First reported 21 Aug 2013•Latest report 27 May 2026
Definition
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
Distinct published reports
Individual concerns
55
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
73
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 Care5
Essex Partnership University NHS Foundation Trust4
College of Policing3
Greater Manchester Police3
Home Office3
Tameside and Glossop Integrated Care NHS Foundation Trust3
Cornwall Partnership NHS Foundation Trust2
HM Prison and Probation Service2
Metropolitan Police Service2
North East London NHS Foundation Trust2
Pennine Care NHS Foundation Trust2
Barts Health NHS Trust1
British Vehicle Rental and Leasing Association1
Care UK1
Chippenham Community Hospital1
NHS trust33
Healthcare site10
Ministerial department8
Police force7
Type not available5
National policing body4
Executive non-departmental public body3
Integrated care board3
English county council2
English unitary authority2
Executive agency2
Private limited company2
Health and care professional regulator1
Health professional body1
Higher education regulator1
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.
Manchester South
Concerns raised1
Failure to document the ICU consultant’s rationale for examination and admission 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 concerns
Each 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
Use an amended ICU daily review chart with a dedicated microbiology input section and documented real-time multidisciplinary decisions.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 9 May 2024.
Action
Audit completion of the amended ICU daily review documentation through the ITU local audit programme.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 9 May 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Leicester City and South Leicestershire
Concerns raised1
Lack of documentation of decisions to remove personal ligature risk assessments
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Essex
Concerns raised1
Failure to record readmission considerations, decision and rationale
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 concerns
Each 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
Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 January 2024.
Action
Arrange bespoke documentation training for all staff working in the urgent care pathway.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 January 2024.
Cornwall and Isles of Scilly
Concerns raised1
Failure to identify the prescribing doctor and record prescribing decision-making
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The records identify the prescriber and document the rationale for suspending aspirin and prescribing dalteparin.
Stated by Royal Cornwall Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised1
Incomplete recording of multidisciplinary decisions, observation rationale and risk-management plans
This report raised 15 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Roll out electronic observations across the Trust while maintaining review and assurance of observation records and multidisciplinary observation-level decisions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Undertake horizon scanning on multidisciplinary-team communication and patient-risk management, then review findings and take required actions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Inner North London
Concerns raised1
Failure to record reasons for crisis-team pathway decisions
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
North East Kent
Concerns raised1
Failure to record reasons for not following Consultant Haematologist anticoagulation advice
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 concerns
Each 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
Communicate to clinical teams the requirement to document decision-makers and rationales when withholding haematology-advised anticoagulant treatment.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 October 2022.
Norfolk
Concerns raised1
Failure to record administration of hazardous items and the rationale for overriding restrictions
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 concerns
Each 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
Provide staff training on contemporaneous, high-standard record keeping through an external law firm.
Stated by Norfolk and Suffolk NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 April 2022.
Action
Ensure agency staff can access electronic patient records and understand expectations to record contemporaneous notes individually and comprehensively.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 26 April 2022.
Essex
Concerns raised1
Failure to document the rationale for non-referral to the MDT
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
London City
Concerns raised2
Failure to properly reason and record offender-manager licence-condition approvals
Failure to record proper rationale for changes to OASys risk ratings
This report raised 22 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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.6
Action
Continue working with partners and stakeholders to update offender-management guidance and products to reflect changes resulting from the report.
Stated by College of PolicingStated in progressThe respondent said that this action was in progress when they made their response on 3 November 2021.
Action
Use Core Groups to examine case detail and recommend decisions to MAPPA panels for final approval.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 3 November 2021.
Action
Arrange emergency MAPPA panels with documented decisions and rationales when urgent matters require timely responses.
Stated by West Midlands PoliceStated completedThe respondent said that this action was complete when they made their response on 3 November 2021.
Action
Publish guidance on licence variation and authorisation, requiring decisions and rationales to be recorded on NDelius.
Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 3 November 2021.
Action
Develop and consolidate the Licence Conditions Policy Framework, including recording and partner-engagement requirements for licence decisions.
Stated by Ministry of JusticeStated plannedThe respondent said that this action was planned when they made their response on 3 November 2021.
Action
Provide reduced NSD caseloads and senior practitioner oversight through countersigning and regular supervision.
Stated by Ministry of JusticeStated completedThe respondent said that this action was complete when they made their response on 3 November 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Licence conditions are a matter for HMPPS, with police supporting MAPPA discussions when its input is required.
Stated by West Midlands PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
MAPPA does not make final decisions to apply, remove or authorise licence conditions; those decisions are recorded on case management systems.
Stated by Ministry of JusticeRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
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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.
