Recurring concern

Failure to reliably document the rationale for consequential decisions

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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

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.

  1. County Durham and Darlington

    AI-generated summary

    Jeffrey Gash · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Jeffrey Gash died after hanging himself on 30 September 2013, following contacts with his GP and the Crisis Team while reporting that he was feeling worse and hearing voices. The concerns included insufficient telephone assessment and exploration of his symptoms, failure to arrange or escalate to a face-to-face assessment, unclear policies and recording regarding home visits, and inadequate risk assessment and management.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record the basis for decisions to decline home visits

    Wider context from the report

    “2. No evidence was provided at the inquest to indicate a formal Trust policy on when to decline home visits on the grounds of personal safety and security and the nurse relied upon being told of concerns about visiting this property from colleagues but did not record the same or any explanation for her decision. The absence of a clear policy and a policy for recording decisions made or understanding and training thereon is an area of concern ”

    Source location

    Jeffrey Gash · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce recording of colleague-reported risks and home-visit decisions in electronic care-record alerts.

    Verbatim wording from the response

    “In relation to recording the information from colleagues, and the individual nurse’s decision making on the shift in question, there is already an ‘alerts’ section in our electronic care record which staff are asked to use to document risks in a way that this information is available to all staff working with a specific patient. The Team Manager has previously highlighted the importance of recording this with the team, but since Mr Gash’s inquest has further reinforced this via team meetings. In addition, the Head of Service for Durham and Darlington AMH Services has asked the Crisis Team Manager to share your recommendations with the Specialty's Acute Care Group in order that the Trust standard operational policy for Crisis Teams can be strengthened accordingly.”

    Source location

    2014-0377-Response-by-Tees-Esk-and-Wear-Valleys-NHS-Trust
    Page 2 · response
    Published 18 August 2014

    Open published response

  2. West Sussex

    AI-generated summary

    MRS KERRY JACOBS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs Kerry Jacobs died on 8 July 2013 from a pulmonary embolism arising from a deep vein thrombosis in her right calf. Concerns included the prescription of a steroid dose outside usual ENT practice and BNF guidelines without adequate documentation or confirmation with the consultant, and the lack of a protocol requiring discussion between pharmacists and clinicians when prescriptions are queried.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of recording of deliberate decisions and grounds for prescribing medication outside usual practice or BNF guidelines

    Wider context from the report

    “(1) There was nothing within Mrs Jacobs’ hospital records indicating any awareness that she had been prescribed steroid dose which was out with usual ENT practice and the BNF guidelines. Nor was the actual prescription issued confirmed with or reported to patient’s consultant. The evidence was that there is no policy or procedure within the Trust which requires a doctor who prescribes a medication outside usual practice and/or BNF guidelines to note within the patient’s clinical record that they have made the deliberate decision to do so and to record their grounds for so deciding. ”

    Source location

    MRS KERRY JACOBS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Issue a directive requiring clinicians to document the rationale for prescribing outside BNF or usual-practice guidance and record pharmacist prescription-query discussions and outcomes.

    Verbatim wording from the response

    “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.”

    Source location

    2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Disseminate the prescribing documentation directive to clinical staff through divisional MDT and departmental meetings.

    Verbatim wording from the response

    “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.”

    Source location

    2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 March 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Add compliance with the prescribing documentation directive to the Trust’s 2014/2015 audit programme.

    Verbatim wording from the response

    “Response: It is correct that there is no formal Trust policy in place, however, ████████ Chief Medical Officer, has issued a directive to the Chiefs of Service in the Divisions (see attached email dated 4 June 2014) that all staff should record and specify the rationale for the decision to prescribe a medication dosage that is outside guidance within BNF, or usual practice. In addition, when a query is raised by a pharmacist regarding a patient’s prescription, an entry must be made within the patient’s medical records, noting the discussion and outcome. This directive will be disseminated to the clinical staff within each Division, at Multi Disciplinary Team (MDT) meetings each week, and departmental meetings; and will be added to the Trust’s Audit Programme for 2014/2015.”

    Source location

    2014-0133-Response-by-Surrey-Sussex-Healthcare-NHS-Trust
    Page 1 · response
    Published 21 March 2014

    Open published response

  3. Manchester South

    AI-generated summary

    Billy Paul Thomas Salton · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to record custody risk assessments and rationale for unchanged assessments

    Wider context from the report

    “1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”

    Source location

    Billy Paul Thomas Salton · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.

    Verbatim wording from the response

    “I do agree with this but can see how this can degrade into quite significant events not being accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 2 · response
    Published 6 January 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Require recording of unchanged risk assessments and monitor compliance through Custody Inspector dip sampling.

    Verbatim wording from the response

    “You are right to point out that all risk assessments, including those where there is no change in the detainee’s circumstances, should also be recorded. This requirement has been communicated to custody staff and is currently being monitored by Custody Inspectors undertaking dip sampling of custody records.”

    Source location

    2014-0002-Response-by-Greater-Manchester-Police
    Page 3 · response
    Published 6 January 2014

    Open published response

  4. West Sussex

    AI-generated summary

    Mr Walker · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Walker, who had depression, suicidal ideation and a history of impulsive self-harm attempts, died after leaving the hospital ward and hanging himself in nearby woodland. Concerns included insufficient risk care planning, unexplained reductions in observation levels, the time taken to declare him missing and inform police, and the scalability of the ward’s external fences.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to document the rationale and risk factors underlying changes in observation levels

    Wider context from the report

    “(2) There was no clear rationale provided for changes in observation levels in the notes or any explanation given in writing as to the considerations or risk factors taken into account. Whilst accepted that these matters may have been discussed, written evidence would have provided clarity and a point of reference for further assessment in light of any change in presentation or condition. The fact that observation levels only decreased (despite evidence heard at the inquest that Mr Walker was expressing ever darker and suicidal thoughts in the week before his death), without explanation, remains of concern. ”

    Source location

    Mr Walker · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide staff training on consistently documenting the rationale for changes in observation levels.

    Verbatim wording from the response

    “2. Documented rationale for the observation level We acknowledge that the rationale for changing the level of observation was not documented. The expectation is that this must be written down and this is what is stated in the policy. This is very important and our Nurse Consultant has provided training to staff to help ensure this happens more consistently.”

    Source location

    2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
    Page 2 · response
    Published 21 August 2013

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Observation rationale need not be recorded when levels remain unchanged unless clinical staff identify a significant risk change.

    Verbatim wording from the response

    “The point you make about the absence of documented rationale when observation levels do not change is a slightly different issue. Firstly, the use of observation to provide support and to manage risk is something clinicians consider constantly, and so we would not always expect the rationale to be recorded during periods when the level remains the same. This would only be necessary when there is a significant change in risk, as determined by clinical staff.”

    Source location

    2013-0213-Response-by-Sussex-Partnership-NHS-Foundation-Trust
    Page 2 · response
    Published 21 August 2013

    Open published response
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Data last updated 7 September 2026