Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

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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
Individual concerns: 568
Date range: 2008–2026
Stated actions: 780

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

25 Oct2021
Manchester South
Concerns raised1
1. Poor documentation of diet and weight monitoring
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 3
1. Action
  Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.
  Stated by Stockport NHS Foundation TrustStated completed
2. Action
  Deliver ward-based toolbox training on MUST, fluid balance, food charts and specialist referrals.
  Stated by Stockport NHS Foundation TrustStated completed
3. Action
  Conduct twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.
  Stated by Stockport NHS Foundation TrustStated completed
AI-generated summary

Alan Harry Hunter · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alan Harry Hunter was admitted to hospital after a fall, with a urinary tract infection, confusion and delirium. He experienced incorrectly calculated BMI and MUST scores, rapid weight loss, increasing frailty, Covid-19 and a further urinary tract infection before dying at Fernlea Care Home; concerns focused on poor documentation and inadequate monitoring of his diet, weight and nutritional risk.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor documentation of diet and weight monitoring
Wider context from the report
“The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers. ”
Source location
Alan Harry Hunter · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.

Verbatim wording from the response
“A seven minute briefing document has been developed related to nutrition and MUST assessment and cascaded to teams. The seven minute briefing format is a standardised method of communication used at Stockport NHS Trust to provide teams with key information to improve patient and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, MUST assessments and the use of food charts, and the importance of protected mealtimes.”

Source location
Response from NHS Stockport
Page 2 · response
Published 4 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver ward-based toolbox training on MUST, fluid balance, food charts and specialist referrals.

Verbatim wording from the response
“Within the investigation report a robust action plan has been provided that gives additional updates on the continuation of improvements across the Trust. This includes the identification of Nutrition and Hydration Champions across wards, tool box training sessions provided across ward areas between July and October 2021 covering MUST, fluid balance, food charts and specialist referrals and the development of Nutrition and Hydration Information Boards in ward areas.”

Source location
Response from NHS Stockport
Page 2 · response
Published 4 November 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.

Verbatim wording from the response
“The action plan also describes the audit processes now in place to ensure oversight of the MUST assessment and the completion of food charts. The Quality Assurance Checks completed by Matron twice weekly include a patient care section which looks at completion of nutrition assessment, that the assessment is up to date, and that fluid balance charts are up to date. The documentation section of the Quality Assurance Check audits that the MUST assessments are completed to the required standard and that standards of documentation are upheld, for example that all nursing entries are legible, signed, dated and timed. Alongside regular audit, daily safety huddles with the matron and ward managers take place to review any concerns in regard to patients. This holistic review includes a review of any nutrition and hydration concerns.”

Source location
Response from NHS Stockport
Page 2 · response
Published 4 November 2021
Open published response
23 Oct2021
Manchester South
Concerns raised1
1. Lack of a standard approach for documenting and signing off supervisory clinical discussions
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Margaret Kinsey · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Margaret Rose Kinsey, who had significant heart disease, was discharged from Stepping Hill Hospital Emergency Department on 11 December 2020 after presenting with shortness of breath and significant bilateral leg swelling. She collapsed at home the following day and died after attempts to resuscitate her were unsuccessful; post mortem examination found acute left ventricular failure caused by her underlying heart disease. The substantive concerns included limited overnight consultant cover, difficulties supervising an inexperienced junior doctor, and inconsistent documentation of clinical discussions and supervision.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a standard approach for documenting and signing off supervisory clinical discussions
Wider context from the report
“3. The inquest heard that there was no standard approach as to how the details of information shared/discussions between clinicians should be detailed or signed off in the notes when one clinician was acting in a supervisory capacity. Given the regular movement of junior doctors across the NHS this meant documentation quality was inconsistent. ”
Source location
Margaret Kinsey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
20 Oct2021
Inner North London
Concerns raised1
1. Failure to record crisis-line calls in the medical record
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 1
1. Action
  Provide medical-records training for senior nurses and Trust managers on record keeping, observations and retrospective entries.
  Stated by East London NHS Foundation TrustStated completed
AI-generated summary

Freeda GLAUSIUSZ · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Freeda Glausiusz died after jumping from her home on 15 May 2021. The report describes concerns that her father’s crisis-line call the previous day was not treated seriously, that the call was not documented appropriately, and that relevant information was not provided promptly to the coroner’s office.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record crisis-line calls in the medical record
Wider context from the report
“1. I was shocked when I listened to the recording of the call that █ ████████ made to the crisis line the day before his daughter died. The East London NHS Foundation Trust (ELFT) serious incident (SI) report observed that the clinician did not elicit clear risks during the conversation; did not listen to ████████; talked over him; did not appear empathic; and dismissed his distress about his daughter, even though she was a patient known to services after a first episode of psychosis. In reaching my conclusion at inquest that the call was not treated with the seriousness it deserved, I agreed with all of those observations. ████████ was not taken seriously, he was not treated respectfully and he was not treated kindly. He was clearly desperate about his daughter’s mental health and, as we now know, he was right to be desperate. He rang the crisis line and he was belittled. The clinician then made no note of the call in the medical records, even retrospectively. I note the many recommendations of the thoughtful SI report, but I remain concerned on three counts. • This is not the first time that I have made a PFD report to ELFT about its crisis line. • Not only did the clinician in question not make a note of the call in the medical record, he told me in court that, after Freeda Glausiusz’s death his manager had told him not to make an appropriately dated retrospective note in the record. He said that he had made a note on a piece of paper, but he did not now have that piece of paper. • When I asked the lead SI reviewer if the trust is confident that it has taken all appropriate actions in respect of that clinician, she was not able to give me that assurance. ”
Source location
Freeda GLAUSIUSZ · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide medical-records training for senior nurses and Trust managers on record keeping, observations and retrospective entries.

Verbatim wording from the response
“To address this matter, medical records training for all senior nurses was provided on 24 November 2021 to all senior nurses and managers at the Trust. The focus of the training was good record keeping, observations and retrospective record keeping.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 22 June 2023
Open published response
16 Sep2021
East London
Concerns raised1
1. Failure to accurately record the frequency of checks in progress notes
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eldine Loretta Lashley · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Eldine Loretta Lashley suffered an unwitnessed fall at a care home on 6 April 2021, sustaining a subdural haemorrhage, and died at home on 14 April 2021 despite medical intervention. Concerns were raised that her mobility care plan was not updated to reflect increased monitoring needs and that progress notes did not accurately record the frequency of checks carried out.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to accurately record the frequency of checks in progress notes
Wider context from the report
“1. Mrs Lashley's mobility care plan was not updated in response to developments in her care needs – specifically she need to observe her more frequently than once per hour. 2. Progress notes created by nursing and care staff did not accurately reflect the frequency of checks carried out on Mrs Lashley. ”
Source location
Eldine Loretta Lashley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Aug2021
Manchester South
Concerns raised1
1. Failure of written documentation to cover communication challenges affecting community care
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Norma Rushworth · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Norma Rushworth underwent surgery for diverticulitis and was later readmitted for emergency surgery after developing an abdominal dehiscence associated with an unidentified wound infection. She deteriorated after developing a chest infection and suffering a cardiac arrest, and died at Tameside General Hospital on 10 October 2020. Concerns included limited support and monitoring after discharge, unclear communication with community health professionals and family, and delayed recognition of her deterioration in the community, with pandemic restrictions contributing to communication difficulties.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of written documentation to cover communication challenges affecting community care
Wider context from the report
“2. The inquest heard that following her discharge back into the community after surgery support and monitoring was limited notwithstanding how vulnerable she was; the complexity of her surgery and the risk she presented. Advice re management of a patient such as her in the community and risks and management of them was not conveyed clearly to community health professionals and to her family. Covid restrictions meant that communication had been difficult, and the written documentation did not cover the challenges this caused. Her deteriorating health in the community was not as a result recognised at an early stage. ”
Source location
Norma Rushworth · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Jul2021
West Yorkshire Eastern
Concerns raised2
1. Inconsistent and insufficiently detailed recording of general wellbeing
2. Lack of a single document providing a holistic view of the person
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.
Respondent positions 1
1. Position
  A formal investigation was not commenced because the apparent recording failures were individual and likely concerned people outside enforcement powers.
  Stated by Care Quality CommissionOutside remit
AI-generated summary

John Dickinson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inconsistent and insufficiently detailed recording of general wellbeing
Wider context from the report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing. (2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained. (3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020. (4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned. (5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring. (6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal. ”
Source location
John Dickinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a single document providing a holistic view of the person
Wider context from the report
“(1) The record keeping was inconsistent and lacked detail on general wellbeing. (2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained. (3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020. (4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned. (5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring. (6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal. ”
Source location
John Dickinson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A formal investigation was not commenced because the apparent recording failures were individual and likely concerned people outside enforcement powers.

Verbatim wording from the response
“In line with CQC’s regulatory responsibilities, we continue to monitor statutory notifications and enquiries related with this service. Having considered the evidence and information available in this case, we have made the decision not to commence a formal Registered Provider investigation into Mr Dickinson’s death. Whilst we acknowledge there were some apparent failures in the recording of care,”

Source location
2021-0310-Response-from-CQC_Published
Page 2 · response
Published 17 September 2021
Open published response
20 Jul2021
Norfolk
Concerns raised2
1. Failure to record pertinent medication history on discharge documentation
2. Failure of staff to complete important care records
This report raised 18 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 1
1. Action
  Develop and improve the Pandora information system through a staff user group.
  Stated by Jeesal Residential Care Services LimitedStated in progress
AI-generated summary

Ben Buster KING · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Ben Buster KING was detained under the Mental Health Act at Jeesal Cawston Park and died in hospital on 29 July 2020 after becoming unwell following respiratory problems and receiving sedative medication. The inquest identified concerns including failure to diagnose obesity hypoventilation syndrome, inadequate consideration of promethazine, failure to recognise the seriousness of a life-threatening situation, and wider care, observation, record-keeping and hospital communication issues.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record pertinent medication history on discharge documentation
Wider context from the report
“5. The section headed “Drug History” was not completed on the Discharge Form on Ben King’s attendances on 9 or 12 July 2020. On 10 July, it states “nil significant”. This is despite Ben King being prescribed Promethazine, a sedative medication, affecting the respiratory system. Evidence was heard that not all prescribed medications could be expected to be included in “the small space” provided. That this is a medication where consideration would have been given to a risk vs benefit analysis but there was no evidence of any such analysis. Regulation 28 evidence was that not all medication can be listed; only “pertinent” medication. ”
Source location
Ben Buster KING · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of staff to complete important care records
Wider context from the report
“3. Basic dietary advice and guidance provided was not followed by staff. 4. The use of the Dietician in training of staff was reduced in 2017 from one day’s training to an hour’s power point presentation 5. Important records were not completed by staff, eg Food intake, Exercise, Weight and vital observations ”
Source location
Ben Buster KING · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and improve the Pandora information system through a staff user group.

Verbatim wording from the response
“6. The MD and members of the GAT have access to every resident’s care file, we also have access to a whole range of information on each resident, all of which we can access remotely. The GAT carries out regular service reviews and unannounced inspections. Where there are deficiencies, the GAT will work with the Registered Manager to correct these deficiencies which may include report writing, care planning, risk assessments and healthy living plans. As an example, the GAT recently found inconsistencies in recording of information on Pandora, with some confusion as to record entries. This led to the establishment of a Pandora User Group, to work with homes to improve consistency of recording and content.”

Source location
2021-0250-Response-from-Jeesal-Residential-Care-Services_Published
Page 3 · response
Published 23 July 2021
Open published response
11 Jul2021
Mid Kent and Medway
Concerns raised1
1. Failure to record required observation levels in medical records
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 2
1. Action
  Develop a post-procedure handover form for use after every procedure.
  Stated by Medway NHS Foundation TrustStated completed
2. Action
  Require written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.
  Stated by Medway NHS Foundation TrustStated planned
AI-generated summary

Johanna Marie MORELAND · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Johanna Marie Moreland died on 8 March 2021 at Medway Maritime Hospital following intra-abdominal haemorrhage after a liver biopsy, in the context of advanced hepatocellular carcinoma. Concerns included delays in receiving lumbar puncture results and starting antiviral treatment, and failure to follow or record required observations after the biopsy due to miscommunication between Trust staff.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record required observation levels in medical records
Wider context from the report
“(3) The Trust policy on the required levels of observations following a liver biopsy were not followed on return to the ward due to a miscommunication between Trust staff and the required levels of observations was not recorded in the medical records. ”
Source location
Johanna Marie MORELAND · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a post-procedure handover form for use after every procedure.

Verbatim wording from the response
“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location
2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require written confirmation of post-procedure observation frequency and handover to nursing staff through the new process.

Verbatim wording from the response
“This report from the Coroner has identified an opportunity for improvement to process within the Trust, and to reduce the likelihood of any similar circumstance the Trust has developed the attached handover form to be competed post every procedure (Appendix 1). This process is led by the Consultant Radiologist and will include written confirmation of frequency of observations to be carried out, as well as written confirmation of handover to nursing staff. Trust policy for post procedure observations has been reiterated to all nursing staff subsequently through consistent inclusion in the Trust’s ‘Big 4’ ward based messaging.”

Source location
2021-0240-Response-from-Medway-Maritime-Hospital_Published
Page 3 · response
Published 15 July 2021
Open published response
7 Jul2021
Warwickshire
Concerns raised1
1. Failure to record resident aggression incidents in care plans
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 3
1. Action
  Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.
  Stated by Crosscrown LimitedStated completed
2. Action
  Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.
  Stated by Crosscrown LimitedStated completed
3. Action
  Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.
  Stated by Crosscrown LimitedStated completed
AI-generated summary

Dorothy Seekings · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Dorothy Seekings, a resident of Clifton Court Nursing Home, was found dead in her room on 8 August 2019 after another resident entered the room; a post-mortem examination showed blunt force injuries, which were probably caused by that resident. Concerns included care plans not recording the other resident’s aggressive incidents towards staff, failure to raise a safeguarding alert, and staff appearing unaware of the care plan contents.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record resident aggression incidents in care plans
Wider context from the report
“(1) the care plans for ████████ did not record incidents where ████████ had acted aggressively to staff members including an occasion when a staff member was kicked in the mouth by ████████. (2) the failure to raise a safeguarding alert with the local authority regarding the above incident. (3) The staff did not appear to be aware of the contents of the care plan for ████████ or other resident ”
Source location
Dorothy Seekings · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement and maintain the CareDocs digital care-planning and recording system across all homes, supported by upgraded Wi-Fi and staff access devices.

Verbatim wording from the response
“The two key changes are the acceleration of the implementation of a digital care management software system called CareDocs. This was being gradually introduced into the Homes run by Crosscrown during the Summer of 2019 but the events of August 8th accelerated the implementation of the new system and it is now in place in all Crosscrown Homes including Clifton Court and has been for some time. The digital CareDocs system allows Care Plans to be created that meet the specific requirements of individual service users and it allows the creation of a care plan reflective of the needs and preferences of the individual user.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 1 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Enhance fortnightly staff-meeting agendas to address infection control, health and safety, and systematic recording of behavioural issues.

Verbatim wording from the response
“The Operations Team has implemented an enhanced agenda for the fortnightly staff meetings that are held at Clifton Court to include inter alia infection control – Covid, health and safety and accurate and systematic recording of behavioral issues.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Record challenging behaviour in CareDocs, require ABC forms, conduct daily managerial checks, escalate safeguarding concerns, and analyse referrals through monthly management reporting.

Verbatim wording from the response
“Under the new scheme such behaviour is recorded on the CareDocs system which prompts the completion of an Antecedent Behaviour Consequences form on the CareDocs system. The Care Home Manager at Clifton Court checks on a daily basis for amongst other things any ABC charts which may have been completed by members of staff. Should any safeguarding issues be recorded then the Manager will contact Adult Social Services and complete that process. The Operations Team are copied into all emails in relation to any safeguarding issues. In the last eighteen months Clifton Court has made eight referrals to the Adult Social Services Team at Warwickshire County Council all of which were closed down without an action by the Council. The issue of safeguarding is also now part of the Monthly Managers Report and is analysed by the Operations Team and evaluated for any patterns or learning issues.”

Source location
2021-0230-Response-from-Crosscrown-Ltd_Published
Page 3 · response
Published 9 July 2021
Open published response
2 Jul2021
Inner North London
Concerns raised1
1. Lack of contemporaneous or accurate retrospective documentation of the timing of clinical interactions
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 4
1. Action
  Work with NHSE/I and HMPPS to resolve mobile-connectivity challenges supporting SystmOne use on prison wings and during emergencies.
  Stated by Practice Plus GroupStated in progress
2. Action
  Reinforce contemporaneous record keeping through staff reminders, supervision, and regular documentation audits.
  Stated by Practice Plus GroupStated completed
3. Action
  Update the record-keeping training package to cover accurate timing of retrospective SystmOne entries.
  Stated by Practice Plus GroupStated completed
1. Action
  Share the updated record-keeping training package with HMP Pentonville staff by 30 September 2021.
  Stated by Practice Plus GroupStated planned
Respondent positions 2
1. Position
  Contemporaneous SystmOne recording cannot always be ensured because prison connectivity limitations prevent reliable use of portable devices.
  Stated by Practice Plus GroupUnable to act
1. Position
  Lack of contemporaneous SystmOne documentation does not necessarily hamper clinical response times because care and escalation can occur before retrospective entry.
  Stated by Practice Plus GroupDisputes the concern
AI-generated summary

Mr Khairul Rahman · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr Khairul Rahman became unwell during a COVID-19 outbreak at HMP Pentonville, was later admitted to hospital, and died on 22 January 2021 from COVID-19. Concerns included inaccurate or non-contemporaneous documentation of clinical interactions, intervals between observations that did not align with the NEWS2 scoring system, reliance on prisoners to self-report deterioration, and the lack of a clear effective alternative system for monitoring in the prison healthcare setting.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of contemporaneous or accurate retrospective documentation of the timing of clinical interactions
Wider context from the report
“1. There does not seem to be a robust system in place in the prison healthcare setting for contemporaneous or accurate retrospective documentation of the timing of clinical interactions. I heard evidence and received a further statement, following the conclusion of the inquest, which set out the difficulties that the prison environment causes, in terms of being able to document accurately. However, I remain concerned that the lack of accurate documentation means that subsequent review of the appropriateness of clinical care, in particular, response times is hampered; 2. The interval to further observations being undertaken were not inline with the NEWS2 scoring system and, in oral evidence, it was set out that prisoners were expected to self-report deterioration. This differs from latter information, provided after the conclusion of the inquest. However, it remains a concern. The use of the NEWS2 scoring system remains unclear; the post-inquest information seemingly sets out both that this system was only to used after a positive COVID-19 result but also at daily handover. Whilst recognising that the prison environment differs from a hospital setting, I remain concerned that the care provided was not as guided by the NEWS2 scoring system and that no alternative system appears to be in place that can be used effectively in the prison healthcare setting. ”
Source location
Mr Khairul Rahman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with NHSE/I and HMPPS to resolve mobile-connectivity challenges supporting SystmOne use on prison wings and during emergencies.

Verbatim wording from the response
“Although it is currently beyond Practice Plus Group’s control to ensure all clinical interactions are contemporaneously recorded on SystmOne, we are committed to continuing to work closely with NHSE/I and HMPPS, via the NHSE/I Digital Assurance Board, to resolve the challenges with mobile connectivity in order to support the use of SystmOne when working on the wings or responding to emergencies.”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Reinforce contemporaneous record keeping through staff reminders, supervision, and regular documentation audits.

Verbatim wording from the response
“Practice Plus Group regularly remind all staff of the importance of contemporaneous record keeping in accordance with Documentation and Record Keeping Guidelines, Nursing and Midwifery Council (2018). This is shared through full staff meetings, management supervision and clinical supervision. In addition a documentation audit for both prescribing and non-prescribing clinicians is undertaken regularly as part of the HIJ Audit Schedule for Practice Plus Group. The quality of record keeping in this case was commented on within the external clinical review:”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Update the record-keeping training package to cover accurate timing of retrospective SystmOne entries.

Verbatim wording from the response
“In addition to the above, Practice Plus Group has also recently updated a record keeping training package to be shared with all staff which includes the importance of correctly recording the time of any interaction within the SystmOne record when making retrospective entries. This will be made available to staff HMP Pentonville by 30th September 2021.”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Share the updated record-keeping training package with HMP Pentonville staff by 30 September 2021.

Verbatim wording from the response
“In addition to the above, Practice Plus Group has also recently updated a record keeping training package to be shared with all staff which includes the importance of correctly recording the time of any interaction within the SystmOne record when making retrospective entries. This will be made available to staff HMP Pentonville by 30th September 2021.”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Contemporaneous SystmOne recording cannot always be ensured because prison connectivity limitations prevent reliable use of portable devices.

Verbatim wording from the response
“Unfortunately, as a result of the prison environment the contemporaneous recording of clinical interactions on the electronic patient record (SystmOne) is often not possible. The limitations of the prison estate, notably the lack of Wi-Fi within HMP Pentonville makes the use of portable devices linking directly to SystmOne very challenging.”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 2 · response
Published 9 July 2021
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Lack of contemporaneous SystmOne documentation does not necessarily hamper clinical response times because care and escalation can occur before retrospective entry.

Verbatim wording from the response
“Practice Plus Group does not agree that response times to clinical care are hampered by the lack of contemporaneous documentation on SystmOne because treatment, escalation measures and/or referrals can be made prior to retrospective entry onto SystmOne. Indeed if a”

Source location
2021-0226-Response-from-Practice-Plus-Group_Published
Page 2 · response
Published 9 July 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Poor documentation of diet and weight monitoring

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

Concerns raised1

Lack of a standard approach for documenting and signing off supervisory clinical discussions

Concerns raised1

Failure to record crisis-line calls in the medical record

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

Concerns raised1

Failure to accurately record the frequency of checks in progress notes

Concerns raised1

Failure of written documentation to cover communication challenges affecting community care

Concerns raised2

Inconsistent and insufficiently detailed recording of general wellbeing

Lack of a single document providing a holistic view of the person

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to record pertinent medication history on discharge documentation

Failure of staff to complete important care records

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

Concerns raised1

Failure to record required observation levels in medical records

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

Concerns raised1

Failure to record resident aggression incidents in care plans

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

Concerns raised1

Lack of contemporaneous or accurate retrospective documentation of the timing of clinical interactions

Actions described in response 3

Actions described in response 1

Respondent positions 1

Actions described in response 1

Actions described in response 2

Actions described in response 3