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. Leicester City and South Leicestershire

    AI-generated summary

    Greg Revell · 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

    Greg Revell was found hanging in his cell at HM YOI Glen Parva, and resuscitation was unsuccessful. The concerns included that a previous ligature self-harm attempt did not lead to an ACCT, uncertainty among prison officers about when to open an ACCT, insufficient consideration of recorded risk factors, and weaknesses in capturing healthcare information and obtaining a GP summary.

    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

    Insufficiently robust and timely capture of available healthcare information

    Wider context from the report

    “7. The system for capturing all available healthcare information was insufficiently robust. There was no clear monitoring of obtaining a GP summary promptly to ensure medications and previous medical history could be checked as soon as possible. An opportunity for restarting anti-depressant medication in this case was missed. ”

    Source location

    Greg Revell · Prevention of Future Deaths report
    Page 2 · 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

    Implement a robust clinical-information process with documented responsibilities, follow-up, escalation and senior risk-system scrutiny for obtaining prisoners’ clinical notes.

    Verbatim wording from the response

    “We now have a robust system in regard how clinical information is sought and there is a flow chart (Attachment 1) identifying team member's responsibilities to ensure consistency and follow up if required. This flowchart details the responsibility of each discipline within the team to ensure that there is a robust mechanism in place to ensure that Prisoners Clinical Notes are requested and followed up.”

    Source location

    2015-0165-Response-by-Leicestershire-Partnership-NHS-Trust
    Page 1 · response
    Published 28 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

    Implement the Safer Prisons recording procedure and train reception and healthcare staff to document risk information and decisions in O-Nomis and SystmOne.

    Verbatim wording from the response

    “A new Safer Prisons strategy was launched in October 2014. This includes a new procedure for recording decisions made in response to the risk information on the self-harm warning form. The new procedure has been disseminated through training and briefings with reception and health care staff, who have been informed that they must refer to all relevant information about newly arrived prisoners, including the Person Escort Record, and make an entry on O-Nomis to record what they have observed and decided. Healthcare staff have also been reminded to record this information on SystmOne (the electronic medical records system).”

    Source location

    2015-0165-Response-by-NOMS
    Page 1 · response
    Published 28 April 2015

    Open published response
  2. Powys, Bridgend & Glamorgan Valleys

    AI-generated summary

    Mr. Brian Francis · 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. Brian Francis was admitted to Princess of Wales Hospital on 5 September 2014 after several days of illness and was treated for presumed chest sepsis. He died of a pulmonary embolism the following day. Concerns included a failed process for recording Consultant attendance and the unavailability of Community medical records, which may have affected assessment and the commencement of anti-coagulation therapy.

    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 Community medical records at hospital admission

    Wider context from the report

    “(2) Had the Community medical records been available at the time of hospital admission the patient would most probably have been assessed differently and in all probability, anti-coagulation therapy commenced immediately or shortly thereafter. ”

    Source location

    Mr. Brian Francis · 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

    Electronic community health records cannot be provided locally until national pilot studies are completed and the service is extended to hospital emergency settings.

    Verbatim wording from the response

    “A summary of the GP record is currently available in out-of-hours GP services. This national service is currently being extended for use in hospital emergency settings. Pilot projects are already underway in Cardiff and the Vale and Aneurin Bevan Health Boards and our Health Board has already indicated our eagerness to provide this service locally as soon as the pilot studies have been completed.”

    Source location

    2015-0085-Response-by-University-Health-Board
    Page 3 · response
    Published 4 March 2015

    Open published response
  3. Sunderland

    AI-generated summary

    Paige Louise Bell · 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

    Paige Louise Bell, aged 20, died at Sunderland Royal Hospital on 14 August 2014 after applying a ligature to her neck following an episode of self-harm. The inquest identified contradictions in the observation policy as a contributing factor. Concerns included case notes not being held together or fully transferred with the patient, and the need for consistent observation policies and updated guidance on managing patients with Borderline Personality Disorder.

    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 medical personnel have immediate electronic access to complete patient notes

    Wider context from the report

    “The case notes were not held in one place and not all transferred with the patient. I wondered if there were any ongoing plans to allow medical personnel to have immediate access to all notes electronically rather than notes following the patient as they will contain essential information for a patient’s healthcare and treatment. ”

    Source location

    Paige Louise Bell · 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

    Choice and implementation of electronic patient-record systems are matters for individual NHS Trusts.

    Verbatim wording from the response

    “In addition, there are a number of versions of electronic patient record and health record systems being used in many hospitals across the UK. These systems are being used to provide accurate, up-to-date, and complete information about patients at the point of care. However, the choice and implementation of these systems is a matter for individual NHS Trusts.”

    Source location

    2015-0075-Response-by-Department-of-Health
    Page 2 · response
    Published 3 March 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

    Electronic RiO records and information-sharing through team meetings and handovers provide a more appropriate account than printed records alone.

    Verbatim wording from the response

    “In respect to the stated over the presentation of written copies of RiO records, ████████ explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how they would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made. This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident. As you heard in evidence, in a very busy and demanding mental health ward”

    Source location

    2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
    Page 2 · response
    Published 3 March 2015

    Open published response
  4. Manchester South

    AI-generated summary

    Paul Moroney · 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

    Paul Moroney attended Tameside Hospital by ambulance on 27 August 2014 with worsening breathing and concern about a blood clot, was discharged with arrangements to return the following day, and later required a second emergency ambulance. Concerns included the lack of monitoring or recording of his oxygen saturations, discontinuation of oxygen before discharge without monitoring, and the absence of previous oxygen-level records when he was readmitted.

    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 records of previous oxygen levels on readmission

    Wider context from the report

    “3. When he was re-admitted to the hospital there was no record available to the staff about his previous oxygen levels. ”

    Source location

    Paul Moroney · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. Manchester South

    AI-generated summary

    John Michael Matthews · 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 Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.

    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 doctor with access to the complete computerised system

    Wider context from the report

    “2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system. ”

    Source location

    John Michael Matthews · Prevention of Future Deaths report
    Page 1 · 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

    Failure to make the PRF available to the doctor providing emergency care

    Wider context from the report

    “2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system. ”

    Source location

    John Michael Matthews · 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 ambulance information system worked: the PRF was scanned before the doctor assessed the patient.

    Verbatim wording from the response

    “In his statement to you, ████████ states that “Paramedic notes were not available to me.” What is clear on review of the events is that the triage nurse received a verbal handover as per usual practice. A review of the electronic system has been undertaken which shows that the ambulance document (PRF) was scanned and was added to the system within 13 minutes of arrival and ten minutes prior to the doctor seeing the patient so it is apparent that the system in place to link the paper document with the electronic document worked. I am unable to explain why the locum doctor did not review this information but am assured he was given the training to enable him to do so.”

    Source location

    2015-0034-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 29 January 2015

    Open published response
  6. Central Lincolnshire

    AI-generated summary

    John Derek Stabler · 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 Derek Stabler was found hanging in a cell at HMP Lincoln on 4 March 2013 and died in Lincoln County Hospital on 6 March 2013. The substantive concerns were the need to review and redesign the Prisoner Escort Record and to ensure medical records were available at HMP North Sea Camp and HMP Lincoln.

    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 System 1 medical records in specified reception units

    Wider context from the report

    “(II) The requirements for System 1 (Medical Records) to be made available in Reception at HMP North Sea Camp and in The Care and Reception Unit at HMP Lincoln ”

    Source location

    John Derek Stabler · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Inner North London

    AI-generated summary

    Andrew James AITKEN · 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

    Andrew Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.

    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 relevant previous inpatient mental health records

    Wider context from the report

    “2. Mr Aitken had been admitted to Prestwich Hospital Psychiatric Hospital when he was 16 years old. When he was admitted on 10 June 2014, no consideration was given to asking for any record of that inpatient stay. That was some 14 years earlier and may not have yielded anything useful but, as Mr Aitken was not registered with a general practitioner, it was the only source of history from healthcare professionals. ”

    Source location

    Andrew James AITKEN · Prevention of Future Deaths report
    Page 2 · 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

    Finalise the RAID Operational Policy with explicit requirements to obtain collateral information.

    Verbatim wording from the response

    “I am in complete agreement with you regarding the importance of gaining collateral information from any available sources. As you are aware the Trust undertook a Serious Incident Review (SIR) looking at the care and treatment of Mr Aitken and the Review considered this issue. Sources of collateral information in the absence of a GP can be: healthcare professionals previously involved with a patient and family and friends. Our SIR agreed that clinical staff had limited information and history regarding Mr Aitken in light of the fact that he did not have a GP. Senior staff in the RAID service are clear that they would expect staff to follow up and try to obtain all information available regarding an individual. The RAID Operational Policy is currently being finalised and the importance of obtaining collateral information will be included within this.”

    Source location

    2014-0561-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 15 December 2014

    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

    Contacting historical psychiatric services was considered unnecessary because information was unlikely to be obtained during the short period of RAID involvement.

    Verbatim wording from the response

    “In considering this it was relevant to consider that RAID involvement with any patient is short term and the SIR concluded that it was highly unlikely that such historical information would have been obtained during the short time he was under their care to inform their assessment of him. It was therefore felt that the decision not to contact services in Prestwich had been reasonable. The Review was satisfied that staff had explored other potential sources of collateral information.”

    Source location

    2014-0561-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 15 December 2014

    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 second and third concerns are being investigated and addressed separately by East London NHS Foundation Trust.

    Verbatim wording from the response

    “Your second and third concerns are being investigated and addressed separately by the East London NHS Foundation Trust.”

    Source location

    2014-0561-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 15 December 2014

    Open published response
  8. North Wales (East and Central)

    AI-generated summary

    Anthony Gwyn 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

    On 9 February 2014, Anthony Gwyn Williams, whose mental health was declining, went to Pentwmpath Woods and took his own life with a ligature while his balance of mind was disturbed. Concerns included insufficient guidance on when staff could deviate from the recognised psychiatric assessment pathway, lack of continuous access to patients’ medical records, and the need for greater engagement with families and carers about care and treatment plans.

    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 continuous access to existing patients' medical records

    Wider context from the report

    “2. There needs to be access to the medical records of existing patients at all times including evenings and weekends especially regarding a patient's Care and Treatment Plan. ”

    Source location

    Anthony Gwyn Williams · Prevention of Future Deaths report
    Page 2 · 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

    Explore electronic case records through the national procurement process and determine the preferred approach to developing them.

    Verbatim wording from the response

    “2. In respect of medical and nursing staff having access to patients’ records, such as Care and Treatment Plans at all times, I can advise you that the adoption of an electronic case record is currently being explored as part of the Community Care Information System national procurement. The Health Board will determine its preferred approach to developing electronic records by March 2015.”

    Source location

    2014-0523-Response-by-University-Health-Board
    Page 1 · response
    Published 2 December 2014

    Open published response
  9. Manchester South

    AI-generated summary

    Agnes Mary Hannan · 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

    Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

    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 availability of prior hospital notes and treatment records to Emergency Department staff

    Wider context from the report

    “1. There was an actual, or perceived, lack of availability of the hospital notes and records of previous diagnoses and treatments by hospital doctors, for the staff working in the Emergency Department. ”

    Source location

    Agnes Mary Hannan · 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

    Replace the medical-records system to provide Emergency Department staff with extensive patient-history access.

    Verbatim wording from the response

    “Response The computer system for medical records which was in place at the time of Mrs Hannan’s attendances at the Accident & Emergency Department has since been replaced by a new system. Staff working in Accident & Emergency are able to access extensive details of patients’ medical records including correspondence, previous in and out-patient attendances including attendances in Accident & Emergency.”

    Source location

    2014-0573-Response-by-Tameside-Hospital-NHS-Trust
    Page 1 · response
    Published 27 October 2014

    Open published response
  10. South Yorkshire (Western)

    AI-generated summary

    Peter Stanley · 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

    Peter Stanley, aged 17, was found hanging in woodland on 2 August 2013 after a history of mental health concerns, suicidal thoughts and a previous suicide attempt. The report identified missed opportunities for mental health assessment and care, alongside concerns about information-sharing, homelessness and accommodation, custody assessments, and support for young people.

    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 awareness among custody medical services of out-of-hours access to Children's Services records

    Wider context from the report

    “(3) On the basis of evidence given by ████████ Assistant Director of Fieldwork Services, Sheffield City Council, it is clear that the custody nurse could have accessed the Children's Services records for Peter on 14 July, even during the night, by calling the Social Services 'out of hours' team. Every local authority has an out of hours system (which would cover adults as well). However I am told that this is not generally known amongst those providing custody medical services. ”

    Source location

    Peter Stanley · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report
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Data last updated 7 September 2026