Recurring concern
Failure of care and safety auditing to identify deficiencies
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Request correctionFirst reported 28 May 2014•Latest report 16 Jun 2026
What this concern includes
Includes failures of audits or compliance-assurance processes specifically examining care and safety records, assessments, reviews, interventions, documentation or related operational practice where the audit fails to identify a material deficiency.
Not included
- Excludes generic weaknesses in governance, staffing, training or documentation unless the report directly ties them to failure of a care and safety audit.
- Excludes deficiencies in the underlying care or safety process when no audit or assurance failure is identified.
- Excludes audits of non-care public-safety activities, such as roads, signage or controlled-drug processes, unless they are explicitly part of the same care and safety auditing concern.
- Reports
- 69
- Individual concerns
- 76
- Date range
- 2014–2026
- Stated actions
- 85
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
Inadequate quality of the call auditing system
This report raised 8 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
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
Stated by South East Coast Ambulance Service NHS Foundation Trust -
Action
Reinforce information capture and communication through continuing operator training, call audits, supervision and operational reviews.
Stated by Appello Careline Limited
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Action
Strengthen QSF criteria for certified TEC monitoring organisations to improve call monitoring and emergency response quality.
Stated by TSA
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
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Position
NHS Pathways owns the national audit framework, so reviewing documentation weighting is its responsibility.
Stated by South East Coast Ambulance Service NHS Foundation Trust
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Position
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
Stated by Association of Ambulance Chief Executives -
Position
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
Stated by TSA -
Position
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
Stated by NHS England -
Position
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
Stated by NHS England
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Concerns raised1
Lack of auditing of trip-out observations against case notes and authorisation
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.
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
Use the new Record of Time Away and Return procedure and form to document leave plans, risk assessment, clinical decisions, and return concerns.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Monitor the implemented actions through ongoing focused auditing and take further improvement action when required.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Lack of assessment and auditing of falls risk assessment accuracy
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 of routine supervision or audit to identify gaps in drug recovery care
This report raised 8 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.1
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Position
Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.
Stated by Practice Plus Group
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Concerns raised1
Failure of records auditing to identify repeated omissions of required information
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
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
Stated by Frimley Health NHS Foundation Trust
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Concerns raised1
Failure to complete audits of radiology scanning processes
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
Complete a formal audit and data analysis of urgent CT head scanning performance for in-patients who fell while receiving anticoagulation.
Stated by Hull University Teaching Hospitals NHS Trust -
Action
Undertake a repeat audit after the improvement actions are embedded to assess reliability of urgent CT head scan delivery.
Stated by Hull University Teaching Hospitals NHS Trust
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Concerns raised2
Omission of quality and nature audits from observation records auditing
Failure of quality assurance and auditing processes to monitor the quality of observations and engagement documentation
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.6
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Action
Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review and co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Review Tendable audit templates within the wider Trust audit-assurance process.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to identify non-compliance with risk assessment policy through auditing
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
Standardise community mental health risk-assessment compliance auditing through a revised Quality Assurance Tool.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust
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Concerns raised1
Delays in auditing compliance with patient identification processes
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.1
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Action
Audit compliance with the patient identification policy regularly.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Concerns raised1
Failure of auditing of nursing and clinical record keeping to produce measurable improvement
This report raised 9 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
Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.
Stated by East London 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
No further action is considered necessary because considerable work has addressed the identified concerns.
Stated by East London NHS Foundation Trust
Data last updated 7 September 2026