Recurring concern
Unreliable traceability of retrospective amendments to safety records
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Request correctionFirst reported 15 Feb 2016•Latest report 17 Mar 2026
What this concern includes
Includes failures of controls dedicated to making retrospective amendments to safety-relevant electronic or structured records apparent and traceable, including amendment history, timing, authorship, reasons and auditability; include the anchor's amendments to electronic medical records and the ACCT-document amendment concern.
Not included
- Excludes ordinary incomplete, inaccurate or unavailable record content where retrospective amendment traceability is not the unsafe condition.
- Excludes generic electronic-record access, retention, validation or usability failures that do not concern identifying later amendments.
- Excludes failures to record contemporaneous care or observations when no retrospective amendment or audit-trail issue is identified.
- Excludes ordinary correction of records where the amendment is clearly marked, attributable, dated and reasoned.
- Reports
- 11
- Individual concerns
- 12
- Date range
- 2016–2026
- Stated actions
- 15
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 raised2
Failure of patient safety incident investigators to correctly identify retrospective medical record entries
Failure to identify and explain retrospective medical record entries
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 label retrospective care records
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.3
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Action
Introduce EnabLE digital care planning, handheld devices and staff recording requirements to standardise care records and support auditing.
Stated by Barchester Healthcare Limited -
Action
Provide refresher training on EnabLE functionality, record-keeping expectations, policy and accurate contemporaneous recording.
Stated by Barchester Healthcare Limited -
Action
Continue remotely reviewing Home documentation quality through the assurance audit programme.
Stated by Barchester Healthcare Limited
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Concerns raised1
Failure to identify retrospective entries and their reasons
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 of the electronic patient record system to identify authors of changes to finalised discharge letters
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
Complete an internal review and consult other Lorenzo users about the Immediate Discharge Summary author-identification process.
Stated by NHS Humber Health Partnership
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
A single remedy to identify all authors of Immediate Discharge Summary changes cannot yet be identified because non-clinical staff manage summaries before finalisation.
Stated by NHS Humber Health Partnership
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Position
The proposed Immediate Discharge Summary process change cannot begin fully until required project, system and stakeholder resources become available and internal approval is completed.
Stated by NHS Humber Health Partnership -
Position
Responsibility for the Lorenzo system relationship sits directly with trusts and the supplier because NHS England has no contract.
Stated by NHS England
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Concerns raised1
Failure to clearly flag amendments to SystmOne medical records
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
Provide a SystmOne audit trail showing amended content, the person making each amendment, and when it occurred.
Stated by The Phoenix Partnership (Leeds) Ltd
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
A Word printout is editable and cannot represent the SystmOne audit trail or establish that an entry was amended.
Stated by The Phoenix Partnership (Leeds) Ltd
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Position
SystmOne’s existing audit trail records amendments, users and times and is readily accessible, providing a complete and robust record.
Stated by The Phoenix Partnership (Leeds) Ltd
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Concerns raised1
Failure of electronic care records to preserve auditable timestamps and record actual entry times
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.
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
Specification of IT systems used within mental health settings falls outside NHS Digital’s remit.
Stated by JAMES MORRIS MP
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Position
Providers are responsible for assessing system fitness, training staff, intended use and clinical safety because approved digital systems are not mandatory.
Stated by JAMES MORRIS MP
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Concerns raised1
Failure to make amendments to electronic records apparent
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 of electronic records to preserve and clearly display original entries
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
Update Rio form guidance to show staff how to find the history of electronic record entries.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Develop the Rio system further to make exact changes between versions of electronic records identifiable.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Failure to make contemporaneous observation-log entries
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.6
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Action
Issue an internal Blue Light Bulletin to registered nurses using the case to reinforce observation and recording practice standards.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Review the Therapeutic Engagement and Observation Policy, focusing on practice-standard clarity and policy implementation.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Deliver annual Learning the Lessons presentations on timely observation and recording to newly registered nurses, using the case as teaching material.
Stated by South London and Maudsley NHS Foundation Trust
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Action
Deliver annual Learning the Lessons presentations on timely observation and recording to nurses in training years one to three, using the case as teaching material.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Develop a timeline for transforming mental health safety and engagement observations into the e-observation framework, beginning with scoping.
Stated by South London and Maudsley NHS Foundation Trust -
Action
Conduct six-monthly snap audits of compliance with observation standards, report results through quality governance meetings, and take necessary improvement steps.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Failure to identify retrospective medical-record entries
This report raised 10 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