Recurring concern

Unreliable access to relevant clinical records for safe care

Pin Get email alerts Request correction

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. Milton Keynes

    AI-generated summary

    Yvonne Sydney Annie Perry · 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

    Yvonne Sydney Annie Perry fractured her left hip after a fall at home, and the possibility of the fracture identified on 19 December 2012 was not acted upon until early January 2013. She later developed a severe urinary tract infection and died of sepsis on 2 February 2013; concerns included the lack of a robust process for tracking radiology reports and the absence of GP access to electronic hospital notes and 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

    Lack of access to electronic hospital notes and records for GPs attending the Windsor Intermediate Care Unit

    Wider context from the report

    “(2) The GPs who attend the Windsor Intermediate Care Unit do not have access to the electronic hospital notes and records and those witnesses from WICU who attended the inquest considered that such access would improve the care afforded to patients. Similarly without access to the patients notes further deaths may occur in the future. ”

    Source location

    Yvonne Sydney Annie Perry · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Norfolk

    AI-generated summary

    Matthew Christopher Dunham · 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 Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

    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 mental health professionals with access to complete patient records and practitioner actions

    Wider context from the report

    “e) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8th of April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014. ”

    Source location

    Matthew Christopher Dunham · 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 an updated system that searches all Trust electronic health records, including PC Mis, to identify current and historical psychological-therapy care episodes.

    Verbatim wording from the response

    “The Trust's internal investigation confirmed that the computer system employed by AAT at the time was able to scan all the Trust electronic health record systems with the exception of the electronic health record system named PC Mis. This meant that it was not readily identified if a patient was attending the Trust's Improving Access to Psychological Therapies (IAPT) service. The Trust has now implemented an updated system (Apverita) which is able to include the system PC Mis and therefore identify any current or historical care episodes an individual has with the IAPT service.”

    Source location

    Response
    Page 3 · response
    Published 26 January 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

    Work towards implementing a single electronic health record across the Trust’s services.

    Verbatim wording from the response

    “E) Most disturbingly the evidence at the hearing displayed a lack of coordination between mental health professionals involved in Mr Dunham's care. Specifically when a mental health nurse saw Mr Dunham on the 8 April he had no knowledge whatsoever that Mr Dunham was already being seen by a psychological wellbeing practitioner. This clearly demonstrates the need for effective information sharing between professionals involved in managing the care of a mentally ill person and the need for each and every professional to have access to all the records relating to the patient and details of interventions and actions by other practitioners. It is recognised that the Trust is working towards the implementation of a single electronic health record in 2014.”

    Source location

    Response
    Page 2 · response
    Published 26 January 2014

    Open published response
Back to top

Data last updated 7 September 2026