Recurring concern

Unreliable traceability of retrospective amendments to safety records

First to latest report 15 Feb 2016 — 17 Mar 2026

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
15

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.

What is 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 and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Adam James Withers · 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

    Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

    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 identify retrospective patient-record entries

    Wider context from the report

    “It was clear from the evidence that any note made in a patient’s record should be made contemporaneously or, if made later, should be timed, dated and labelled as retrospective. This is necessary to ensure that all notes are accurate and reliable. The evidence at the inquest revealed that at least one member of nursing staff made entries on Adam Withers’ manuscript observation record after he had died, without marking the entries as retrospective. When giving evidence, the member of staff in question did not appear to understand that he ought not to have done so. If permitted to continue, this practice could result in current and future patients’ notes containing inaccurate and unreliable, and potentially misleading, information and this could have an adverse impact on their assessment, treatment and care and upon the protection of their lives. ”

    Source location

    Adam James Withers · Prevention of Future Deaths report
    Page 4 · 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

    Review the Records Management Policy and establish standards for factual, accurate, evidence-based and timely record keeping.

    Verbatim wording from the response

    “We have since reviewed our Records Management Policy which has a section outlining the ‘Standards for Record Keeping’. Under these standards there is clear expectation that:”

    Source location

    Adam-WITHERS-Response
    Page 2 · response
    Published 15 February 2016

    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

    Use electronic patient records in Acute Services to provide an auditable record-entry time trail.

    Verbatim wording from the response

    “In an emergency where staff are unable to record the times we would expect them to highlight that the record/entry is retrospective, but should still follow a chronological format of proceedings. Our use of the electronic patient record system in our Acute Services now removes any doubt about record entry time as every entry now leaves a clear audit trail which can be reviewed as required. Quality is further maintained when we share learning from our record keeping audits which we undertake as part of our clinical audit program.”

    Source location

    Adam-WITHERS-Response
    Page 2 · response
    Published 15 February 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026