Recurring concern
Failure to reliably document the rationale for consequential decisions
- Reports that mention this concern
- 54
- Times this concern has been raised
- 55
- Stated actions linked to this concern
- 73
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 54 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- Greater Manchester Police
- Home Office
Stated actions 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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Greater Manchester Police
Require pre-service vulnerability risk assessments, documenting the rationale and potential impact on the suspect in Child Abduction Warning Notice records.
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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Home Office
Operational and procedural concerns about police practice are for the police to address.
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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.
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 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.
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 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.
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.
Linked response
- Sheffield Health Partnership University NHS Foundation Trust
Stated actions 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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Sheffield Health Partnership University NHS Foundation Trust
Review and revise the inpatient record-keeping procedure to clarify consistent documentation standards.
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Sheffield Health Partnership University NHS Foundation Trust
Pilot handheld tablets on Maple Ward to improve timely clinical-record entry and identify observation-level changes and authorisation.
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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.
Linked response
- Lancashire & South Cumbria NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Lancashire & South Cumbria NHS Foundation Trust
Consider amending the Leave Policy to include additional requirements for care planning regular patient leave.
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Lancashire & South Cumbria NHS Foundation Trust
Pilot leave diaries in secure services to assess whether they improve the quality of post-leave documentation.
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Lancashire & South Cumbria NHS Foundation Trust
Write to consultants and ward managers reiterating the need to document the rationale, risks and benefits for each patient accessing leave.
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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.
Linked response
- Surrey Police
Stated actions 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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Surrey Police
Triage SCARF referrals by checking factual content, risks, vulnerabilities, warnings, previous referrals and escalation needs, with risk ratings adjusted and justified where necessary.
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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.
Linked response
- Care UK
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Care UK
Use a Patient Wing Movement Assessment requiring senior clinical review, documented fitness decisions and reasons, regular review meetings, and communication of outcomes before transfers.
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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.
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026