Recurring concern

Unreliable recording of care plan and risk assessment reviews

First to latest report 24 Jun 2015 — 15 Jan 2024

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
9

What this concern includes

Includes failures in recording, preserving or assuring records of care plan and risk assessment reviews, including omitted review records, missing outcomes, inaccurate entries and records falsely indicating that reviews occurred.

What is not included
  • Excludes the substantive quality of a care plan or risk assessment where the review record itself is reliable.
  • Excludes generic clinical or care-record deficiencies that do not concern recording care plan or risk assessment reviews.
  • Excludes failures to carry out protective actions after a review was accurately recorded, unless the review-recording control is also deficient.
  • Excludes unrelated observation, incident, medication or other safety records unless the assertion specifically concerns a care plan or risk assessment review.

Reports and published responses 4 reports

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

  1. Essex

    AI-generated summary

    Nadia Wyatt · 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

    Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.

    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 record risk assessment completion and outcomes

    Wider context from the report

    “(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”

    Source location

    Nadia Wyatt · Prevention of Future Deaths report
    Page 2 · concerns

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    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

    Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.

    Verbatim wording from the response

    “Response: The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

    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 Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.

    Verbatim wording from the response

    “Response: The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

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    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

    Audit Home Treatment Team assessments regularly and share findings with the team to improve assessment documentation.

    Verbatim wording from the response

    “In order to ensure the assessments undertaken by the Home Treatment Team are comprehensive and the findings (including the rationale for the decisions made) are clearly documented, regular audits on Home Treatment Team assessments will be undertaken and the findings shared with the team to continuously improve practice.”

    Source location

    Response from Essex Partnership NHS
    Page 1 · response
    Published 19 January 2024

    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

    Randomly audit patient records monthly for discrepancies in RAG-rated risk assessments and take action where discrepancies are found.

    Verbatim wording from the response

    “The Trust also randomly audits patients’ records on a monthly basis to identify any concerns with RAG rating of risk assessments in order for actions to be taken where discrepancies are found.”

    Source location

    Response from Essex Partnership NHS
    Page 3 · response
    Published 19 January 2024

    Open published response

  2. Nottinghamshire

    AI-generated summary

    Beryl Simcock · 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

    Beryl Simcock, who lived in a care home because of dementia, suffered several falls, including a fall on 10 June 2021 that caused an impacted fractured neck of femur and led to a severe deterioration in her health. The concerns included inadequate care-plan and risk-assessment reviews, potentially inaccurate records, insufficient oversight, and inadequate information for her family when she was deprived of her liberty.

    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

    Falsification of records to indicate completed care plan and risk assessment reviews

    Wider context from the report

    “I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period. I was also concerned that at times when Mrs Simcock was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place. ”

    Source location

    Beryl Simcock · 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

    Evaluate shortlisted digital care planning systems to improve linked risk assessment, trend analysis and point-of-care record keeping.

    Verbatim wording from the response

    “A summary of the report is attached. (The full report contains details of the care plans of a number of residents from which they could be identified.) The main thrust of the report is that the paper-based care plan system currently used by the Home makes the identification of risk and progression to mitigation difficult, and this has not been helped by the fact that risk assessment procedures have been adapted from various sources. The two major recommendations of the report are:”

    Source location

    Response from Radcliffe Manor House
    Page 1 · response
    Published 27 September 2022

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    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

    Fully implement the selected digital care planning system for all residents.

    Verbatim wording from the response

    “• In order to improve care planning and record keeping, the Home should introduce a digital care planning system which will enable the linking of care plans to risk assessments; this digital system should also be capable of providing good quality trend analysis and facilitating point-of-care-delivery record keeping.”

    Source location

    Response from Radcliffe Manor House
    Page 1 · response
    Published 27 September 2022

    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

    Improve management oversight of care plan documentation.

    Verbatim wording from the response

    “Where the home is now The original safeguarding was taken very seriously by the trustees and management team, and several initiatives (with the active involvement of the CQC and the GP) were immediately implemented to improve safety. These included:”

    Source location

    Response from Swift Management services
    Page 2 · response
    Published 27 September 2022

    Open published response

  3. Swansea and Neath Port Talbot

    AI-generated summary

    Christopher John Llewellyn Roberts · 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

    Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.

    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 record care plan reviews and their outcomes

    Wider context from the report

    “1. The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time. ”

    Source location

    Christopher John Llewellyn Roberts · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    Alice MEAD · 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

    Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.

    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 document risk assessment reviews

    Wider context from the report

    “(4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015. If it was, such reviews should have been documented in accordance with the Care Programme Approach. They were not ”

    Source location

    Alice MEAD · 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

    Review and redesign Trust-wide Care Programme Approach processes, including developing the new policy and preparing for electronic-record rollout.

    Verbatim wording from the response

    “The Care Programme Approach (CPA) is in the process of being reviewed across the Trust. This work is being led by ████████, Director of Occupational Therapy and Recovery Practice. We have a newly constituted CPA steering group, with cross care group representation and we are agreeing the new processes in preparation for the roll out of Carenotes (the new electronic records system). A new CPA policy has been drafted and we hope to launch it in September 2015. When the new CPA policy is launched there will be full staff training in place. Information leaflets and short films will be available and all information will be available on the Trust’s intranet. The training will be co-produced with service users and peer trainers to ensure a holistic approach.”

    Source location

    2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
    Page 1 · response
    Published 24 June 2015

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    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

    Track risk-assessment dates in the East ATS caseload spreadsheet and monitor and audit compliance, escalating required action.

    Verbatim wording from the response

    “Staff in the East ATS and MHRRS, responsible for assessing service users’ risk, have undergone bespoke Applied Suicide Intervention Skills Training (ASIST). This internationally renowned training was delivered in June 2015 by Grassroots, Suicide Prevention charity. To ensure risk assessments are up to date we have developed a new East ATS caseload spread sheet to capture risk assessment dates; supervisors will monitor this frequently, audit compliance, and escalate to the Team Leaders if action is required.”

    Source location

    2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
    Page 2 · response
    Published 24 June 2015

    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