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. Inner North London

    AI-generated summary

    Siân Louise WITHERIDGE · 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

    Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis 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

    Unavailability of mental health records to crisis house staff

    Wider context from the report

    “1. While Ms Witheridge was staying in Crisis House, her mental health records were not available to the OneHousing staff there. ”

    Source location

    Siân Louise WITHERIDGE · 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

    Work with OneHousing to establish shared access to clinical records and risk assessments for Highbury Grove staff.

    Verbatim wording from the response

    “We agree that Highbury Grove Crisis House staff should have access to our clinical records. To this end, we have been working with One Housing to enable members of their staff to acquire access to our IT system. We are aiming to have shared access in place in early 2018 following staff completing the relevant training and necessary checks.”

    Source location

    2017-0305-Response
    Page 1 · response
    Published 27 November 2017

    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

    Information-sharing problems have been rectified through ready access to relevant clinical information and established communication channels.

    Verbatim wording from the response

    “We are aware that Highbury Grove has sent you our ‘Working Protocol’ setting out how our teams work together. As set out earlier, we accept that there have been challenges with information sharing. We are confident however that this has been rectified and Highbury Grove and staff will in the future have ready access to all the relevant clinical information.”

    Source location

    2017-0305-Response
    Page 3 · response
    Published 27 November 2017

    Open published response
  2. Manchester City

    AI-generated summary

    Mr John Griffiths · 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 John Griffiths had a history including ischaemic heart disease and presented with worsening shortness of breath and other symptoms before suffering a cardiac arrest at home and dying in hospital on 8 April 2016. The substantive concerns included failures to complete and process a cardiology referral, inadequate review of previous emergency-department records and investigations, and the absence of a system to identify relevant recent attendances or admissions.

    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 access and consider appropriate records and previous relevant investigation and assessment results

    Wider context from the report

    “2. If so, then appropriate records are accessed and considered including the results of previous relevant investigations and assessments. If a completely electronic patient record is introduced then this gives the opportunity for that to be achieved easily. Unless and until that occurs other checking processes need to be considered. ”

    Source location

    Mr John Griffiths · 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

    Use emergency-department alerts to identify recent attendances and prompt clinicians to review relevant electronic records.

    Verbatim wording from the response

    “The ED system puts an alert on the front of the attending patient’s card when the patient’s details are entered into the system, which identifies how many previous attendances the patient has had in the last 2 years. An alert runs across the top of the electronic record as a prompt for the clinician to refer back to previous attendances if required. When Mr Griffiths attended on the 28 March 2017, the system successfully identified that he had attended once in the last 3 months and twice in the last 2 years. The Emergency Department will attempt to take a history from the patient and collate a historical history from those in attendance with them. The decision to refer back to the earlier admission on the electronic record is an individual decision and the alert is a prompt within the system to ensure the clinician is aware of previous attendances.”

    Source location

    2017-0222-Response-by-UHSM
    Page 1 · response
    Published 24 September 2017

    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

    Introduce the Electronic Patient Record System to enhance identification of patients’ relevant clinical histories in the emergency department.

    Verbatim wording from the response

    “As described by ████████ within her evidence the systems in place to identify a patient’s relevant clinical history when presenting at the Emergency Department will be enhanced by the introduction of”

    Source location

    2017-0222-Response-by-UHSM
    Page 1 · response
    Published 24 September 2017

    Open published response
  3. Wiltshire and Swindon

    AI-generated summary

    Doreen Helen 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

    Doreen Helen MILLER, a vulnerable and housebound adult, was discharged home after an intermediate-care placement despite concerns about unusual toileting behaviour, possible cognitive impairment, self-neglect and limited provisions. She was found severely hypothermic in her cold, dark flat the next morning and died at hospital on 13 January 2016. The principal concerns included safeguarding referrals not being properly investigated, important cognitive information not being communicated, poor record-keeping and decision-making, insufficient assessment of mental capacity, and inadequate systems for reviewing serious incidents and learning from them.

    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 healthcare-record archiving system to retain and provide records

    Wider context from the report

    “c) (Wiltshire Council, Wiltshire Health & Care and Great Western Hospital) As a general comment, my view in relation to the quality and substance of case notes was that they were poor in quality. My investigation was hampered due to the fact that the Archiving System at Great Western Hospital for Doreen’s therapy led healthcare notes failed in that the notes or at least the scanned images were lost and were not available. Given that some notes were recorded on the Wiltshire Council Care First System and the evidence was that the Healthcare records would not have been significantly different my concerns remain. Crucial and important decisions did not contain any rationale as to why and the basis upon which that decision was being made. As indicated when I summed up the evidence my view is that recording a rationale can act as a check in relation to the decision making process itself as it forces the author to consider the process and information that has led to that decision being made. I also have concerns in relation to the way MDT’s work and reach decisions. The decisions very much appear in relation to the case decision amongst relevant members of the team as opposed to an individual making the decision based on information provided by relevant team members. There was no leadership. My concern as regards this consensual approach is that no-one actually takes ownership and responsibility for the decision itself and a consensual approach as evidenced in Doreen’s case can in my view lead to a situation whereby there is a false sense of reassurance in believing that nothing more could be done for Doreen that in this case led to wrong decisions being taken. ”

    Source location

    Doreen Helen MILLER · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  4. Birmingham and Solihull

    AI-generated summary

    Ahshiyah Bibi · 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

    Ahshiyah Bibi died at Birmingham Heartlands Hospital on 22 December 2016 after admission with reduced consciousness and acute renal failure. During her treatment, there was a delay in commencing treatment for high potassium and an insulin prescribing and dispensing error. The report identified concerns about missing blood gas results and the absence of a Trust-wide review or system to reduce the risk of similar errors.

    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 arterial blood gas results remain available to clinicians

    Wider context from the report

    “1. When reviewing Mrs. Bibi at 02:14 ████████ did not have the results from an arterial blood gas performed by the nursing team at 01:52 which demonstrated high potassium therefore treatment for high potassium was not commenced until approximately 04:00 when the high potassium had been identified. It was the evidence of ████████ and ████████ that from time to time the hard copy blood gas results do get separated from the records and if the Clinician doesn’t know the test has been undertaken they will have no reason to go and source the results. ”

    Source location

    Ahshiyah Bibi · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  5. North West Kent

    AI-generated summary

    Sian Marie Hollands · 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

    Sian Hollands attended Darent Valley Hospital on 14 November 2015 with breathlessness and chest pain after recent surgery and possible opiate withdrawal. She was later suspected to have a pulmonary embolus, suffered a cardiac arrest, and died on 15 November 2015. The stated concerns included PAR scoring and staff training, doctors not being provided with nurses’ medical notes, and failure to correctly diagnose pulmonary embolism.

    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 doctors with nurses' medical notes

    Wider context from the report

    “(2) The failure of doctors to be provided with nurses medical notes ”

    Source location

    Sian Marie Hollands · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Birmingham and Solihull

    AI-generated summary

    Leah Abby Ratheram · 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

    Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.

    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 share and access mental health records effectively between organisations

    Wider context from the report

    “2. Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other’s records when patients present to one or other of the services. ”

    Source location

    Leah Abby Ratheram · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Inner North London

    AI-generated summary

    Tedros Habtom KAHSSAY · 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

    Tedros Kahssay killed himself by hanging in HM Prison Pentonville about a month after being admitted on a charge of murdering his pregnant partner. Concerns included incomplete transfer and recording of information, shortcomings in reception screening, and significantly deficient and chaotic resuscitation procedures. The report states that he was already dead when resuscitation commenced, while expressing concern for other prisoners requiring first aid.

    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 general practitioner records

    Wider context from the report

    “3. The general practitioner records were never obtained (an issue that I have raised in the past), despite there being a system in place for Pentonville healthcare administrative staff to do this. Whilst that did not impact upon Mr Kahssay’s care, it might for another prisoner. ”

    Source location

    Tedros Habtom KAHSSAY · 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

    Obtain consent for general practitioner records during reception screening and trigger an auditable SystmOne task for administrative staff to request them.

    Verbatim wording from the response

    “As you heard in evidence, consent for the obtaining of general practitioner records is now sought as part of the reception screen and it is also a mandatory field that needs to be completed by the member of healthcare prior to finishing the screen. When consent is taken, the screening tool requires a task be sent to the Administrative staff to make them aware that”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 1 · response
    Published 6 December 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

    GP practices cannot be guaranteed to send requested medical records, limiting the ability to obtain them.

    Verbatim wording from the response

    “Whilst we have a system in place to request medical records and follow up, it is important to highlight that we cannot ensure that a GP practice will send records to us. It is anticipated that this is an issue which will be eased once the new clinical IT system is in place providing access to the NHS spine and patients Summary Care Records.”

    Source location

    2016-0437-Response-by-Care-UK.pdf
    Page 2 · response
    Published 6 December 2016

    Open published response
  8. Birmingham and Solihull

    AI-generated summary

    Alfie Rose · 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

    Alfie Rose, aged 17, died on 09 June 2016 following deterioration from obstructive hydrocephalus, severe brain injury and brain stem death. The report identified poor communication between the two hospitals and inadequate guidance and education for clinicians in outlying hospitals as principal concerns. The inquest concluded that earlier detailed MRI scanning, admission and treatment at the Queen Elizabeth Hospital neurosurgical unit would, on balance, have avoided 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

    Failure of the NORSE system to make all entries visible

    Wider context from the report

    “1. There was poor communication between both hospitals in relation to Alfie’s condition and care. Details of his neurosurgical review on 16/05/16 were not made available to Russell’s Hall Hospital. His clinical condition was not relayed to QE hospital on 27/05/16 or morning of 06/06/16. These were vital missed opportunities to transfer him back to QE for treatment. Both Trusts need to look at their communication systems and identify areas for improvement and to clarify if the NORSE system is effective. I heard evidence to suggest that all the NORSE system entries cannot always be seen. ”

    Source location

    Alfie Rose · 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

    Develop and agree a detailed cross-Trust action plan addressing identified communication, referral and emergency-management concerns.

    Verbatim wording from the response

    “Issues Identified:”

    Source location

    2016-0382-Response-by-The-Dudley-Group-NHS-Trust
    Page 2 · response
    Published 26 October 2016

    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

    Deliver the agreed cross-Trust action plan to address identified safety concerns.

    Verbatim wording from the response

    “A detailed action plan has been developed (attached to this letter) and the actions have been agreed by both UHB and DGFT. We have commenced on the delivery of these actions and recorded our progress on the action plan for you information.”

    Source location

    2016-0382-Response-by-The-Dudley-Group-NHS-Trust
    Page 2 · response
    Published 26 October 2016

    Open published response
  9. Swansea and Neath Port Talbot

    AI-generated summary

    David Nigel Phillips · 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

    David Nigel Phillips, who had a history of mental illness, previous suicide attempts, alcohol-related issues and type 2 diabetes, was found drowned in a rock pool near Mumbles Pier on 4 January 2015. He had been arrested the previous day after being found intoxicated in his parked car and had told police he had been attempting to take his own life. The principal concerns were that an experienced mental health professional should have assessed him and that the healthcare professional lacked access to his medical records, including mental health records, to review his medication and risks accurately.

    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 healthcare professional access to detainees’ medical and mental health records

    Wider context from the report

    “My concerns are that:- (1) An experienced mental health doctor or nurse should have been called to carry out the assessment rather than a nurse. The quality of the assessment is critical rather than a box ticking exercise. (2) The Health Care Professional did not have access to detainee’s medical records to accurately identify reasons as to why and how medications are changed or as to when this may or may not have occurred. An ability to review medication and if necessary prescribe medication would be helpful and access to medical records is critical. Access to electronic Individual Health Records to include mental health records ”

    Source location

    David Nigel Phillips · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. East London

    AI-generated summary

    Mrs Catherine Dinnen · 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

    Mrs Catherine Dinnen was admitted to hospital after left-sided weakness and suspected stroke, later developing vomiting, diarrhoea and breathing difficulties. She suffered a cardiorespiratory arrest on 27 August 2013 and was pronounced deceased that day. The principal outstanding concern was the timeliness of obtaining a medical review, in the context of reported difficulties securing out-of-hours medical attendance and concerns about staffing levels.

    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

    Loss of patient observation records

    Wider context from the report

    “2. The outstanding area of concern was in relation to provision of a timely medical review. The evidence provided by the family was that the nursing staff had a great deal of difficulty in securing a medical review. It would appear from the records that the on-call doctor was informed at 18:30 on 25 August, but did not attend until 23:15. The Trust had lost the observation records and these were not therefore available for review at the Inquest. One of the investigation reports however refers to the observations at 19:20 on the 25th August, triggering a review by an FY1 and discussion with an SPR, within 30 minutes. The consultant who gave evidence at the Inquest confirmed that there had been no changes to medical staffing since August 2013. She further confirmed that the medical staffing at weekends, bank holidays and out of hours is one FY1 and one SHO to cover all medical wards (7 or 8 of them). One medical registrar to cover emergency admissions to hospital, acute admissions unit and all patients on medical wards. One consultant on call. She described this cover as “not ideal, but the same as in other Trusts”. The ward manager stated that the level of medical staffing out of hours can be a problem and is still a problem. He confirmed that nurses have to continuously bleep the medical team to come to review patients. The Trust legal representative confirmed that the Trust had not considered medical cover out of hours as part of their internal investigation. ”

    Source location

    Mrs Catherine Dinnen · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
Back to top

Data last updated 7 September 2026