Recurring concern

Unreliable access to relevant clinical records for safe care

First to latest report 12 Sep 2013 — 22 Jun 2026

Reports that mention this concern
122
Times this concern has been raised
129
Stated actions linked to this concern
192

What this concern includes

Includes failures to retrieve, locate, present or provide access to relevant existing records for assessment, treatment and care decisions.

What is not included
  • Excludes absent or inaccurate information that was never reliably recorded.
  • Excludes failures to transfer otherwise available information to another service or recipient.
  • Excludes failure to review records that were already available unless access or retrieval was also deficient.

Reports and published responses 122 reports

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

  1. Inner North London

    AI-generated summary

    Thomas Charles TAYLOR · 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

    Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

    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

    Delays and lack of focus in locating missing clinical records

    Wider context from the report

    “2. There was no protocol for the loss of notes and drug chart. Attempts by the ward staff to locate these were not prompt, focused or sustained. The notes and chart were later found simply in a drawer on the ward. ”

    Source location

    Thomas Charles TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Inner South London

    AI-generated summary

    Vijay Sonagara · 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

    Vijay Sonagara, who had alcoholic liver disease, underwent routine surgery for repair of an inguinal hernia on 8 February 2013. His condition deteriorated rapidly, and he died at St Thomas’ Hospital on 22 February 2013 after developing decompensated alcoholic liver disease requiring intensive care. The concerns were that medical records were held under different hospital numbers and in a temporary file, were not amalgamated or cross-referenced, and contained potentially relevant information that was unavailable to his treating doctors.

    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

    Unavailability of potentially relevant information from separate medical records to treating doctors

    Wider context from the report

    “My concerns are therefore as follows: (1) Mr Sonagara had two different sets of medical records under two different hospital numbers that were not amalgamated or cross referenced. (2) In addition a third temporary file of medical records was not incorporated into the permanent file. (3) Potentially relevant information contained in the second and third set of records was not available to Mr Sonagara’s treating doctors. ”

    Source location

    Vijay Sonagara · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. West Yorkshire (East)

    AI-generated summary

    Anne Whitworth · 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

    Anne Whitworth developed worsening abdominal symptoms and became acutely unwell on 8 September 2013. She suffered respiratory and cardiac arrest while being taken to hospital and died later that evening; a post-mortem examination identified aspiration of gastric contents due to intestinal obstruction caused by volvulus of the sigmoid colon. Concerns included the failure to access her prior GP records out of hours and a missed opportunity to escalate her treatment.

    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

    Unavailability of electronic medical records to out-of-hours GPs

    Wider context from the report

    “2. He explained that out of hours he could not access Mrs Whitworth’s medical records. Their computer systems were not compatible and therefore he could not access her medical records electronically which is a major handicap to GPs working on urgent presentations out of hours. ”

    Source location

    Anne Whitworth · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Norfolk

    AI-generated summary

    Graeme Alexander Kidd · 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

    Graeme Alexander Kidd was found hanging at home on 6 March 2014 and died in hospital on 7 March 2014. The report identified concerns about locum doctors’ access to records and knowledge of local mental health services, delays in GP referrals, the lack of medication advice when the prescribing doctor was unavailable, and the delayed implementation of an action plan addressing these matters.

    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 locum doctor access to electronic care records and related systems

    Wider context from the report

    “(1) Locum Doctors do not have access to electronic CareNotes and other electronic records and systems relating to Patients ”

    Source location

    Graeme Alexander Kidd · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Manchester South

    AI-generated summary

    THOMAS PATRICK MAHER · 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

    Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

    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

    Unavailability of nursing notes, observation charts and pressure ulcer charts

    Wider context from the report

    “1. All the nursing notes, observation charts and pressure ulcer charts for the period 20th December 2013 to 29th January 2014 are missing, and despite a widespread search by the hospital, it has proved impossible to locate them. This had the effect of hampering the High Level Investigation and potentially the inquest itself. ”

    Source location

    THOMAS PATRICK MAHER · 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

    Scan records for deceased patients and patients involved in high-level incidents into the electronic patient record as a priority.

    Verbatim wording from the response

    “Trafford Hospital acknowledges that the loss of these nursing records is unacceptable. In order to minimise the risk of this issue arising again, a new process has been implemented by the Trafford Medical Records Manager that all records, including nursing charts, for any patient who has died and for any patient involved in a high level incident will be scanned into the electronic patient records (EPR) system as a priority.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 1 · response
    Published 5 June 2014

    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

    Implement the Patientrack electronic observation and early-warning-score monitoring system across Trafford Hospital.

    Verbatim wording from the response

    “In the future, the recording of observations will be electronic with the implementation of the Patientrack early warning score monitoring system. The implementation of this new system is planned to commence across Trafford Hospital from the end of October 2014. Once fully installed, observation charts will always be available electronically.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 1 · response
    Published 5 June 2014

    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 roll out the Chameleon electronic patient-record system across the Trust in stages.

    Verbatim wording from the response

    “There is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust using a system called Chameleon. This will minimise the risks that documentation will be lost. The timeframe for this to be complete across the entire Trust is 2018. However, this is being developed and implemented in stages so it is likely that Trafford will be fully electronic before then.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 1 · response
    Published 5 June 2014

    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

    Run the Health Records Improvement Programme to address patient-record management risks.

    Verbatim wording from the response

    “The Trust acknowledges that the management of patient records is a significant risk. The risk is included on the Trust Risk Register and a Health Records Improvement Programme is underway to address the issues. As explained earlier, there is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 5 · response
    Published 5 June 2014

    Open published response

  6. Swansea and Neath Port Talbot

    AI-generated summary

    Matthew Thomas Purser · 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

    Matthew Thomas Purser hanged himself in his cell at Swansea Prison on 13 June 2012, after being remanded there and placed on self-harm monitoring. The report identified concerns about inadequate ACCT training, insufficiently objective recording and review of trigger events and significant interactions, and unclear arrangements for obtaining community mental health 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

    Unclear process for promptly obtaining community mental health records

    Wider context from the report

    “3. The prison appreciated that Mr. Purser was due to have a psychiatrist’s appointment in the community soon after coming into prison. Although he was booked into the primary care prison mental health service the means by which community health records were to be obtained was not clear. For an appropriate assessment to be made there is a need for an urgent contact with community mental health services to be made so that records are promptly obtained. ”

    Source location

    Matthew Thomas Purser · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Manchester South

    AI-generated summary

    Gary Bradshaw · 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

    Gary Bradshaw attended hospital with groin pain and kidney stones, later developed hyperparathyroidism and died during a hospital admission. The report identified concerns including delays and errors in diagnosis and testing, prescribing bendroflumethiazide before blood-test results, discharge before full investigation, inadequate escalation and fluid monitoring, and incomplete clinical 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 of the electronic system to reveal notes of a previous admission

    Wider context from the report

    “10. Hospital notes and especially those in the E.D. (on the ADVANTIS SYSTEM) seem to have been less than comprehensive and efficient. The emergency doctor fed the patient’s ‘number’ into the computer but it did not reveal the notes of the previous admission.(Stockport NHS Trust) ”

    Source location

    Gary Bradshaw · Prevention of Future Deaths report
    Page 1 · 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

    The hospital record system links both hospital numbers, while searching with the NHS number displays all associated records.

    Verbatim wording from the response

    “The Advantis system has been checked to try to replicate ████████ issues: if the search is his F number Mr Bradshaw’s details appear as well as all his records under both the F number and the J number which is his actual patient number. If the search is for the J number then both the J number records and the F number records are shown.”

    Source location

    2014-0232-Response-2
    Page 4 · response
    Published 15 May 2014

    Open published response

  8. North East Kent

    AI-generated summary

    Nicos Andreas MICHAEL · 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

    Nicos Andreas MICHAEL died in hospital on 1 November 2013 after suffering a cardiac arrest and significant brain injury following an acute anaphylactic reaction to intravenously administered Augmentin. The principal concerns were that allergy information was conflicting or incompletely recorded, a historic hospital record of an Augmentin reaction was not carried forward or passed to the GP, and systems did not reliably make previous allergy information available to treating staff.

    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

    Medical reporting and patient-tracking systems failing to make known or suspected allergies readily available at presentation

    Wider context from the report

    “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen). (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP. (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate. (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies. ”

    Source location

    Nicos Andreas MICHAEL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Milton Keynes

    AI-generated summary

    Doris Phoebe Miller · 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

    The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.

    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 provide the GP surgery with access to transferred patient records

    Wider context from the report

    “(1) Mrs Miller’s notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery, following the closure of the Willen practice in April 2013. Indeed I was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records. Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk. ”

    Source location

    Doris Phoebe Miller · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. Inner North London

    AI-generated summary

    John Frank Henry LANSDOWNE · 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

    John Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.

    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 complete retrieval of medical and nursing records

    Wider context from the report

    “2. There was confusion regarding the retrieval of the entirety of the medical/nursing records after Mr Lansdowne’s death, and one observation sheet was never recovered. ”

    Source location

    John Frank Henry LANSDOWNE · Prevention of Future Deaths report
    Page 2 · 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