First reported 7 Aug 2014•Latest report 9 Dec 2025
Definition
What this concern includes
Includes failures of controls dedicated to linking, cross-referencing, amalgamating or making jointly relevant information available across related patient records, including records for a mother and baby or records held under different hospital numbers, where the failure can leave clinicians without the complete relevant history.
Not included
Excludes general clinical-record completeness, accuracy or availability failures where no failure to link or cross-reference separate related records is identified.
Excludes failures to transfer records between healthcare organisations where the material problem is transmission between organisations rather than integration or cross-referencing of related records.
Excludes generic inter-agency communication or information-sharing failures where separate related patient records are not the bounded unsafe object.
Excludes failures limited to reviewing or acting on records after the related records were reliably linked and made available.
Reports
4
Distinct published reports
Individual concerns
6
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
19
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.
Barts Health NHS Trust1
Care UK1
Department of Health and Social Care1
Derbyshire Community Health Services NHS Foundation Trust1
Derbyshire Healthcare NHS Foundation Trust1
HM Prison and Probation Service1
NHS Derby and Derbyshire Integrated Care Board1
NHS England1
Pentonville Prison1
Sett Valley Medical Centre1
University Hospitals of Derby and Burton NHS Foundation Trust1
NHS trust3
Executive agency1
Executive non-departmental public body1
Healthcare site1
Integrated care board1
Ministerial department1
Multi-service care provider1
Prison or young offender institution1
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.
Derby and Derbyshire
Concerns raised1
Failure to record or cross-reference information relevant to both mother and baby in both records
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.14
Action
Document telephone advice-line discussions in the relevant parent’s health record when information concerns parental mental health.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Require staff to cross-reference relevant parental mental-health information in both child and parent records.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Use the SystmOne auto-consultation function to create parent-record entries referencing relevant information from child contacts.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Incorporate documentation and cross-referencing guidance into the Trust’s Perinatal Mental Health standard operating procedure.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Reinforce parental-record documentation standards through staff training and supervision.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Share a one-page document with all staff clarifying expected record-keeping standards for parental mental health.
Stated by Derbyshire Community Health Services NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Discuss developing guidance with DCHS on when health visitors should cross-reference medical notes for babies and mothers.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Add screen alerts to the records of mothers referred to perinatal mental health services and their children under two.
Stated by Sett Valley Medical CentreStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Document significant maternal mental-health concerns identified during appointments for children of mothers receiving perinatal mental-health care in the mother’s record and send consultation notes to the perinatal team.
Stated by Sett Valley Medical CentreStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Add a note to the child’s record directing clinicians to the mother’s notes when significant maternal mental-health concerns are identified.
Stated by Sett Valley Medical CentreStatus unclearThe respondent did not make the status of this action clear when they made their response on 15 December 2025.
Action
Encourage specialist perinatal mental health teams to include record keeping in training for the wider perinatal pathway.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Provide providers with guidance on recording information relevant to mother and baby and sharing information about frequent service access.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Request discussion of recording information in both mother’s and baby’s notes at the next local maternity network meeting.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Work with NHS England on cross-referencing information in mother and baby records.
Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned 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.2
Position
Confidentiality prevents documenting the mother’s health information in the child’s record, requiring a cross-reference instead.
Stated by Sett Valley Medical CentreUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Some concerns, particularly cross-referencing mother and baby records, extend beyond the ICB’s organisational influence and require work with NHS England.
Stated by NHS Derby and Derbyshire Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Staffordshire and Stoke-on-Trent
Concerns raised1
Failure of allergy information to automatically cross-populate between 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.
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
Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 6 June 2024.
Action
Establish a multidisciplinary allergy working group to ensure robust systems for managing allergies and alerts.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 June 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
Position
The Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.
Stated by University Hospitals of Derby and Burton NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The Care Quality Commission will assess the incident and determine whether further regulatory action is needed.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
The University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Inner North London
Concerns raised1
Failure to maintain single, accurate NOMIS and SystmOne records
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.3
Action
Run a monthly report to identify and merge duplicate prisoner records created by differing name spellings.
Stated by HM Prison and Probation ServiceStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Share learning about duplicate medical records with clinical teams through national and regional quality-assurance meetings.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Action
Remind clinicians to review relevant records thoroughly and query missing records or other anomalies.
Stated by Care UKStated completedThe respondent said that this action was complete when they made their response on 23 May 2019.
Inner South London
Concerns raised3
Failure to incorporate temporary medical records into the permanent file
Unavailability of potentially relevant information from separate medical records to treating doctors
Failure to amalgamate or cross-reference medical records held under different hospital numbers
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.
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Includes failures of controls dedicated to linking, cross-referencing, amalgamating or making jointly relevant information available across related patient records, including records for a mother and baby or records held under different hospital numbers, where the failure can leave clinicians without the complete relevant history.
