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 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.
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
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Action
Review accepted clinical documentation standards to maximise clinicians’ time for compassionate, person-centred care and discussions with families and carers.
Stated by Cornwall Partnership NHS Foundation Trust -
Action
Consider including a concise template for documenting inpatient discharge decisions in the discharge policy review.
Stated by Cornwall Partnership NHS Foundation Trust
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
Finite services and limited clinical time prevent consistently prioritising comprehensive documentation alongside direct patient and family care.
Stated by Cornwall Partnership NHS Foundation Trust
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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.
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
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Action
Conduct the commissioned serious incident investigation and present its findings to the Executive Scrutiny Panel.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Conduct the documentation standards audit.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Develop an action plan addressing issues identified by the documentation standards audit.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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
Existing GMC documentation standards and junior doctor induction sufficiently require recording clinical decisions, specialist advice, deviations and reasons in medical records.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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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.
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
Run MCA and Best Interests audits to assess practical application, recording, patient and family involvement, and Health Passport use.
Stated by Sheffield Teaching Hospitals NHS Foundation Trust
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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.
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
Add vital signs, pain score and diversion-decision rationale to ambulance pre-arrival documentation at Whipps Cross, with random manual auditing.
Stated by Barts Health NHS Trust and North East London NHS Foundation Trust
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
Existing documentation processes at other Barts Health Emergency Departments are considered sufficient for recording decisions to divert patients.
Stated by Barts Health NHS Trust and North East London NHS Foundation Trust
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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.
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 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.
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
Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
Stated by Manchester University NHS Foundation Trust
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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.
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 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.
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 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.
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 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.
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