Recurring concern

Unreliable access to relevant clinical records for safe care

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First reported 12 Sep 2013•Latest report 22 Jun 2026

Definition

What this concern includes

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

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
122

Distinct published reports

Individual concerns
129

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
192

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 Care23
NHS England22
Care Quality Commission6
Barts Health NHS Trust5
Betsi Cadwaladr University LHB5
HM Prison and Probation Service5
Cwm Taf Morgannwg University Local Health Board4
Manchester University NHS Foundation Trust4
Recipient name withheld4
Swansea Bay University Local Health Board4
Leicestershire Partnership NHS Trust3
North London NHS Foundation Trust3
Nottinghamshire Healthcare NHS Foundation Trust3
Royal London Hospital3
Tameside and Glossop Integrated Care NHS Foundation Trust3

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.

  1. Black Country

    AI-generated summary

    Kinga Cieciorska · 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

    Kinga Cieciorska, a 16-year-old girl with complex medical needs, was taken to hospital with abdominal pain and distension. She was diagnosed with constipation and discharged, but deteriorated overnight and died after being returned to hospital on 11 March 2016; the stated cause of death was peritonitis from a perforated gastric ulcer. Concerns included failure to investigate tachycardia and an abnormal ECG, failures in recording and transmitting clinical information, and failure to consider the significance of her medication.

    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 forward and make available GP medical notes for clinical examination

    Wider context from the report

    “2. During the inquest it emerged there was evidence of systemic failings in recording of and transmission of information. The Junior Doctor failed to record the name of the Specialist Paediatric Registrar giving advice. More worryingly the Paediatric Registrar at inquest could not recollect giving any advice in relation to the patient. It also emerged during the inquest that medical notes provided by the GP were given to reception staff by the parents on admission. Unfortunately these documents were not forwarded or seen by the Junior Doctor on examination of the patient. ”

    Source location

    Kinga Cieciorska · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. Essex

    AI-generated summary

    Mr Roy Henry Oakley · 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

    Mr Roy Henry Oakley was taken to Orsett Hospital for a routine blood test and, after being told to wait in the coffee shop without a settled collection arrangement, went to the ambulance bays and suffered an accident. He died on 12 June 2015. The report identified concerns that his dementia was not communicated to the transport and phlebotomy services, that no carer had been arranged to attend with him, and that information-sharing limitations may have played some part in his 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 commissioned services' access to relevant hospital records

    Wider context from the report

    “TAS had not been told that Mr Oakley suffered from Dementia and nobody had arranged for a Carer to attend with him. During the course of the inquest it emerged that the Phlebotomy Service who arranged the transport, were unaware that Mr Oakley had Dementia. The Phlebotomy Service is, commissioned out to a private company by Basildon Hospital and they do not have access to Basildon Hospitals Record Keeping System which flagged up Mr Oakley’s Dementia. Other commissioned out services are in a similar position. The failure to communicate and the lack of information sharing may have played some part in the death of Mr Oakley. ”

    Source location

    Mr Roy Henry Oakley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester South

    AI-generated summary

    Ranjan Raman · 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 report states that the deceased was admitted to hospital with low sodium levels and high blood pressure, fell three times, and sustained a head injury followed by a fatal bleed. Concerns included insufficient falls-risk assessment, missing or incomplete neurological observation charts, poor communication between medical and nursing staff, destruction of shift hand-over sheets, and inadequate incident-report details.

    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 or retain neurological observation charts

    Wider context from the report

    “2. The Neurological observation charts were either never completed or had been lost from the notes. ”

    Source location

    Ranjan Raman · 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

    Reissue the neurological-observations flowchart and direct ward leaders to apply its recording requirements after relevant unwitnessed falls.

    Verbatim wording from the response

    “This indicates that the requirement for staff to undertake neurological observations as cited on the flowchart needs to be reinforced and practices monitored to ensure robust implementation of the policy standards.”

    Source location

    R-Mistry-Response
    Page 2 · response
    Published 4 March 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

    There is no evidence that neurological observation charts were lost from the records; that inference would be conjecture.

    Verbatim wording from the response

    “The Trust has a Falls Policy in place which clearly includes a flowchart which relates to the requirement to assess the patient following a fall or suspected fall. The Falls Policy and flowchart indicates that neurological observations would only be appropriate where a head injury was indicated or suspected. The Trust acknowledges that in the unwitnessed event involving Mrs Mistry on the 17/02/2016 a head injury could not be ruled out. In this event the flowchart indicates the taking of neurological observations (Unwitnessed fall and was verbalising that she had banged her head). However staff did not commence the charts. There is no evidence to suggest that these charts had been lost from the records. Any inference to this would be conjecture.”

    Source location

    R-Mistry-Response
    Page 2 · response
    Published 4 March 2016

    Open published response
  4. Nottinghamshire

    AI-generated summary

    Philip Anthony Denning · 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

    Philip Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

    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 CRI access to Nottinghamshire Healthcare electronic patient records

    Wider context from the report

    “4. The CRI is an entirely separate entity from Nottinghamshire Healthcare and has no access to RiO, Nottingham Healthcare’s electronic record-keeping system. If, for instance, one of their patients had been seen regularly by Nottinghamshire Healthcare following overdoses, they would not be aware of this unless their patient told them about this. ”

    Source location

    Philip Anthony Denning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. North East and North Central Wales

    AI-generated summary

    Vera Hilda Williams · 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

    Vera Hilda Williams attended the Emergency Department on several occasions with different symptoms and was later found by CT scan to have a ruptured aorta associated with an oesophageal rupture. She died at Glan Clwyd Hospital on 28 October 2015. The report raised concerns that Emergency Department staff did not have a digital central record of patients’ previous attendances, symptoms and treatment, requiring reliance on patient accounts and retrieval of paper notes, which could delay access to accurate information.

    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 an accessible, accurate central Emergency Department patient record

    Wider context from the report

    “(1) Doctors and staff in the Emergency Department do not have a DIGITAL CENTRAL RECORD ( ie on a computer database) of who has passed through the Emergency Department , their symptoms and what treatment they have received. (2 )Doctors must rely upon the patient telling them what has happened and then there is a delay whilst previous paper notes are located and retrieved. This lack of easy and swift access to accurate information is fraught with risks for patients and clinicians in the arena of Emergency medicine where time is of the essence in coming to a diagnosis. An accurate history is an essential tool in coming to that diagnosis. Any delay can have potentially fatal consequences for a patient. ”

    Source location

    Vera Hilda Williams · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Inner North London

    AI-generated summary

    Naiya Diarra · 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

    Naiya Diarra died aged 9 months on 25 June 2015 from dilated cardiomyopathy arising from severe Vitamin D deficiency. Vitamin supplementation was provided but was ultimately insufficient, and the significance of her sibling’s Vitamin D deficiency was not recognised, resulting in missed opportunities to address this. The report also raised concerns about relevant information being held in disparate record silos and not being accessible to clinicians, particularly the reviewing psychiatric team.

    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 accessible sharing of relevant clinical information across NHS record silos

    Wider context from the report

    “(1) Multiple pieces of relevant information regarding ████████ current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular. I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS. ”

    Source location

    Naiya Diarra · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Cardiff and the Vale of Glamorgan

    AI-generated summary

    Geoffrey Parry · 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

    Geoffrey Parry underwent major surgery for aggressive bladder cancer on 1 May 2015, developed infection and pneumonia, and died on 29 June 2015. Concerns included an ECG result being unavailable to anaesthetists before surgery and an unlabelled intravenous noradrenaline line becoming disconnected in intensive care, causing a significant drop in blood pressure and the need for cardiopulmonary resuscitation.

    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 investigative test and scan results with patients' medical notes

    Wider context from the report

    “During the evidence it transpired that an ECG test which was undertaken on 21st April 2015 was not available to the reviewing consultant anaesthetists prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient's medical notes. In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened. The evidence at the hearing suggested that this was not an uncommon problem. In this case the unavailability of the scan was not in any way causative of Mr Parry's death but could have been. ”

    Source location

    Geoffrey Parry · 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

    Review systems and processes for storing ECG investigations.

    Verbatim wording from the response

    “• An ECG test undertaken on 21 April 2015 was not available to the reviewing consultant anaesthetist prior to surgery. The evidence suggested that there was a problem within the hospital, not specific to ECG tests whereby results from investigative tests and scans are not kept with the patient’s medical notes. In this instance, it appeared that there was a facility for the result of the ECG to be electronically uploaded onto the hospital computer system but this had not happened.”

    Source location

    2015-0400-Response-by-University-Health-Board
    Page 1 · response
    Published 7 October 2015

    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

    Review ECG machines for MUSE connectivity and improved patient identification.

    Verbatim wording from the response

    “In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including:”

    Source location

    2015-0400-Response-by-University-Health-Board
    Page 2 · response
    Published 7 October 2015

    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

    Review MUSE usage and supporting infrastructure capacity for increased ECG activity.

    Verbatim wording from the response

    “In order to strengthen use of the MUSE system across the Health Board a number of actions are planned. An improvement plan to support this is in development and will address numerous areas including:”

    Source location

    2015-0400-Response-by-University-Health-Board
    Page 2 · response
    Published 7 October 2015

    Open published response
  8. Nottinghamshire

    AI-generated summary

    Thomas Farrell · 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 Farrell died after becoming unwell with a chest infection while resident at Springfield Care Home and being admitted to hospital, where he died on 16 July 2014. The principal concern was that the care home had not obtained a full medication record from his GP, resulting in several prescribed medicines not being administered; the report stated this omission did not cause or contribute to his death but posed a clear risk in other circumstances.

    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 obtain a full record of residents’ prescribed drugs

    Wider context from the report

    “1. That the Home did not know the true extent of the prescription drugs which were indicated for Mr Farrell while he was a resident, having not approached Mr Farrell’s GP for a full record. The result of this was that the prescription drugs aspirin, senna, doxalil and omeprazole were not given. Whilst in the event this did not cause or contribute to his death on 16th July 2014, the risk of such an omission causing death in other circumstances is clear. ”

    Source location

    Thomas Farrell · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  9. Leicester City and South Leicestershire

    AI-generated summary

    Derick James Stanmore · 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

    Derick James Stanmore, who was serving a life sentence in HMP Gartree and had recognised medical conditions including heart disease and type II diabetes, complained of chest pains on 7 July 2014. He collapsed in his cell on 10 July 2014 and was pronounced deceased shortly after arriving at hospital; the inquest recorded acute myocardial infarction due to coronary artery atheroma. Concerns included abnormal observations not being recognised or acted upon and the attending nurse not accessing available healthcare records before taking observations.

    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 healthcare staff with relevant clinical information before observations

    Wider context from the report

    “2. The nurse attending Mr. Stanmore did not access his healthcare records that were available and did not appear to have any information regarding the need for a healthcare assessment. He was therefore taking observations without the benefit of relevant clinical information in order to consider these in context. Consideration should be given to ensuring all staff have appropriate access whenever possible to information before conducting examinations or observations of prisoners. ”

    Source location

    Derick James Stanmore · 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

    Provide all staff with access to clinical information before seeing prisoners.

    Verbatim wording from the response

    “After review, I can confirm that all staff are able to access clinical information prior to seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order to make a well informed clinical decision.”

    Source location

    2015-0172-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 1 May 2015

    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

    Remind staff to access clinical notes during routine prisoner consultations to inform clinical decisions.

    Verbatim wording from the response

    “After review, I can confirm that all staff are able to access clinical information prior to seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order to make a well informed clinical decision.”

    Source location

    2015-0172-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 1 May 2015

    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

    Clinical information is already accessible to all staff before prisoners are seen, addressing the need for appropriate access.

    Verbatim wording from the response

    “After review, I can confirm that all staff are able to access clinical information prior to seeing Prisoners. Staff will be reminded that it is an expectation that when Prisoners are seen routinely, clinical notes should be accessed in order to make a well informed clinical decision.”

    Source location

    2015-0172-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 2 · response
    Published 1 May 2015

    Open published response
  10. Inner North London

    AI-generated summary

    Finnulla Catherine MARTIN · 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

    Finnulla Catherine Martin took her own life by jumping from the sixth-floor balcony of her home less than an hour after discharge from Whittington Hospital following a mental health assessment. Concerns included failures to obtain and share relevant information, incomplete assessment of suicide and harm risks, inadequate collateral history-taking, uncertainty about procedures for police-accompanied voluntary attendance, and failure to characterise the police contact as an emergency after Ms Martin left hospital.

    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 obtain the triage record before patient assessment

    Wider context from the report

    “2. The team then saw a patient without waiting to obtain the triage record created by Whittington Hospital Trust staff. ”

    Source location

    Finnulla Catherine MARTIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 triage records of patient attendance

    Wider context from the report

    “2. I was told at inquest by Camden & Islington that the Whittington had been unable to locate the Whittington triage record of Ms Martin’s attendance, and I did not discover any record of the call made by Ms Martin’s sister to the emergency department that night. ”

    Source location

    Finnulla Catherine MARTIN · Prevention of Future Deaths report
    Page 3 · 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

    Agree which aspects of the Medway system Camden and Islington staff will use.

    Verbatim wording from the response

    “Recommendation: For all Camden and Islington Foundation Trust employees and associated locum staff to have good understanding of the Emergency Department computer system “Medway” to improve information available to them”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 4 · response
    Published 29 April 2015

    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 a written Medway user guide for Camden and Islington staff.

    Verbatim wording from the response

    “Key Action(s): Provide written guide on use of Emergency Department computer system”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 4 · response
    Published 29 April 2015

    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

    Repeat training for Camden and Islington staff on the Medway system.

    Verbatim wording from the response

    “To repeat training on the Medway system”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 4 · response
    Published 29 April 2015

    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 triage assessment was recorded electronically, including the patient’s arrival, assessment, police attendance and high risk of self-harm.

    Verbatim wording from the response

    “Whittington Health response – all triage assessments are recorded electronically. Patient FM was triaged. Arrived with police at 21:00 and was assessed and triaged at 21:15: Pt brought in by police c/o suicidal ideations. Family concerned about patient. Patient voluntary. pmh: unknown. National Triage category – mental illness – category 2 very urgent- discriminator – high risk of self-harm”

    Source location

    2015-0173-Whittington-Health-NHS-Trust
    Page 4 · response
    Published 29 April 2015

    Open published response
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Data last updated 7 September 2026