First reported 12 Sep 2013•Latest report 16 Jun 2026
Definition
What this concern includes
Includes failures of electronic patient-record systems or their dedicated workflows that prevent relevant information from being reliably accessed, displayed, preserved, shared, handed over or acted upon across clinical care.
Not included
Excludes failures concerning paper-only records or information sharing with no explicit electronic patient-record connection.
Excludes generic failures of clinical attention, staffing, training or communication unless the report directly ties them to the electronic patient-record system or its dedicated workflow.
Excludes concerns about the clinical decision itself where the electronic patient-record system did not contribute to the information-access or action failure.
Excludes unrelated information systems that are not electronic patient-record systems or directly integrated clinical-record workflows.
Reports
67
Distinct published reports
Individual concerns
75
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
102
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 Care19
NHS England19
Care Quality Commission5
Avon and Wiltshire Mental Health Partnership NHS Trust3
University Hospitals of Derby and Burton NHS Foundation Trust3
Essex Partnership University NHS Foundation Trust2
Greater Manchester Health and Social Care Partnership2
Ministry of Justice2
NHS Derby and Derbyshire Integrated Care Board2
Appello Careline Limited1
Association of Ambulance Chief Executives1
Association Of British Neurologists1
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1
NHS trust40
Ministerial department22
Executive non-departmental public body19
Healthcare site6
Health and social care service regulator5
Integrated care board5
Private limited company4
Community interest company2
Domiciliary care provider2
Health-system partnership2
Independent healthcare provider2
Registered charity2
Type not available2
Company1
Company limited by guarantee1
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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to record clinically relevant information in EMA notes
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 concerns
Each 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
Action
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Review training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.
Stated by South East Coast Ambulance Service NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 August 2026.
Action
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
Stated by TSAStated plannedThe respondent said that this action was planned when they made their response on 14 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
Position
Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.
Stated by Appello Careline LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Stated by Association of Ambulance Chief ExecutivesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
Stated by TSAOutside remitThe respondent said that this matter was outside its role or authority.
Position
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Electronic Section 17 Leave recording failing to preserve leave timings, conditions and return visibility
This report raised 11 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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to transfer all prescribed medication into the electronic MAR and cross-check it at agency handover
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 concerns
Each 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.7
Action
Complete a formal review of the MAR chart SOP for UCR and Home First services.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Update the MAR chart SOP with guidance on discontinued medicines remaining in patients’ homes and mandatory GP second checks for discrepancies.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Revise and implement UCR referral documentation to require receiving agencies to reconcile medicines with prescribers and pharmacies and clarify that UCR MAR charts are for SCFT staff only.
Stated by Sussex Community NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 March 2026.
Action
Strengthen referral-pathway expectations that medicines reconciliation is confirmed when care responsibility transfers.
Stated by Sussex Community NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Conduct a themed review of UCR medication incidents involving MAR charts and report findings through Trust governance structures.
Stated by Sussex Community NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 March 2026.
Action
Photograph all medicines present at assessment and onboarding for every new care package.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Action
Require staff to cross-check medicines against prescribing records, administration records, and referral documentation during handover.
Stated by Coastal Homecare (Hove) Ltd.Stated completedThe respondent said that this action was complete when they made their response on 26 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Receiving care agencies are responsible for medicines reconciliation with prescribers and pharmacies; SCFT MAR charts are not definitive records for external providers.
Stated by Sussex Community NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised2
Failure of the patient records management system to accurately highlight important information for patient care and treatment
Failure of the patient records management system to accurately highlight important information for patient care and treatment
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Consider adding an explicit CAA bleeding-risk prompt to the VTE assessment tool through the Thrombosis Committee and embed any agreed change in Trust guidelines.
Stated by West Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2026.
Action
Develop the safer handovers quality-improvement project to improve highlighting of essential information during nurse-to-nurse transfers.
Stated by West Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
An automated CAA anticoagulation alert cannot be implemented because eCare lacks the necessary functionality and reliable evidence base.
Stated by West Suffolk NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Sunderland
Concerns raised2
Inconsistent use of the Omnicell cabinet and electronic medication record
Failure to record the actual administering nurse on the electronic medication record
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 concerns
Each 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.6
Action
Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Integration of Omnicell and EPMA is currently not viable because evidence is limited, costs are significant, and integration may introduce patient safety risks.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Derby and Derbyshire
Concerns raised1
Lack of a single electronic patient record accessible to all services
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.
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.9
Action
Share identified non-SystmOne GP practices with Perinatal CMHT clinicians and administrators.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Add alerts to patient records identifying GP practices that do not use SystmOne.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Draft an information leaflet explaining different electronic records, their impact, and risk mitigation.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Send the electronic-record information leaflet to GPs when referring patients from practices using different systems.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Add contextual-information-sharing guidance to the electronic referral document for professionals.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Provide team training on using EMIS interoperability to view SystemOne within two months.
Stated by Sett Valley Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Provide £20 million investment to connect care records across England by March 2026.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Develop the Single Patient Record to provide unified access to patient information across care settings.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Work with the Summary Care Record Programme to support wider access to relevant patient information.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Configuration and interoperability of clinical record systems across NHS providers and GP practices fall outside the Trust’s direct control and remit.
Stated by Derbyshire Community Health Services NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Resolving the absence of a unified patient record requires system-wide and national action overseen by NHS England, rather than action by an individual Trust.
Stated by Derbyshire Community Health Services NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing universal health visiting, professional communication, GP liaison and record-access arrangements address local information-sharing needs despite the absence of a single record.
Stated by Derbyshire Community Health Services NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Changing from EMIS to SystmOne would significantly increase risk across integrated primary-care and community services.
Stated by Sett Valley Medical CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Interoperability specifications and related information-technology due diligence are outside the Practice’s authority and control.
Stated by Sett Valley Medical CentreOutside remitThe respondent said that this matter was outside its role or authority.
Position
Developing interoperability between EMIS and SystmOne is the responsibility of the NHS Derby and Derbyshire Integrated Care Board as service commissioner.
Stated by Sett Valley Medical CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England does not mandate IT infrastructure, so it cannot require a single electronic patient record across providers.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
East London
Concerns raised1
Lack of a coordinated process for producing and storing critical respiratory action plans in online clinical 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 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.
West Yorkshire (Western)
Concerns raised1
Failure to act on relevant electronic patient record entries across clinical colleagues
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.
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
Action
Establish a Quality Assurance Group reporting to the Board subcommittee to oversee care standards and record-keeping compliance.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 July 2025.
Action
Further develop the learning-disability dashboard to support patient identification, care prioritisation, audit compliance and oversight.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
Action
Revise the learning-disability care plan and support implementation with training on completion expectations.
Stated by Calderdale and Huddersfield NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 July 2025.
Gateshead and South Tyneside
Concerns raised2
Fragmented clinical information systems requiring users to switch between systems
Failure of multiple clinical systems to support safe transfers of care
Responses linked to these concerns
Each 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
Action
Establish the Single Patient Record to unify patient data and provide clinicians with accessible patient information.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Each provider organisation is responsible for sharing information across different digital systems through its established local digital governance processes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Birmingham and Solihull
Concerns raised1
Failure to adequately record heel-skin inspections in electronic inpatient notes
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 concerns
Each 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
Action
Require the nurse in charge on each shift to check that care assessments, including skin inspection charts, are fully completed.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.
Action
Conduct ward spot checks of care documentation to verify completion of required assessments and skin inspection charts.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Reviews found no pressure damage before 15 October, when a blister was identified, documented, escalated and assessed.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Pin
Get email alerts
Request correction
Includes failures of electronic patient-record systems or their dedicated workflows that prevent relevant information from being reliably accessed, displayed, preserved, shared, handed over or acted upon across clinical care.
