Recurring concern
Unreliable documentation of safety risk assessments
First reported 14 Jul 2014•Latest report 12 Jan 2026
What this concern includes
Includes failures to document formal, informal or clinically judged safety risk assessments, risk discussions, risk formulations, assessor identities and material assessment details in the records used for ongoing care, custody, safeguarding or safety review. Includes the anchor assertion, post-triage risk assessments, mental-health risk-assessment details and comparable police or prison risk-assessment records.
Not included
- Excludes failures to perform or clinically formulate a risk assessment where documentation is not itself deficient.
- Excludes generic clinical, care or administrative record-keeping failures that do not specifically concern documentation of a safety risk assessment.
- Excludes failure to communicate or act on a risk assessment after it has been accurately documented, unless the documentation process is also deficient.
- Excludes hazard-specific or named risk systems, such as mental-health, falls, suicide, prisoner or safeguarding risk-assessment systems, when the assertion is confined to a distinct system with a more specific supported parent.
- Reports
- 27
- Individual concerns
- 27
- Date range
- 2014–2026
- Stated actions
- 47
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 record risk assessments prior to leave
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.
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 perform and document VTE risk assessments after reduced mobility from baseline
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.
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
Update medical trainee, local and junior doctor induction materials to cover physical health emergencies, diagnostic overshadowing, VTE assessment, prophylaxis and escalation guidance.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Roll out face-to-face bite-size physical-health training across the Trust, including VTE and thrombolisation.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to accurately record and file important medical records
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.1
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Action
Provide record-keeping training to Turner Ward staff on Trust expectations.
Stated by Trust
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Concerns raised1
Failure to document store operator and regular delivery driver views and experiences in DPRA risk assessments
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
Apply the revised Nisa DPRA process across delivery locations using risk-based prioritisation and weekly management oversight.
Stated by DHL Supply Chain Ltd UK & Ireland
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Concerns raised1
Failure to accurately record progress notes and risk assessments
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.
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
Remind staff to validate records and routinely audit unvalidated notes, providing audit feedback to clinical teams.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Extend mandatory clinical risk management training to cover the revised mental-health risk assessment and management procedures.
Stated by Midlands Partnership University 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
Automatic validation of all electronic records is not achievable because some staff entries must be validated by other staff.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Inadequate and disorganised choking risk assessment record keeping
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.4
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Action
Complete swallowing risk assessments with independent validation and Care Manager sign-off of updates.
Stated by Hc-One Limited -
Action
Rewrite residents’ care plans to specify detailed individual care requirements.
Stated by Hc-One Limited -
Action
Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.
Stated by Hc-One Limited
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Action
Implement daily ‘Resident of the day’ care-plan reviews and report changing needs through the clinical risk register.
Stated by Hc-One Limited
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Concerns raised1
Failure to record falls risk consistently with the assessment score
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 document consultant VTE assessments
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.
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
Advise consultants and associate specialists to ensure VTE assessments are completed and documented during post-take ward rounds and to support trainees.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure to maintain complete, sufficient and consistent nursing records, handovers, risk assessments and care plans
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 risk, contact details, appointment information and follow-up arrangements
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