Recurring concern

Unreliable completion of admission documentation

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First reported 3 Sep 2014•Latest report 28 Aug 2025

Definition

What this concern includes

Includes failures in the dedicated admission-documentation process, including unclear or inadequate completion protocols, missing or delayed care plans, risk assessments and other required admission records, and failures to complete or update those records during admission.

Not included

Excludes general clinical or care-record deficiencies that are not specifically connected to admission documentation.
Excludes failures in the substantive clinical admission assessment where the admission documentation process is not deficient.
Excludes discharge, transfer and post-admission documentation processes unless the assertion specifically concerns completion of required admission documentation.
Excludes generic staffing, training or communication deficiencies unless they directly impair completion of admission documentation.

Reports: 15
Individual concerns: 15
Date range: 2014–2025
Stated actions: 22

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Aden Court Care Home1

Amplius Living1

Avery Healthcare Group1

Avon and Wiltshire Mental Health Partnership NHS Trust1

Bedfordshire Hospitals NHS Foundation Trust1

Department of Health and Social Care1

Devon Partnership NHS Trust1

East London NHS Foundation Trust1

East Surrey Hospital1

Elvy Court Care Home1

Greater Manchester Mental Health NHS Foundation Trust1

Healthcare Safety Investigation Branch1

National Institute for Health and Care Excellence1

Somerset NHS Foundation Trust1

Stepping Hill Hospital1

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.

25 Oct2016
Exeter and Greater Devon
Concerns raised1
1. Failure of the admission recording system to make obtaining carer and family information mandatory
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Use an active Care Notes care-planning field to record information sought from carers or family.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Activate a Care Notes risk-assessment area recording carers’ and family members’ views.
  Stated by Devon Partnership NHS TrustStated planned
Respondent positions 1
1. Position
  A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.
  Stated by Devon Partnership NHS TrustExisting arrangements considered sufficient
AI-generated summary

Matthew Llewellyn-Jones · 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

Matthew Llewellyn-Jones, who had been detained under section 2 of the Mental Health Act after becoming acutely unwell with psychosis, left a locked hospital ward unaccompanied and was later found hanging by a ligature in the hospital grounds. The concerns included breaches of the ward’s locked door, predictable observations, inadequate collection of information from family and carers, insufficient assessment and observation, inadequate staff induction, and staffing levels that contributed to failings in his care and security.

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 of the admission recording system to make obtaining carer and family information mandatory
Wider context from the report
“(3) A new system of note recording has been introduced since this death, but it still does not make obtaining information from carers and/or family mandatory on admission. The importance of this information was readily acknowledged by the Trust in their internal inquiry and at inquest. The electronic recording system should be able to facilitate capturing such information with the use of mandatory fields to avoid this oversight and could assist the Trust in achieving their stated aims in this respect. ”
Source location
Matthew Llewellyn-Jones · Prevention of Future Deaths report
Page 2 · 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
Use an active Care Notes care-planning field to record information sought from carers or family.

Verbatim wording from the response
“A copy of the Care Notes forms are attached, the specific changes that have been made are-”

Source location
2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 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
Activate a Care Notes risk-assessment area recording carers’ and family members’ views.

Verbatim wording from the response
“• Risk Assessment (Specific area looking at carer/family views) – this is due to become active by the end of January 2017 (ref 2.2)”

Source location
2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A mandatory field for carer and family information will not be added; free-text recording and audit follow-up are considered sufficient.

Verbatim wording from the response
“The introduction of a mandatory field has been considered by the Care Notes team and senior clinical colleagues. The decision has been made not to add as a mandatory field, it will continue to be recorded as a ‘free text’ field. The rational for this decision is that a mandatory field could be completed with a generic comment for example ‘have been unable to contact family at this time’, when audited as detailed below, this would be identified as completed. If the field is left ‘blank’ the audit will highlight this and allow individual review and follow up with the staff member concerned.”

Source location
2016-0385-Response-by-Devon-Partnership-NHS-Trust
Page 2 · response
Published 25 October 2016
Open published response
10 May2016
Brighton and Hove
Concerns raised1
1. Failure to complete admission and fall documentation
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Follow up poor documentation with nursing and medical staff.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Organise a monthly neurosurgical records audit to improve documentation quality.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
1. Action
  Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
AI-generated summary

Christine Valerie STREET · 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

Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

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 complete admission and fall documentation
Wider context from the report
“(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed). The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street’s notes. ”
Source location
Christine Valerie STREET · Prevention of Future Deaths report
Page 2 · 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
Follow up poor documentation with nursing and medical staff.

Verbatim wording from the response
“I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 10 May 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
Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.

Verbatim wording from the response
“It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 10 May 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
Organise a monthly neurosurgical records audit to improve documentation quality.

Verbatim wording from the response
“In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 10 May 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
Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.

Verbatim wording from the response
“In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

Source location
2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 10 May 2016
Open published response
6 Nov2015
Brighton and Hove
Concerns raised1
1. Failure to create care plans, risk assessments and other admission documentation
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Mr Brian James SHILLINGLAW · 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

The supplied text does not provide the circumstances or date of Mr Brian James SHILLINGLAW’s death. The principal concerns relate to the creation, updating and use of care plans and risk assessments, communication and coordination among staff, observation policy, and recording and communicating Deprivation of Liberty Safeguarding status.

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 create care plans, risk assessments and other admission documentation
Wider context from the report
“(1) The creation of Care Plan, Risk Assessment and other admission documentation (2) The amending and updating of these plans, particularly the Risk Assessment by the relevant members of clinical and nursing staff (3) A discussion about the role of the primary nurse and care coordinator with particular reference to ensuring ongoing communication between various members of the multi-disciplinary team who will look after a patient like Mr Shillinglaw (4) Complying with the Trusts own policies with regard to Risk Assessment and Management which was clearly extremely poorly understood in Mr Shillinglaw’s case. (5) The use of dynamic Risk Assessment, the importance of clearly updating Risk Assessment documentation (6) Understanding the necessity of implementing the Trust’s Observation Policy as part of the Risk Assessment and Management process. Ensuring that the Patient’s status is recognised and recording it correctly in all paperwork. (7) The knowledge that a Patient is the subject of a Deprivation of Liberty Safeguarding Order, understanding the significance of that and recording that in the paperwork in the Trust’s own premises and ensuring that notification of status travels with the Patient should he or she need to be admitted to the Acute Hospital Trust. ”
Source location
Mr Brian James SHILLINGLAW · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Jul2015
Avon
Concerns raised1
1. Lack of documented risk assessments at admission onto Mason Unit
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Simon Peter REYNOLDS · 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

Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of risk.

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
Lack of documented risk assessments at admission onto Mason Unit
Wider context from the report
“(1) I heard evidence that there is no documented risk assessment produced at the time of a service user's admission onto Mason Unit. I would ask that you review whether this is still appropriate. ”
Source location
Simon Peter REYNOLDS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Sep2014
Surrey
Concerns raised1
1. Failure to complete the falls management plan
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Hilda Florence Thompson · 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

Hilda Florence Thompson, who had limited mobility and a history of falls, was admitted to hospital with breathlessness and later identified as a high falls risk. She collapsed on 19 January 2014, sustained an extensive intracranial injury, and died on 22 January 2014; concerns included an incomplete admission management plan, incorrect initial identification as not being at risk of falls, delayed falls assessment, and poor 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 complete the falls management plan
Wider context from the report
“• Upon her admission to hospital, her management plan was not completed and she was wrongly identified as not being a falls risk. • There was no further review of Mrs Thompson and it was not until 11/1/14 when a full falls risk assessment was made and preventable measures put into place. • Poor note taking of 2/1/14 to account for this. • This left a gap of some 10 days during which she was not properly risk assessed for falls. ”
Source location
Hilda Florence Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of the admission recording system to make obtaining carer and family information mandatory

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to complete admission and fall documentation

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

Concerns raised1

Failure to create care plans, risk assessments and other admission documentation

Concerns raised1

Lack of documented risk assessments at admission onto Mason Unit

Concerns raised1

Failure to complete the falls management plan

Actions described in response 2

Respondent positions 1

Actions described in response 4