Recurring concern

Unreliable recording of service-user movements

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First reported 20 Feb 2015•Latest report 8 Jun 2023

Definition

What this concern includes

Includes failures in dedicated records or processes for recording service-user movements into, out of or within a controlled care setting, including incomplete walk books and sign-in/sign-out books, missing entries for short absences, and related checks needed to maintain an accurate movement record.

Not included

Excludes general clinical, care or custody record-keeping failures where service-user movement recording is not the material concern.
Excludes failures to supervise, locate or respond to an absent service user when movement records were reliably maintained and the problem is a downstream response failure.
Excludes ordinary appointment, leave or discharge records unless they specifically record service-user movements in the same controlled care-setting process.
Excludes generic staffing, communication or documentation deficiencies that do not directly impair recording of service-user movements.

Reports: 3
Individual concerns: 3
Date range: 2015–2023
Stated actions: 4

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

East London NHS Foundation Trust1

St Edward's School1

Tameside and Glossop Integrated Care NHS Foundation Trust1

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.

8 Jun2023
Inner North London
Concerns raised1
1. Failure to record service-user movements in the unit sign-in/sign-out book
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.
  Stated by East London NHS Foundation TrustStated completed
2. Action
  Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.
  Stated by East London NHS Foundation TrustStated in progress
AI-generated summary

Hilary Clare (Billy) Guedalla · 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

Hilary Clare (Billy) Guedalla died by suicide after leaving Gardener Ward, Homerton Hospital, unaccompanied on 29 October 2021 and was found on 30 October 2021. The report identifies concerns including failures to communicate the decision restricting unescorted leave and information about suicide risk, inadequate risk assessment, delays and failures in contacting emergency services and family, non-compliance with missing-patient procedures, and inadequate staffing.

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 record service-user movements in the unit sign-in/sign-out book
Wider context from the report
“4. The “Sign in/Sign out” book which was supposed to record the movements of service users in the unit was frequently not completed, particularly when service users went out for short periods. ”
Source location
Hilary Clare (Billy) Guedalla · 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
Relocate and revise inpatient Sign In/Sign Out books to capture leave, return, documentation, belongings and search information.

Verbatim wording from the response
“I have been provided with assurances that the process for managing the Sign In/Sign Out book (the “book”) on all inpatient units in City and Hackney has been improved. The book is now located at the nursing office to enhance completion. It has been revised to include the following information: service user name, whether leave is escorted (and by whom) or not, location of planned leave, time left and time returned, the validity of Section 17 leave papers for detained patients, description of items taken, and whether search on return was completed.”

Source location
Response from East London NHS Foundation Trust
Page 3 · response
Published 22 June 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
Spot-check each Sign In/Sign Out book once per shift and develop a more robust audit system.

Verbatim wording from the response
“Presently, either the nurse in charge or the shift coordinator spot checks the book to ensure completion one time per shift. However, work is being done to develop a more robust audit system.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 22 June 2023
Open published response
28 Jun2016
Manchester South
Concerns raised1
1. Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
2. Action
  Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concern
AI-generated summary

David Michael little · 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 Michael Little was admitted to hospital with abdominal pain and a suspected small-bowel mass. His condition worsened, and a scan revealed a blockage caused by ischaemic bowel; delays in scanning, reporting, and insertion of an NG tube meant that surgery was considered when it was deemed too late. The report raised concerns about poor record-keeping, lack of a clear diagnostic and monitoring pathway, failure to recognise the seriousness of bowel obstruction, and poor communication among staff and with the family.

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 keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
Wider context from the report
“1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the procedure had been carried out, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day. ”
Source location
David Michael little · 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
Implement the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.

Verbatim wording from the response
“Following Mr Little’s death, the department has published a ‘Radiology Requesting and Reporting Policy’ in February 2016 (Document 1 attached). The Policy requires the clinician to document the discussion in the clinical notes of the request made to Radiology and the response given. Once the scan is requested, the Radiology department must then ensure that they document any changes to the planned appointment and communicate them with the responsible clinician. It is clear that at the time of Mr Little’s death, the communication appeared to be confusing and there are insufficient documented records to confirm what conversations actually took place at the time.”

Source location
2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016
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
Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.

Verbatim wording from the response
“In addition, there is currently a documented tracking/handover policy in draft (Document 2 attached) which will document any specific requests that are given to the patient via the ward staff to prepare them for their investigation, e.g. nil by mouth or the requirement for a full bladder. It will include a feedback form that the porter will take to the ward when collecting the patient for a member of the nursing staff to sign to confirm the patient’s identification and the test/imaging the patient is scheduled for. On return of the patient to the ward, the sheet will document what investigation has taken place and any special observations required. This form will form a part of the radiology record and be filed in the patient’s notes.”

Source location
2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 28 June 2016
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 patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.

Verbatim wording from the response
“1. There was strong evidence of a failure by the hospital staff to keep clear records of when an inpatient was to be taken to “radiology”, for what purpose, whether the patient had been returned to the ward. In the present case, Mr Little was taken ‘by mistake’ in the belief that he was another patient, and it was only on arrival at radiology that this was realised when they decided to proceed with his scan which had been planned for the following day.”

Source location
2016-0237-Response-by-Tameside-Hospital-NHS-Trust
Page 1 · response
Published 28 June 2016
Open published response
20 Feb2015
Southampton and the New Forest
Concerns raised1
1. Failure to complete movement logs accurately and with sufficient detail
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Daniel Stickland · 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

Daniel Stickland, aged 17, was found collapsed after falling from his bed at his residential school on 14 May 2014, following two seizures earlier that day. He was taken to hospital and pronounced dead the following day; concerns included inadequate handovers, inaccurate or inaccessible logs, and no clear central method for recording significant medical events.

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 movement logs accurately and with sufficient detail
Wider context from the report
“(2)Movement log that was not completed accurately or with enough detail ”
Source location
Daniel Stickland · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to record service-user movements in the unit sign-in/sign-out book

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

Concerns raised1

Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to complete movement logs accurately and with sufficient detail

Actions described in response 2

Actions described in response 2

Respondent positions 1