Recurring concern
Failure of care and safety auditing to identify deficiencies
- Reports that mention this concern
- 69
- Times this concern has been raised
- 76
- Stated actions linked to this concern
- 85
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 69 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- Appello Careline Limited
- Association of Ambulance Chief Executives
- NHS England
- South East Coast Ambulance Service NHS Foundation Trust
- TSA
Stated actions 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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South East Coast Ambulance Service NHS Foundation Trust
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
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South East Coast Ambulance Service NHS Foundation Trust
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
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Appello Careline Limited
Reinforce information capture and communication through continuing operator training, call audits, supervision and operational reviews.
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TSA
Strengthen QSF criteria for certified TEC monitoring organisations to improve call monitoring and emergency response quality.
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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South East Coast Ambulance Service NHS Foundation Trust
NHS Pathways owns the national audit framework, so reviewing documentation weighting is its responsibility.
-
Association of Ambulance Chief Executives
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
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TSA
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
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NHS England
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
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NHS England
Apello Careline is best placed to respond to concerns about its emergency-call guidance, information handling and artificial intelligence trials.
-
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.
Linked response
- Sussex Partnership NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Sussex Partnership NHS Foundation Trust
Use the new Record of Time Away and Return procedure and form to document leave plans, risk assessment, clinical decisions, and return concerns.
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Sussex Partnership NHS Foundation Trust
Monitor the implemented actions through ongoing focused auditing and take further improvement action when required.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Practice Plus Group
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Practice Plus Group
Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.
-
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.
Linked response
- Frimley Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Frimley Health NHS Foundation Trust
Run the Harm Free Care audit programme to monitor food-chart completion, nutritional care and significant-weight-loss escalation.
-
Concerns raised1
Failure to complete audits of radiology scanning processes
Linked response
- Hull University Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Hull University Teaching Hospitals NHS Trust
Complete a formal audit and data analysis of urgent CT head scanning performance for in-patients who fell while receiving anticoagulation.
-
Hull University Teaching Hospitals NHS Trust
Undertake a repeat audit after the improvement actions are embedded to assess reliability of urgent CT head scan delivery.
-
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.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions 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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Essex Partnership University NHS Foundation Trust
Conduct spot checks of consistently high-compliance audits while reinforcing accurate results and accountability with staff.
-
Essex Partnership University NHS Foundation Trust
Review and co-produce the Trust Tendable audit programme with ward matrons, including governance reporting improvements.
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Essex Partnership University NHS Foundation Trust
Launch and operate the inpatient Quality Assurance Audit Programme by consolidating audit questions and integrating observation checks into Ward Managers’ Tendable audits.
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Essex Partnership University NHS Foundation Trust
Review Tendable audit templates within the wider Trust audit-assurance process.
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Essex Partnership University NHS Foundation Trust
Implement three Oxevision audits covering consent, staff training, and policy and governance, with findings reported and corrective actions monitored.
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Essex Partnership University NHS Foundation Trust
Strengthen audit-result reporting through monthly quality and safety meetings and a Power BI dashboard providing organisation-wide visibility.
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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.
Linked response
- Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Standardise community mental health risk-assessment compliance auditing through a revised Quality Assurance Tool.
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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.
Linked response
- York and Scarborough Teaching Hospitals NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
York and Scarborough Teaching Hospitals NHS Foundation Trust
Audit compliance with the patient identification policy regularly.
-
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.
Linked response
- East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
East London NHS Foundation Trust
Require completion and review of Dialog+ and My Safety Plan documentation within 72 hours of admission, including weekly case-note audits.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
East London NHS Foundation Trust
No further action is considered necessary because considerable work has addressed the identified concerns.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026