First reported 13 Dec 2008•Latest report 26 Jun 2026
Definition
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
Distinct published reports
Individual concerns
568
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
780
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.
Department of Health and Social Care64
NHS England38
Care Quality Commission30
NHS Greater Manchester Integrated Care Board12
University Hospitals Sussex NHS Foundation Trust11
Essex Partnership University NHS Foundation Trust10
Greater Manchester Mental Health NHS Foundation Trust10
Stockport NHS Foundation Trust10
Tameside and Glossop Integrated Care NHS Foundation Trust10
Office of the Chief Coroner9
Recipient name withheld9
Sussex Partnership NHS Foundation Trust9
Barts Health NHS Trust8
East London NHS Foundation Trust8
Manchester University NHS Foundation Trust8
NHS trust265
Healthcare site91
Ministerial department73
Executive non-departmental public body44
Private limited company32
Health and social care service regulator30
Integrated care board26
Type not available24
Local health board21
Residential care home17
Multi-service care provider15
Nursing home15
Health professional body14
Independent healthcare provider12
Coronial office9
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.
Cornwall and Isles of Scilly
Concerns raised1
Failure to record the full extent of significant critical incidents in hospital notes
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 concerns
Each 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
Position
The clinical record comprehensively documented the critical incident, and there was no omission in record keeping or handover.
Stated by University Hospitals Plymouth NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Plymouth, Torbay and South Devon
Concerns raised1
Failure to complete observation charts adequately
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 concerns
Each 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
Action
Amend the observation policy to require shift-by-shift completion checks by the nurse in charge and immediate action on omissions.
Stated by Devon Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 19 December 2023.
Action
Conduct monthly senior nurse manager audits of observation completion, submit results to governance, provide feedback, and review performance with ward managers.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
Action
Review inpatient wards' shift-by-shift observation-record initials to check that nurses in charge evidence completion.
Stated by Devon Partnership NHS TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2023.
South Yorkshire (Western)
Concerns raised1
Failure to keep accurate and complete records of interactions
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 concerns
Each 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.10
Action
Incorporate discharge-quality compliance into biannual record-keeping audits and address results through ward governance.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Request regular clinical record-keeping audit reports and monitor progress through Directorate Leadership Teams and the Clinical Quality and Safety Group.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Implement the new electronic record system to deliver automated record-keeping improvements.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Complete and roll out a Trustwide clinical record-keeping policy and associated staff training.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Establish Trustwide, team-level supervision and spot-check audits within the clinical record-keeping quality-assurance programme.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Issue a Blue Light Learning Notice and cascade the requirement for timely, accurate recording of patient-facing interactions to clinical teams.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Audit clinical record keeping, including risk assessments and discharge summaries.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Implement a clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Disseminate and publish a staff alert reminding all staff about good-quality record keeping.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
Action
Roll out the clinical record keeping training package across the Trust following its development and pilot session.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 December 2023.
East Sussex
Concerns raised1
Unavailability of NHS notes to private healthcare providers at admission
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 concerns
Each 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
Action
Provide qualified medical staff with read-only access to referred patients’ NHS medical records.
Stated by The Langford CentreStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
Action
Publish guidance on information sharing and holistic assessment during admission, including key actions within 72 hours.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 14 November 2023.
Action
Enhance sharing of patient information with commissioned voluntary, charitable, social enterprise and independent-sector providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 14 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Integrated Care Boards are responsible for determining which independent providers connect to local Shared Care Records and supporting their connection.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Berkshire
Concerns raised1
Failure to record vascular surgery consultations
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 concerns
Each 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
Action
Appraise options for documenting TVVN vascular referrals and consultant advice.
Stated by Oxford University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Action
Implement a Microsoft 365 Form to document emergency vascular referrals from across the TVVN.
Stated by Oxford University Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 6 November 2023.
Norfolk
Concerns raised1
Failure to record observations in Care Records
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Milton Keynes
Concerns raised1
Lack of clear recording of potential medication-abuse risks in patient medical records
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 concerns
Each 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
Action
Review the electronic health record for proportionate additional safety measures affecting discharge medication processes.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
Action
Introduce a coded limited-supply question that triggers prominent alerts and directs doctors and pharmacists to review the medication history before discharge prescribing or dispensing.
Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 1 November 2023.
East London
Concerns raised1
Poor standard of clinical records
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 concerns
Each 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
Action
Disseminate record-keeping standards and safety concerns through staff alerts, intranet video, computer screensavers and clinical governance meetings.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
Action
Require medical staff record-keeping e-learning from their first working day and include record keeping in nursing preceptorship and junior-doctor induction.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 October 2023.
Action
Conduct and report an Emergency Department medical-records audit of Careflow free-text completion, with oversight by the Trust Audit Committee.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 October 2023.
Inner North London
Concerns raised1
Failure to record relevant family medical history
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 concerns
Each 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
Action
Update the NHS health-check template to record negative family history of ischaemic heart disease.
Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Action
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
Stated by Church Lane SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
Action
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
Stated by Church Lane SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
Action
Train staff to collect and accurately record family-history information in the clinical system.
Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Action
Audit new family-history entries every 12 months to assess system progress.
Stated by Church Lane SurgeryStated plannedThe respondent said that this action was planned when they made their response on 6 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
Stated by Church Lane SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to accurately record medication adherence in shared clinical records
Responses linked to these concerns
Each 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
Action
Speak with colleagues who made inaccurate entries and remind them during management supervision about accurate record keeping.
Stated by St Andrew's HealthcareStated plannedThe respondent said that this action was planned when they made their response on 30 October 2023.
Action
Audit medication-related Rio notes against ePMA records to assess the extent of inaccurate documentation.
Stated by St Andrew's HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Action
Disseminate messages to all colleagues on accurate record keeping and documenting missed medication doses in Rio.
Stated by St Andrew's HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
Action
Require Care Plan Update Meetings and ward rounds to review patients’ previous two weeks of ePMA medication records.
Stated by St Andrew's HealthcareStated completedThe respondent said that this action was complete when they made their response on 30 October 2023.
Action
Assess whether ePMA can automatically create Rio progress notes documenting medication administration events.
Stated by St Andrew's HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Action
Investigate whether ePMA can alert responsible clinicians when consecutive medication doses are missed, including alert-fatigue effects.
Stated by St Andrew's HealthcareStated in progressThe respondent said that this action was in progress when they made their response on 30 October 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ePMA records, regular care reviews and the Patient Safety Dashboard adequately address risks from inaccurate medication information in Rio notes.
Stated by St Andrew's HealthcareExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
