Recurring concern

Unreliable recording of safeguarding information

First to latest report 12 Sep 2014 — 25 Feb 2026

Reports that mention this concern
11
Times this concern has been raised
14
Stated actions linked to this concern
23

What this concern includes

Includes failures to record, update or preserve material safeguarding information in designated safeguarding forms, admission records or comparable care and custody records where the omission can impair recognition, assessment, communication or management of safeguarding risk.

What is not included
  • Excludes generic clinical or administrative record-keeping failures where safeguarding information is not the material object.
  • Excludes failures to investigate, refer, escalate or act on safeguarding information after it has been accurately recorded.
  • Excludes failures involving transfer or access to safeguarding information where the information was recorded reliably and the unsafe condition is only later communication or retrieval.
  • Excludes generic safeguarding training or professional-judgement deficiencies that do not directly cause incomplete or absent recording of safeguarding information.

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Isle of Wight

    AI-generated summary

    Barbara Monica May Cooke · 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

    Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.

    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

    Lack of admission recording of open safeguarding concerns

    Wider context from the report

    “4. I am concerned that there does not appear to be a system in place at St Mary’s Hospital to record on admission that a patient is the subject of an open Safeguarding concern. (In this case, the subject of the Safeguarding alert was an adult, but this concern relates to both adults and children.) ”

    Source location

    Barbara Monica May Cooke · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026