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 discuss and record the rationale for departing from the manufacturer’s instructions for use
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.
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Concerns raised1
Failure to document or record therapy selection options and rationale
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.1
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Action
Initiate a case-note process recording completion of treatment-options sessions, selected treatment modalities, and allocation to the appropriate treatment pathway.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to record the rationale for crucial 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 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 who made significant clinical decisions and why
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.
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 and patient consent for a change of GP
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.4
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Action
Require providers to document discussions and information received from residents, record potential changes in care plans and clinical systems, and update records promptly.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board -
Action
Contact care homes to recommend policies and documentation standards for staff signing on behalf of residents who can consent but cannot physically sign.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board -
Action
Issue standard practice application forms to membership practices, including a section for signing on behalf of another person.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board
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Action
Require care homes to confirm patients’ awareness, consent and appropriate next-of-kin notification when capable residents change GP practice.
Stated by Northfield Medical Centre
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
There is usually no need to record the rationale for changing a patient's registered GP in the medical record.
Stated by Hazelmere Medical Centre
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Position
Care homes are responsible for confirming patient awareness, consent and, where appropriate, next-of-kin notification when facilitating GP practice changes.
Stated by Northfield Medical Centre
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Concerns raised1
Failure to record rationale for decisions not to allocate additional cover or resources
This report raised 13 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, launch, disseminate and apply the FWIN Escalation Policy with defined responsibilities, risk assessment, escalation, resourcing and delay-recording requirements.
Stated by Greater Manchester Police
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Concerns raised1
Failure to maintain consistent and adequately justified clinical records
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.1
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Action
Continue rolling out the SBAR structured record-keeping tool across all services.
Stated by Cornwall Partnership NHS Foundation Trust
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Concerns raised1
Difficulties navigating records to establish event chronology and decision rationale
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.
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
Electronic RiO records and information-sharing through team meetings and handovers provide a more appropriate account than printed records alone.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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Concerns raised1
Failure to document unavailable consent or self-consenting rationale
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 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
Roll out refresher training on mental-capacity, consent and communication policies.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to record rationales for changes to risk 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.
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
No further action is needed regarding the general system for assessing and managing risk.
Stated by Hampshire County Council
Data last updated 7 September 2026