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
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Concerns raised1
Poor quality of clinical record keeping
This report raised 5 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.
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Concerns raised1
Failure to properly record, store or audit paper observations and records
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Hampshire and Isle of Wight Healthcare NHS Foundation Trust
- Portsmouth Hospitals University 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.4
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Attend inpatient handovers, audit clinical records, and escalate audit outcomes through governance meetings to assure handover quality and accuracy.
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Hampshire and Isle of Wight Healthcare NHS Foundation Trust
Replace paper-based clinical observation forms with electronic forms feeding directly into SystmOne, including tablet procurement and ward testing.
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Portsmouth Hospitals University NHS Trust
Provide temporary staff and partner mental health teams with electronic access to document assessments and care plans in Oceano.
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Portsmouth Hospitals University NHS Trust
Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
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Concerns raised1
Inconsistencies in record keeping between specialities
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Royal Cornwall 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
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Royal Cornwall Hospitals NHS Trust
Progress the contracted integrated electronic patient record programme toward operational use from Spring 2025.
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Royal Cornwall Hospitals NHS Trust
Require inpatient clinical entries to be recorded in written paper notes, except in specified intensive-care areas, with the change communicated and effective from 13 September 2023.
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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Royal Cornwall Hospitals NHS Trust
Because specialties must record inpatient entries in paper notes, no electronic alert is considered necessary for handwritten clinical entries.
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Concerns raised1
Failure of the community team to consistently record key clinical assessment information
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Gateshead 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
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Gateshead Health NHS Foundation Trust
Make changes to electronic clinical-record proformas to strengthen record keeping and capture accurate, relevant clinical information.
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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Gateshead Health NHS Foundation Trust
The Trust disputes that key clinical information was inconsistently recorded, stating that information was recorded and concerns were appropriately escalated.
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Concerns raised1
Failure to include bed rail assessment in the Welsh Nursing Care Record
Linked response
- Betsi Cadwaladr University LHB
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
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Betsi Cadwaladr University LHB
Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.
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Betsi Cadwaladr University LHB
Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.
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Betsi Cadwaladr University LHB
Finalise and introduce the updated Bed Rails Procedure.
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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Betsi Cadwaladr University LHB
Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.
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Concerns raised1
Failure to complete and retain sufficiently detailed MDT discussion documentation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Leicestershire Partnership 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.1
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Leicestershire Partnership NHS Trust
Review Crisis Team MDT processes and improve the functionality of recording and documenting MDT meeting notes through a quality improvement programme.
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Concerns raised2
Failure to record clinical observations during hospital attendance
Failure to record inter-hospital clinical communications
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Leeds Teaching Hospitals NHS Trust
- 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.4
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Update and disseminate clinical record-keeping guidance to clinical staff.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Draft and send a patient safety briefing to all staff on documenting clinician communications.
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York and Scarborough Teaching Hospitals NHS Foundation Trust
Present the case to surgical colleagues at a Surgical Clinical Governance meeting.
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Leeds Teaching Hospitals NHS Trust
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
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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Leeds Teaching Hospitals NHS Trust
The Trust has no record or recollection of any communication from York Hospital about the deceased’s admission.
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Concerns raised1
Lack of written nursing documentation of patient care
This report raised 7 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.
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Concerns raised1
Failure to record injuries from body maps in daily communication records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sequoia CH Group 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.5
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Sequoia CH Group Ltd
Prepare, distribute and display record-keeping guidance, and require all staff to review it and the record-keeping policy.
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Sequoia CH Group Ltd
Provide record-keeping training during induction and staff supervisions throughout the year.
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Sequoia CH Group Ltd
Review record-keeping quality through weekly and monthly management audits and documentation spot checks.
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Sequoia CH Group Ltd
Strengthen staff communication by requiring documented concerns, daily records, written handovers, shift briefings and review of relevant resident records.
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Sequoia CH Group Ltd
Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
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Concerns raised2
Inaccurate clinical record keeping
Failure to reconcile clinical documentation with the patient’s observed condition
This report raised 13 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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026