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.
Inner North London
Concerns raised1
Failure to produce clear and sufficient clinical notes
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.1
Action
Remind staff of clinical record-keeping requirements and monitor compliance through supervision and record-keeping audits.
Stated by North London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
Norfolk
Concerns raised1
Failure to fully record Multi Team Meetings and decision rationales in clinical records
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 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
Improve MDT record completeness using a meeting aide memoire and recorded daily brief reviews of patients.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Action
Monitor MDT meeting quality monthly and provide results and feedback to the ward team.
Stated by Norfolk and Suffolk NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 3 October 2022.
Herefordshire
Concerns raised1
Failure to record information given to patients
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to record relevant clinical history and symptoms
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 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.
Sefton St Helens & Knowsley
Concerns raised1
Failure to record skin integrity or breakdown in daily care records
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 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.
Manchester City
Concerns raised2
Lack of appropriate contemporaneous clinical record keeping by support workers
Lack of appropriate contemporaneous clinical record keeping by nurses
This report raised 12 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.
North Northumberland and South Northumberland
Concerns raised1
Limited documentation of wound management and pressure care
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Mid Kent and Medway
Concerns raised2
Failure to record clinical attendance and patient assessment in the medical records
Failure to document senior clinician treatment directions in the medical records
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.8
Action
Remind medical doctors of required healthcare record-keeping standards.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Audit adherence to national and Trust record-keeping standards monthly and share results through local and divisional governance boards.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Remind all staff to record every patient contact in the medical record in line with national and Trust guidelines.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Action
Conduct an annual Trust-wide audit of healthcare record keeping, including compliance with relevant Trust policy.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Roll out documentation standards within the Ward to Board Assurance and Accreditation Process.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Report record-keeping audit results through the Trust’s quality governance structures, including outcomes and exceptions.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Undertake ongoing regular record-keeping audits through the Trust Gather reporting system and use findings to inform local audit programmes.
Stated by Medway NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 29 April 2022.
Action
Discuss the Serious Incident Investigation findings at the junior doctor grand round.
Stated by Medway NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 29 April 2022.
Birmingham and Solihull
Concerns raised1
Inaccuracies in clinical records
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.5
Action
Issue and disseminate bulletins requiring accurate records and comprehensive, consistent shift handovers.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Update monthly Quality Walk Round assessments to check consistency between patient records and handover notes.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Review and reissue Policy H62 Healthcare Records, prohibiting copying and pasting between patient records.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Action
Continue compliance reviews of CareNotes records for accuracy during inspections.
Stated by Priory GroupStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Update documentation Quality Walk Round checks to identify inaccurate records and copying between patient records.
Stated by Priory GroupStated completedThe respondent said that this action was complete when they made their response on 27 April 2022.
Manchester City
Concerns raised1
Inadequate or incomplete clinical record keeping
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
