Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
- Reports that mention this concern
- 474
- Times this concern has been raised
- 568
- Stated actions linked to this concern
- 780
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
What is 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
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 474 reports
See individual reports that have raised this concern, and the actions taken in response
-
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.
Linked responses
- Care Quality Commission
- Westfield Residential Home
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
-
Westfield Residential Home
Implement the electronic care management system and complete staff training for its use.
-
Westfield Residential Home
Operate the structured incident-reporting workflow, including witnessed entries, senior authorisation and management escalation.
-
Westfield Residential Home
Conduct monthly governance audits of accident and incident records to monitor documentation and identify service improvements.
-
Westfield Residential Home
Operate the Resident of the Day process to review care plans, risks, mobility, falls risk and documentation.
-
Care Quality Commission
Conduct an unannounced inspection assessing record keeping, falls management and staff handover processes.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Care Quality Commission
No regulatory action is currently required because inspection found no ongoing risk issues relating to the concerns.
-
Care Quality Commission
Inspection evidence did not demonstrate poor record keeping overall, although sampling could not exclude shortfalls in individual records.
-
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.
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
-
South East Coast Ambulance Service NHS Foundation Trust
Contribute to NHS Pathways discussions and share learning about documentation standards and audit weighting.
-
South East Coast Ambulance Service NHS Foundation Trust
Review local assurance processes to identify, escalate and address significant omissions in emergency call records.
-
South East Coast Ambulance Service NHS Foundation Trust
Review training, guidance and development enhancements to improve Emergency Medical Advisors’ documentation of emergency calls.
-
TSA
Strengthen CPD and learning programmes for QSF-certified organisations, covering records, operator competence, training, decision-support tools, escalation, and information-sharing with emergency services.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.5
-
Appello Careline Limited
Note-taking and clinical triage concerns are the responsibility of the relevant ambulance service, so no further action is proposed.
-
Association of Ambulance Chief Executives
The specific case concerns should be addressed by Appello and SECAMB, rather than by the national ambulance membership organisation.
-
TSA
Internal ambulance processes concerning note-taking, auditing, clinical advice and escalation fall outside the respondent’s ability to influence or comment on them.
-
NHS England
Concerns about Apello Careline’s emergency-call guidance, information handling and artificial intelligence trials are outside NHS England’s remit.
-
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 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.
Linked responses
- London Ambulance Service NHS Trust
- NHS England
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
-
London Ambulance Service NHS Trust
Strengthen staff messaging on capturing clear, readable ECG images pending enhanced digital recording solutions.
-
London Ambulance Service NHS Trust
Commence procurement of ECG monitoring equipment requiring direct ECG data upload into electronic patient care records.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
London Ambulance Service NHS Trust
Existing policy requires ECG images to be clear, relevant and clinically usable, providing an established control for record quality.
-
NHS England
Local ambulance services are responsible for the operational concerns and are best placed to respond to them.
-
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.
Linked responses
- Mid and South Essex NHS Foundation Trust
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Mid and South Essex NHS Foundation Trust
Review documentation standards within the anticoagulation service.
-
Mid and South Essex NHS Foundation Trust
Implement a structured clinical note template covering presentation, symptoms, risks, advice, escalation decisions and follow-up, with staff briefing and documentation audits.
-
Mid and South Essex NHS Foundation Trust
Introduce the trust-wide electronic patient record to integrate clinical information and make observations and electronic notes visible across encounters and hospital sites.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
Mid and South Essex NHS Foundation Trust is best placed to address the medical-records concern because it concerns specific practitioners’ practice.
-
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.
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.4
-
Essex Partnership University NHS Foundation Trust
Save care-related emails to patient records and deliver Trust-wide training on timely records storage.
-
Essex Partnership University NHS Foundation Trust
Escalate medication non-adherence to the responsible Consultant Psychiatrist, discuss it in MDT and zoning meetings, assess risk, and document an agreed action plan.
-
Essex Partnership University NHS Foundation Trust
Conduct every-shift record-keeping audits at the Linden Centre and cascade identified corrective actions.
-
Essex Partnership University NHS Foundation Trust
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Tameside and Glossop Integrated Care 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
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Establish and operate a District Nursing Documentation Group to improve documentation standards and drive continuous improvement.
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Review and refine EMIS templates to support professional decision-making, risk assessment and clinical oversight.
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Strengthen documentation of clinical reasoning, escalation decisions and patient-centred care plans.
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Assign Team Leaders active responsibility for record review, staff development and documentation-quality assurance.
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Use enhanced documentation audits, Quality Assurance Rounds, accreditation and governance processes to monitor and assure record quality.
-
Tameside and Glossop Integrated Care NHS Foundation Trust
Establish a District Nursing Improvement Group to lead work on triage, caseload management, documentation, escalation and monthly audited assurance reporting.
-
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.
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.1
-
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.
-
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.
Linked response
- Multi-Care Community Services Suffolk Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Multi-Care Community Services Suffolk Ltd
Audit care records and care-plan activities, addressing identified concerns and non-compliance.
-
Multi-Care Community Services Suffolk Ltd
Implement and operate a digital care-recording system with management monitoring, automated alerts and audit capability.
-
Multi-Care Community Services Suffolk Ltd
Implement standardised documentation procedures for accurate records, fluid-balance monitoring, escalation and consistent record standards.
-
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.
Linked response
- Waythrough Charity (Waythrough
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
-
Waythrough Charity (Waythrough
Review assessment and documentation practices regularly to support continuous improvement.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Waythrough Charity (Waythrough
Records documented signposting to emergency services, the GP, the CRISIS Team and Samaritans at the initial assessment.
-
Waythrough Charity (Waythrough
Initial assessment procedures, including risk assessment, recovery planning and follow-up arrangements, were considered robust and appropriate.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026