Accident and Emergency Department, failure to undertake or escalate a clinically indicated review, and inadequacies in the Trust's investigation and subsequent measures.

    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 medical records completed by junior doctors

    Wider context from the report

    “1. For patients remaining for a considerable period of time in the Accident and Emergency Department there is no clear indication or understanding as to who is responsible for the overall patient's clinical care. 2. EWS scores indicated that a clinical review was mandated for which there is no evidence in the medical records that any such review took place by A & E medical staff or that the matter was referred to any of the on call clinical teams. 3. When the NG tube was unable to be sited and no obvious clinical review in response to the EWS scores had occurred, there is no evidence of escalation by the nursing staff either through the nursing hierarchy or the medical hierarchy. 4. The Trust's Serious Incident Review to identify the root causes of the incident raises the following concerns concerning the adequacy of the Trust's investigation and measures taken: a. NG tube not sited - the Trust's response does not address why there was a failure of escalation or referral back to the requesting teams and the updated action plan that "training on insertion should shorten time taken to decompress" is inadequate; b. that the EWS score mandated review by the acute care team (whoever that may be for these purposes-see first point), there is no evidence in the medical records apart from a blood gas that any such review took place or that any treatment occurred; c. the investigating consultant had informal conversations during the investigation with a middle grade doctor who had performed the arterial blood gas but was unable to state who this was, why no medical records were created and why no action was taken; d. the report states that there was a "correct escalation of the EWS at every stage" for which no evidence has been provided and appears to be factually incorrect; e. medical records created by the surgical registrar were in accurate as they were completed by a junior doctor and not checked; f. that no audit has taken place to ascertain whether the Trust's measures have had the appropriate effect. ”

    Source location

    Gillian McKinlay · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. West Sussex

    AI-generated summary

    Mildred Horrex · 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

    Mildred Horrex suffered an unwitnessed fall while sleeping in a chair at Pelham House on 30 December 2017, sustaining fractures to her C1 and C2 vertebrae, and died in hospital on 18 January 2018. The concerns identified were poor and sometimes inaccurate record keeping, insufficient information for an adequate fall-risk assessment, and discrepancies between medication records and the amount of medication held that were not detected by audits.

    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 monthly medication audits to detect recording discrepancies

    Wider context from the report

    “2. Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held. ”

    Source location

    Mildred Horrex · 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

    Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.

    Verbatim wording from the response

    “to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed”

    Source location

    2020-0126-Response-from-Pelham-House.pdf
    Page 2 · response
    Published 13 August 2020

    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

    Conduct monthly medication audits with internal management oversight, visible summaries, and external review of medication administration.

    Verbatim wording from the response

    “POINT 2 medication Medication is audited monthly CCG / Kamsons pharmacy myself and the GP have worked together to ensure safe practices are ongoing. Home manager Audits internally alongside the deputy manager and there is a visible summary at the end of the audit to highlight any potential concerns. External auditor also audits medication and administration when he visits. There is ongoing support from the CCG and Kamsons pharmacy After a request from myself GPs now provide patient summaries for all residents that are currently in Pelham house and coming in to Pelham house.”

    Source location

    2020-0126-Response-from-Pelham-House.pdf
    Page 2 · response
    Published 13 August 2020

    Open published response

  6. Inner North London

    AI-generated summary

    Collin Gary GRIFFITHS · 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

    Collin Gary Griffiths received a yellow fever vaccination on 23 March 2018 despite having previously undergone a thymectomy for a thymoma, and subsequently died from yellow fever vaccine-associated viscerotropic disease and multi-organ failure. The concerns identified were reliance on verbal communication to record medical conditions and the lack of auditing of the accuracy of nurses’ records at the travel clinic.

    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 auditing of the accuracy of nurses' medical records

    Wider context from the report

    “2. MASTA currently has no way of auditing whether the record a nurse makes is accurate. This could be assessed by questioning patients as they leave, or by sending in a patient specifically to test this anonymously. ”

    Source location

    Collin Gary GRIFFITHS · 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 standardized nurse audit covering completion and documentation of the medical risk-assessment process.

    Verbatim wording from the response

    “• We have written an audit for the nurses, to ensure that the assessments are being completed in full, looking at how the risk assessment is conducted, but more specifically looking to ensure the following actions are taken;”

    Source location

    2018-Response-by-Masta
    Page 4 · response
    Published 18 January 2019

    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

    Conduct rotating face-to-face clinic audits, investigate concerns through action plans and re-audits, and maintain scheduled rolling coverage.

    Verbatim wording from the response

    “• Face to face audits have been carried out at selected clinics in October and this will be alternated monthly going forwards to ensure that all clinics are covered; then this will be reviewed and any clinics of concern will be issued with an action plan and re-audited; this will work on a rolling basis. Previously this had been a bespoke audit, but has now been written to ensure consistency, in re-audit. Re-audits of 3 clinics have been scheduled during November 2018.”

    Source location

    2018-Response-by-Masta
    Page 4 · response
    Published 18 January 2019

    Open published response

  7. 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

    Lack of periodic audits of record keeping in similar cases

    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

  8. Gateshead and South Tyneside

    AI-generated summary

    EDWIN THOMPSON · 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

    Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and 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

    Failure to reinforce effective record keeping through regular management file checks

    Wider context from the report

    “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents. The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard. Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers. ”

    Source location

    EDWIN THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 regularly evaluate care-note quality and communicate shortcomings to staff

    Wider context from the report

    “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents. The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard. Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers. ”

    Source location

    EDWIN THOMPSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026