Failure to reliably review clinical records for safety deficiencies
First to latest report 6 Mar 2015 — 16 Jun 2026
Reports that mention this concern
10
Times this concern has been raised
10
Stated actions linked to this concern
11
What this concern includes
Includes dedicated clinical-record review, audit or management-oversight processes intended to identify safety-relevant gaps, omissions or unrecognised clinical issues in records, including failures to detect such issues without a complaint or staff report.
What is not included
Excludes failures to create, complete or maintain clinical records where the record-review or oversight process is not itself deficient.
Excludes failures to retrieve or transfer records between services when the review process is adequate but the records are unavailable.
Excludes failures to review records before making an individual clinical-care decision; those concern prospective clinical record review rather than retrospective safety assurance.
Excludes generic governance, audit or management-oversight deficiencies not specifically involving review of clinical records for safety deficiencies.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
NHS England2
Amberley Hall Care Home1
Appello Careline Limited1
Association of Ambulance Chief Executives1
Athena Care Homes (UK) Limited1
Cardinal HC Limited1
Frimley Health NHS Foundation Trust1
Masta Limited1
Rush Green Medical Centre1
South East Coast Ambulance Service NHS Foundation Trust1
Sussex Partnership NHS Foundation Trust1
Torbay and South Devon NHS Foundation Trust1
TSA – The Voice of Technology Enabled Care1
United Lincolnshire Teaching Hospitals NHS Trust1
NHS trust5
Private limited company3
Executive non-departmental public body2
Company1
Healthcare site1
Health-sector membership body1
Nursing home1
Professional membership body1
Reports and published responses 10 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked responses
Appello Careline Limited
Association of Ambulance Chief Executives
NHS England
South East Coast Ambulance Service NHS Foundation Trust
TSA
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
South East Coast Ambulance Service NHS Foundation Trust
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
South East Coast Ambulance Service NHS Foundation Trust
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
South East Coast Ambulance Service NHS Foundation Trust
Review training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
South East Coast Ambulance Service NHS Foundation Trust
Current AI and automated call-handling solutions are not sufficiently developed or practicable for EMA call processes.
Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
Appello Careline Limited
Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Association of Ambulance Chief Executives
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
TSA
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
Outside remitThe respondent said that this matter was outside its role or authority.
NHS England
Operational concerns about ambulance care are the responsibility of SECAMB, which is best placed to respond directly.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Devon, Plymouth and Torbay
Concerns raised1
Lack of effective clinical-note review to identify unrecognised or unreported clinical issues
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Torbay and South Devon NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Torbay and South Devon NHS Foundation Trust
Use Medical Examiner reviews to systematically examine deaths and associated records, report concerns to DCIQ, and request structured judgement reviews where care may have contributed.
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.
Linked response
Frimley Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Frimley Health NHS Foundation Trust
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Worcestershire
Concerns raised1
Failure of investigations to identify false care records and related care deficiencies
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Cardinal HC Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Cardinal HC Limited
Conduct daily Resident of the Day spot checks to identify documentation gaps and take corrective action until Care Vision operates.
Cardinal HC Limited
Establish a multi-layered senior-management review process for internal investigations.
Cardinal HC Limited
Train all home managers to review care documentation and conduct investigations thoroughly.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Cardinal HC Limited
The missed false entry was an unfortunate oversight, not evidence of a failure in the investigation process.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Norfolk
Concerns raised1
Failure to identify gaps in records through routine management oversight
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Failure to audit patient records for prescribing outside surgery policy
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
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.
Linked response
Masta Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Masta Limited
Implement a standardized nurse audit covering completion and documentation of the medical risk-assessment process.
Masta Limited
Conduct rotating face-to-face clinic audits, investigate concerns through action plans and re-audits, and maintain scheduled rolling coverage.
West Sussex
Concerns raised1
Failure of auditing of nursing records to identify documentation gaps
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure of paper-record review to identify mental health diagnoses and lack of medication
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England Lancashire and Greater Manchester
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
NHS England Lancashire and Greater Manchester
Remind practices to check, highlight and correctly code significant diagnoses when patients transfer to another practice.
Central Lincolnshire
Concerns raised1
Failure to identify and rectify missing full notes after a death
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.