Recurring concern
Failure to reliably document the rationale for consequential decisions
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Request correctionFirst reported 21 Aug 2013•Latest report 27 May 2026
What this concern includes
Includes failures to record the rationale, evidence considered, decision basis or responsible decision-maker for consequential clinical, care, custodial or operational safety decisions where the record is needed for safe review, communication, accountability or continuity.
Not included
- Excludes ordinary record-keeping omissions that do not concern the rationale or evidential basis of a consequential safety decision.
- Excludes poor decisions where the rationale was adequately documented and the deficiency lies only in the decision’s substance or later implementation.
- Excludes generic clinical communication, handover or documentation failures unrelated to recording the basis of a consequential decision.
- Excludes routine administrative decisions with no identified patient, public or operational safety significance.
- Reports
- 54
- Individual concerns
- 55
- Date range
- 2013–2026
- Stated actions
- 73
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to record the timing and rationale for returning usual clothing after ligature risk
This report raised 18 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Inadequate communication and recording of leave decisions
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Develop a replacement electronic patient record system incorporating redesigned risk assessment, safety planning, leave documentation and monitoring capabilities.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Implement electronic ward-round templates for documenting leave discussions, risk considerations, plans and actions and sharing them across multidisciplinary teams and shifts.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Publish and disseminate patient-safety learning on informal leave management, documentation and failure to return to relevant staff.
Stated by South London and Maudsley NHS Foundation Trust
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Action
Develop a standardised leave log suitable for detained and informal patients.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Investigate and explore producing the leave form electronically, including with the new EPR provider, to improve access, recording and monitoring.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Failure to record clinical rationale for continued repeat prescribing in light of overdose risk
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Amend the self-harm follow-up policy to require medication review and consideration of reducing prescription quantities where ongoing risk exists.
Stated by Your Health Partnership PCN -
Action
Amend the self-harm risk-assessment template to record medication review discussions, stockpiling, medication safety, prescription quantity, and medication supervision options.
Stated by Your Health Partnership PCN
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Concerns raised1
Failure to document the rationale for important SALT-related decisions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record key detail about observations and the rationale for clinical decision making
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Deliver recurring documentation lectures and training to departments and aspiring Band 6 leaders, incorporating learning from real-life cases.
Stated by West Suffolk NHS Foundation Trust -
Action
Disseminate documentation-learning content nationally through professional conference teaching.
Stated by West Suffolk NHS Foundation Trust -
Action
Create and issue a deteriorating-patient safety-alert bulletin emphasising clear documentation.
Stated by West Suffolk NHS Foundation Trust
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Action
Carry out a safety walkabout addressing documentation standards and related safety issues.
Stated by West Suffolk NHS Foundation Trust -
Action
Continue working with system partners to monitor and review record-keeping performance while developing further safety improvements.
Stated by West Suffolk NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
There is no universally right or wrong clinical record, and existing guidance is general rather than specifying one required level of detail.
Stated by West Suffolk NHS Foundation Trust
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Concerns raised1
Failure to record the rationale for mental health assessment decisions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record the rationale for decisions not to detain following mental health assessments
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Transfer Mental Health Act assessment recording from RIO to Mosaic to enable inclusion in the audit programme.
Stated by Cornwall Council
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Concerns raised1
Failure to properly record the rationale for critical NRPF decisions
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Provide ongoing NRPF practice-development coaching, including workshops, individual coaching, joint visits, observation, record review and reflective feedback.
Stated by London Borough of Newham -
Action
Undertake focused case audits covering supervision, management oversight, recording, plans and children’s voices.
Stated by London Borough of Newham -
Action
Embed purposeful, child-centred and compassionate recording standards through training and quality-assurance reviews.
Stated by London Borough of Newham
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Action
Develop Integrated Children’s System changes to strengthen recording of notes and management decisions.
Stated by London Borough of Newham
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Department for Education is responsible for responding to concerns about child social care and is best placed to provide a formal response.
Stated by Department of Health and Social Care
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Concerns raised1
Inadequate recording and structuring of accommodation offer decisions
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Use an implemented Offer/Acceptance document to record offer conditions and share them with relevant parties.
Stated by Steps2Recovery -
Action
Record prospective-client communications, discussions and decisions in Lamplight and audit them through senior management.
Stated by Steps2Recovery -
Action
Provide mandatory continuous staff training on updated processes, decision recording, policies and procedures.
Stated by Steps2Recovery
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Action
Collaborate with Lamplight to configure the case-management system for more efficient and effective operation.
Stated by Steps2Recovery -
Action
Provide further staff training on Lamplight to improve system use and documentation accuracy.
Stated by Steps2Recovery
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Concerns raised1
Failure to document MDT meeting decision making and risk downgrading rationale
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Implement the revised MDT template and pre-MDT referral process to clarify referrals and capture clinical information, decisions, actions and owners.
Stated by Leicestershire Partnership NHS Trust -
Action
Include a senior nurse clinician, medical colleagues and crisis-service members in MDT meetings to oversee and support the process.
Stated by Leicestershire Partnership NHS Trust -
Action
Conduct monthly audits of MDT processes and documentation, share feedback with staff, review outcomes through quality governance, and undertake additional six-month senior scrutiny.
Stated by Leicestershire Partnership NHS Trust
Data last updated 7 September 2026