Recurring concern
Failure to reliably document the rationale for consequential decisions
- Reports that mention this concern
- 54
- Times this concern has been raised
- 55
- Stated actions linked to this concern
- 73
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 54 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to document the rationale for discharge safety decisions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cornwall Partnership NHS Foundation Trust
Stated actions 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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Cornwall Partnership NHS Foundation Trust
Review accepted clinical documentation standards to maximise clinicians’ time for compassionate, person-centred care and discussions with families and carers.
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Cornwall Partnership NHS Foundation Trust
Consider including a concise template for documenting inpatient discharge decisions in the discharge policy review.
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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Cornwall Partnership NHS Foundation Trust
Finite services and limited clinical time prevent consistently prioritising comprehensive documentation alongside direct patient and family care.
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Concerns raised1
Failure to document clinical decisions and rationale, including decisions contrary to neurosurgical advice
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Tameside and Glossop Integrated Care NHS Foundation Trust
Stated actions 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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Tameside and Glossop Integrated Care NHS Foundation Trust
Conduct the commissioned serious incident investigation and present its findings to the Executive Scrutiny Panel.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Conduct the documentation standards audit.
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Tameside and Glossop Integrated Care NHS Foundation Trust
Develop an action plan addressing issues identified by the documentation standards audit.
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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Tameside and Glossop Integrated Care NHS Foundation Trust
Existing GMC documentation standards and junior doctor induction sufficiently require recording clinical decisions, specialist advice, deviations and reasons in medical records.
-
Concerns raised1
Inadequate detail in best-interests documentation
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sheffield Teaching Hospitals NHS Foundation Trust
Stated actions 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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Sheffield Teaching Hospitals NHS Foundation Trust
Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
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Concerns raised1
Failure to document the decision-making process and rationale for redirecting patients from A&E
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barts Health NHS Trust
- North East London NHS Foundation Trust
Stated actions 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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Barts Health NHS Trust and North East London NHS Foundation Trust
Add vital signs, pain score and diversion-decision rationale to ambulance pre-arrival documentation at Whipps Cross, with random manual auditing.
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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Barts Health NHS Trust and North East London NHS Foundation Trust
Existing documentation processes at other Barts Health Emergency Departments are considered sufficient for recording decisions to divert patients.
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Concerns raised1
Failure to maintain meaningful records of prescribing consultations and their rationale
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to maintain sufficiently detailed clinical documentation
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Manchester University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Manchester University NHS Foundation Trust
Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
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Concerns raised1
Failure to make contemporaneous records and document decision-making rationale including capacity assessments
This report raised 1 other concern. They are not shown here because they do not form part of this recurring 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 document important clinical decisions and rationale in the triage of GP referrals
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to keep contemporaneous documentation of decision-making rationale and changes in risk and capacity
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to record the rationale for departing from recognised best practice timescales
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026