Recurring concern

Failure to maintain clear accountability for care documentation

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First reported 19 Sep 2013•Latest report 23 Jun 2025

Definition

What this concern includes

Includes failures of dedicated care-documentation accountability controls, including unclear assignment of responsibility for forms or records, inability to identify the staff member who completed them, and absence of a designated person responsible for keeping care documentation current.

Not included

  • Excludes general omissions, inaccuracies or delays in care records where responsibility or attribution is not itself the unsafe condition.
  • Excludes generic staffing, training, audit or governance deficiencies unless they directly impair accountability for care documentation.
  • Excludes clinical care, observation, assessment or treatment failures where care documentation accountability is not the shared unsafe condition.
  • Excludes documentation for non-care administrative, building-control or unrelated operational processes.
Reports
8

Distinct published reports

Individual concerns
8

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
5

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care2
Ashford and St Peter'S Hospitals NHS Foundation Trust1
Care Quality Commission1
Greater Manchester Mental Health NHS Foundation Trust1
Harbour Healthcare Ltd.1
Hc-One Limited1
Manchester University NHS Foundation Trust1
New Park Residential Home1
NHS England1
NHS Greater Manchester Integrated Care Board1
North London NHS Foundation Trust1
Queen's Hospital, Romford1
South West Yorkshire Partnership Teaching NHS Foundation Trust1
Stars Social Support Limited1
Stoke-on-Trent City Council1

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.

  1. Inner North London

    AI-generated summary

    Louise Elizabeth Amy Crane · 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

    Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action plan.

    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 ensure that staff make records using their own identification and accurately identify the author

    Wider context from the report

    “1) Record Keeping / Professional Standards There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to makes notes on the records system, without making it clear who the entry was actually made by. In this case there were two entries that appeared to have been made by a support worker, that were actually made by a nurse. Such misleading and inaccurate record keeping risks significant confusion in the provision of care and potentially creates significant risk in relation to the continuity of care. ”

    Source location

    Louise Elizabeth Amy Crane · 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

    Streamline Smart Card access and require bank staff to hold cards and complete Rio training before booking shifts.

    Verbatim wording from the response

    “Record Keeping / Professional Standards The Trust recognises the vital importance of accurate record keeping in supporting safe patient care. It is acknowledged that access to Smart Cards to support the use of Rio (the Trust’s Electronic Patient Record system) has been an issue, particularly for staff working via our bank staff provider NHS Professionals (NHSP). As part of the EMS program, this was investigated and processes streamlined so that all existing and new staff are now able to apply for a Smart Card and complete RIO training. Going forward, in order to be booked onto a bank shift, NHSP staff must have a Smart Card. As a result, all staff (substantive and NHSP) can now make their own records on the RIO System thereby reducing any reliance on using other colleagues’ accounts.”

    Source location

    Response from North London NHS Foundation Trust
    Page 4 · response
    Published 14 July 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 ward staff access daily and reinforce requirements against sharing Smart Cards or misattributing electronic records.

    Verbatim wording from the response

    “Ward managers are expected to complete a daily review of staff attending their wards to check access and ability to record accurately.”

    Source location

    Response from North London NHS Foundation Trust
    Page 4 · response
    Published 14 July 2025

    Open published response
  2. South Yorkshire (Western)

    AI-generated summary

    Anthony Wilkinson · 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

    Anthony Wilkinson died on 4 April 2018 after choking, with the inquest concluding that he was unlawfully killed as a result of foreign body obstruction of the airway. The report identifies concerns about the failure to incorporate Speech and Language Therapy advice on diet and supervision into care plans, risk assessments and staff communications, alongside wider concerns about care-provider governance and regulatory oversight.

    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 assign lead-carer responsibility for accurate and current home documentation

    Wider context from the report

    “(10)The Director, in evidence, did not describe consideration of a lead carer for service users who would hold some responsibility for ensuring documentation in the service users’ home was accurate and up to date. ”

    Source location

    Anthony Wilkinson · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

    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

    A decision to cease operating prevents provision of a detailed response to the indicated corrective actions.

    Verbatim wording from the response

    “A decision has been taken by the Registered Manager and Director of Stars Social Support Limited for the organisation to cease to continue. The Registered Manager and Director at Stars Social Support Limited has contacted the Local Authority and the Care Quality Commission to notify them that Stars Social Support Limited will cease to continue.”

    Source location

    2021-0102-Response-from-Stars-Social-Support-Ltd-Redacted
    Page 1 · response
    Published 13 April 2021

    Open published response
  3. Surrey

    AI-generated summary

    Mrs Alice Doris Dixon · 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

    Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

    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 identify the staff member completing and initialling part of a consent form

    Wider context from the report

    “5. Part of the consent form was filled in and initialled by a person who cannot be identified by the Trust as to which member of staff it was. ”

    Source location

    Mrs Alice Doris Dixon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Manchester South

    AI-generated summary

    Joan Lunt · 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

    Joan Lunt, who had idiopathic pulmonary fibrosis and lived in a nursing home, became seriously unwell on 26 October 2017 and died after being transferred to hospital; the inquest recorded natural causes. Concerns were raised about significant deficiencies in agency care staff’s recording of information on the nursing home’s electronic records system, including unclear staff identification, potential miscommunication, and effects on continuity of care. Evidence also indicated that the issue had apparently been raised previously but assurances that it had been addressed were not reflected in Mrs Lunt’s records.

    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 accurately identify the staff member and role responsible for resident care records

    Wider context from the report

    “In the course of evidence heard at the inquest, it emerged that there were significant deficiencies in the way in which agency care staff recorded information about residents on Hilltop Hall’s electronic records system. The evidence before the court was that agency staff would either: 1. Relay matters to be recorded in the notes to a substantive member of staff who would then make an entry reflecting what they had been told (i.e. in the name of the substantive staff member in question); or 2. Make an entry directly on the system which simply records it has been made by ‘Agency Staff’, rather than explaining the identity and role of the person making the record. This issue raises significant concerns about the integrity of Hilltop’s electronic patient record, particularly as far as it relates to checks made on vulnerable residents by care staff. In addition to making it difficult or impossible in retrospect to identify which member of staff has undertaken what activity, the current system has the potential to lead to miscommunication between staff members (for example, in relation to which staff member on a shift has undertaken important checks on residents’ wellbeing), and can be detrimental to continuity of care. A further matter of concern which emerged in evidence from the Team Manager from Stockport Metropolitan Borough Council’s Adult Safeguarding service is that this issue has apparently been raised previously by the local authority in the context of another safeguarding investigation. The Team Manager’s evidence was that assurances had been received from managers at Hilltop Hall that this issue had been addressed, whereas Mrs Lunt’s records suggest this is not, in fact, the case. ”

    Source location

    Joan Lunt · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Sunderland

    AI-generated summary

    Patricia Ann Heslop · 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

    Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.

    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

    Unclear responsibility for completing care forms

    Wider context from the report

    “7. There were numerous forms for staff to complete and read, instead of an integrated IT system. Staff were unsure, who had to complete the forms either for themselves, or on behalf others. ”

    Source location

    Patricia Ann Heslop · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Stoke-on-Trent and North Staffordshire

    AI-generated summary

    Janine Eugenie Pierrette KAISER · 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

    Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.

    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 identify staff completing care records

    Wider context from the report

    “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses. ”

    Source location

    Janine Eugenie Pierrette KAISER · 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

    Share investigation learning with New Park House and recommend improvements to recording practices.

    Verbatim wording from the response

    “Some turns had been missed but Mrs Kaiser was known to regularly refuse to comply with the turn regime in place. It was acknowledged that such refusals were not always documented and the home took this away as a recommendation from the investigation for further work with the staff.”

    Source location

    2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
    Page 3 · response
    Published 14 July 2015

    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

    Failure to assign clear responsibility for recording increased observations

    Wider context from the report

    “2. Whenever an increased level of observations is initiated pending a mental health assessment because of the concern about a patient’s mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations actually involve (e.g. what 1 in every 15 minutes means and precisely what should be recorded) and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done. I am concerned that at present such does not exist. ”

    Source location

    Kimberley Lauren Lindfield · Prevention of Future Deaths report
    Page 7 · 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 a joint observation procedure and recording charts defining observation requirements, recording arrangements, and staff responsibility.

    Verbatim wording from the response

    “2. Whenever an increased level of observation is initiated, pending a mental health assessment, because of the concern about patients’ mental state and/or self harm/suicidal behaviour there should be a clear written policy or protocol setting out what those observations involve and the recording of them with a clear chain of responsibility with the obligation on one appropriate member of staff to ensure that this is done.”

    Source location

    2015-0036-Greater-Manchester-West-NHS-Trust
    Page 2 · response
    Published 2 February 2015

    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 UHSM with advice on developing its self-harm policy and guidance and protocols for observing patients at risk.

    Verbatim wording from the response

    “In respect of the other concerns raised in your report, MMHSCT has agreed to provide UHSM with advice in respect of their development of a self-harm policy and also with their development of guidance and protocols on observation of patients at risk. MMHSCT has suggested that they may wish to build on our existing observation policy.”

    Source location

    2015-0036-Response-by-Manchester-Mental-Health-NHS
    Page 2 · response
    Published 2 February 2015

    Open published response
  8. London Eastern

    AI-generated summary

    Tripta Rani KUMAR · 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

    Tripta Rani KUMAR underwent planned hysterectomy and was discharged, but was readmitted the following day with abdominal pain and a perforated bowel. She developed sepsis, suffered a cardiac arrest on 25 August 2012, and died despite CPR. A principal concern was that penicillin-containing Tazocin was prescribed despite records and a wristband indicating a penicillin allergy, after an unsigned handwritten alteration changed the record to “nil allergies”.

    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 maintain accurate and attributable penicillin allergy records

    Wider context from the report

    “In the emergency department, during the course of treatment given on the 24th August 2012, the deceased was attended to by an ST4, doctor in Obstetrics and Gynaecology. The doctor documented the likely diagnosis, requested an urgent CT scan and prescribed intravenous antibiotics in the form of Tazocin. Tazocin contains two active ingredients, Piperacillin, which is a penicillin type antibiotic and Tazobactum which is a medicine that prevents bacteria from inactivating Piperacillin. Evidence from the family of the deceased, confirmed by ████████ (Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. ████████ further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead. This was in handwriting but with no signature to confirm who had written the note. The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in an anaphylactic shock which, in turn, could have resulted in death. ”

    Source location

    Tripta Rani KUMAR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026