Recurring concern
Failure to assure the quality of clinical and care records
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Request correctionFirst reported 22 Dec 2014•Latest report 16 Jun 2026
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
- Individual concerns
- 20
- Date range
- 2014–2026
- Stated actions
- 30
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to properly record, store or audit paper observations and records
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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.4
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Action
Attend inpatient handovers, audit clinical records, and escalate audit outcomes through governance meetings to assure handover quality and accuracy.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Replace paper-based clinical observation forms with electronic forms feeding directly into SystmOne, including tablet procurement and ward testing.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Provide temporary staff and partner mental health teams with electronic access to document assessments and care plans in Oceano.
Stated by Portsmouth Hospitals University NHS Trust
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Action
Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Stated by Portsmouth Hospitals University NHS Trust
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Concerns raised1
Failure of ACCT audits to identify inadequate document completion
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 concernsEach 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
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Action
Operate an accountability system for ACCT quality assurance, feeding findings back to staff and rectifying serious concerns.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to audit and robustly review handover documents
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Attend weekly ward shift handovers and check their content, accuracy and detail.
Stated by Priory Group -
Action
Monitor handover quality through internal compliance and divisional quality inspections.
Stated by Priory Group -
Action
Introduce and trial an electronic handover template that consolidates patient and incident information and enables contemporaneous content audits.
Stated by Priory Group
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Concerns raised1
Failure to check medical records completed by junior doctors
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure of monthly medication audits to detect recording discrepancies
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.
Stated by Pelham house -
Action
Conduct monthly medication audits with internal management oversight, visible summaries, and external review of medication administration.
Stated by Pelham house
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Concerns raised1
Lack of auditing of the accuracy of nurses' medical records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach 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
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Action
Implement a standardized nurse audit covering completion and documentation of the medical risk-assessment process.
Stated by Masta Limited -
Action
Conduct rotating face-to-face clinic audits, investigate concerns through action plans and re-audits, and maintain scheduled rolling coverage.
Stated by Masta Limited
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Concerns raised1
Lack of periodic audits of record keeping in similar cases
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure to reinforce effective record keeping through regular management file checks
Failure to regularly evaluate care-note quality and communicate shortcomings to staff
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026