Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
Not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
- Reports
- 474
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
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
Inaccurate and inconsistent record keeping
This report raised 2 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.5
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Action
Implement the electronic care management system and complete staff training for its use.
Stated by Westfield Residential Home -
Action
Operate the structured incident-reporting workflow, including witnessed entries, senior authorisation and management escalation.
Stated by Westfield Residential Home -
Action
Conduct monthly governance audits of accident and incident records to monitor documentation and identify service improvements.
Stated by Westfield Residential Home
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Action
Operate the Resident of the Day process to review care plans, risks, mobility, falls risk and documentation.
Stated by Westfield Residential Home -
Action
Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
Stated by Care Quality Commission
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Position
Inspection evidence did not demonstrate poor record keeping overall, although sampling could not exclude shortfalls in individual records.
Stated by Care Quality Commission
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Concerns raised1
Failure to record clinically relevant information in EMA notes
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
Review training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.
Stated by South East Coast Ambulance Service NHS Foundation Trust
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Action
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
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
Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.
Stated by Appello Careline Limited
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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 guidance for clear and readable photographs of ECGs uploaded to attendance records
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.
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
Strengthen staff messaging on capturing clear, readable ECG images pending enhanced digital recording solutions.
Stated by London Ambulance Service NHS Trust -
Action
Commence procurement of ECG monitoring equipment requiring direct ECG data upload into electronic patient care records.
Stated by London Ambulance Service NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Existing policy requires ECG images to be clear, relevant and clinically usable, providing an established control for record quality.
Stated by London Ambulance Service NHS Trust
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Position
Local ambulance services are responsible for the operational concerns and are best placed to respond to them.
Stated by NHS England
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Concerns raised2
Inadequate clinical records of the patient’s presentation, INR results and medication dose
Failure to clarify the nature and clinical impact of reported illness in records
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.3
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Action
Review documentation standards within the anticoagulation service.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Implement a structured clinical note template covering presentation, symptoms, risks, advice, escalation decisions and follow-up, with staff briefing and documentation audits.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Introduce the trust-wide electronic patient record to integrate clinical information and make observations and electronic notes visible across encounters and hospital sites.
Stated by Mid and South Essex 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
Mid and South Essex NHS Foundation Trust is best placed to address the medical-records concern because it concerns specific practitioners’ practice.
Stated by NHS England
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Concerns raised2
Failure to maintain significant clinical information and escalate deterioration to the Consultant Psychiatrist
Failure to appropriately record all clinical contacts
This report raised 17 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
Save care-related emails to patient records and deliver Trust-wide training on timely records storage.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Escalate medication non-adherence to the responsible Consultant Psychiatrist, discuss it in MDT and zoning meetings, assess risk, and document an agreed action plan.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Conduct every-shift record-keeping audits at the Linden Centre and cascade identified corrective actions.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised4
Failure to record changes in mental health diagnosis in Psychology records
Illegibility of medical records about medication
Significant cutting and pasting in medical records and documentation
Inaccuracies and omissions in medical records about diagnosis, care and treatment
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Poor quality of District Nursing team 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
Establish and operate a District Nursing Documentation Group to improve documentation standards and drive continuous improvement.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Review and refine EMIS templates to support professional decision-making, risk assessment and clinical oversight.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Strengthen documentation of clinical reasoning, escalation decisions and patient-centred care plans.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Action
Assign Team Leaders active responsibility for record review, staff development and documentation-quality assurance.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Use enhanced documentation audits, Quality Assurance Rounds, accreditation and governance processes to monitor and assure record quality.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Establish a District Nursing Improvement Group to lead work on triage, caseload management, documentation, escalation and monthly audited assurance reporting.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to complete records of decisions taken
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.1
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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
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Concerns raised1
Inadequate recording of care attendances and actions taken
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 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.3
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Action
Audit care records and care-plan activities, addressing identified concerns and non-compliance.
Stated by Multi-Care Community Services Suffolk Ltd -
Action
Implement and operate a digital care-recording system with management monitoring, automated alerts and audit capability.
Stated by Multi-Care Community Services Suffolk Ltd -
Action
Implement standardised documentation procedures for accurate records, fluid-balance monitoring, escalation and consistent record standards.
Stated by Multi-Care Community Services Suffolk Ltd
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Concerns raised1
Failure to maintain records providing a full and verifiable account of information and assistance provided
This report raised 1 other concern. 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
Review assessment and documentation practices regularly to support continuous improvement.
Stated by Waythrough Charity (Waythrough
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Records documented signposting to emergency services, the GP, the CRISIS Team and Samaritans at the initial assessment.
Stated by Waythrough Charity (Waythrough
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Position
Initial assessment procedures, including risk assessment, recovery planning and follow-up arrangements, were considered robust and appropriate.
Stated by Waythrough Charity (Waythrough
Data last updated 7 September 2026