Recurring concern
Failure to reliably document the rationale for consequential decisions
Pin
Get email alerts
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.
-
Concerns raised1
Lack of documentation explaining the rationale for CAWN issuance
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.1
-
Action
Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.
Stated by Greater Manchester Police
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
Operational and procedural concerns about police practice are for the police to address.
Stated by Home Office
-
Concerns raised1
Failure to record reasons for closing a Subject of Interest
This report raised 17 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.
-
Concerns raised1
Failure to document the rationale for RAID decisions not to refer to a psychiatrist
This report raised 4 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.
-
Concerns raised1
Failure to record clinical presentations, diagnoses, medication-change rationale and attendances
This report raised 5 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.
-
Concerns raised1
Failure to record the rationale for changes to patient observation regimes
This report raised 4 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
-
Action
Review and revise the inpatient record-keeping procedure to clarify consistent documentation standards.
Stated by Sheffield Health Partnership University NHS Foundation Trust -
Action
Pilot handheld tablets on Maple Ward to improve timely clinical-record entry and identify observation-level changes and authorisation.
Stated by Sheffield Health Partnership University NHS Foundation Trust
-
Concerns raised1
Insufficient recording and care planning of patient leave, including its rationale, benefits and risks
This report raised 3 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
-
Action
Consider amending the Leave Policy to include additional requirements for care planning regular patient leave.
Stated by Lancashire & South Cumbria NHS Foundation Trust -
Action
Pilot leave diaries in secure services to assess whether they improve the quality of post-leave documentation.
Stated by Lancashire & South Cumbria NHS Foundation Trust -
Action
Write to consultants and ward managers reiterating the need to document the rationale, risks and benefits for each patient accessing leave.
Stated by Lancashire & South Cumbria NHS Foundation Trust
-
Concerns raised1
Failure to record the basis for reduced risk-of-self-harm assessments
This report raised 1 other concern. 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
-
Action
Triage SCARF referrals by checking factual content, risks, vulnerabilities, warnings, previous referrals and escalation needs, with risk ratings adjusted and justified where necessary.
Stated by Surrey Police
-
Concerns raised1
Lack of process for recording transfer decisions, reasons and decision-maker identity
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.1
-
Action
Use a Patient Wing Movement Assessment requiring senior clinical review, documented fitness decisions and reasons, regular review meetings, and communication of outcomes before transfers.
Stated by Care UK
-
Concerns raised1
Inadequate recording of medication reviews and reasons for repeat prescribing
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.
-
Concerns raised1
Failure to document consideration of recent suicide attempts during care plan review
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.
Data last updated 7 September 2026