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
Failure to add NHS 111 consultation reports to patients’ medical records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Royal College of General Practitioners
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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Royal College of General Practitioners
Place workflow, information coding and clinical correspondence availability concerns on the Health Informatics Group agenda within three months.
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Royal College of General Practitioners
Ask the Health Informatics Group to examine inconsistent recording of NHS 111 reports and determine whether further escalation or membership communication is required.
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Royal College of General Practitioners
Use this case to inform guidance, member communications and engagement with system partners on safe handling of clinical correspondence.
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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Department of Health and Social Care
ICBs, as GP contract commissioners, are responsible for monitoring compliance and taking action when practices breach contractual requirements.
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Concerns raised1
Inadequate documentation of clinical findings
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Cardiff & Vale 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.5
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Cardiff & Vale University LHB
Introduce a clinical history sheet requiring red-flag assessment and documented inspection of device implantation sites during device-check appointments.
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Cardiff & Vale University LHB
Conduct monthly notes audits during the quarter following SOP presentation.
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Cardiff & Vale University LHB
Require clinic entries to document clinical findings, implant-site observations, red flags, patient symptoms, device data, and associated tests.
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Cardiff & Vale University LHB
Establish audits of notes-standard compliance and e-Advice usage and response times.
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Cardiff & Vale University LHB
Implement the Fysicon electronic patient record to incorporate clinical notes and provide trend data for clinical decision-making.
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Concerns raised1
Failure to record what to do when the district nurse cannot gain access
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Central London Community Healthcare 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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Central London Community Healthcare NHS Trust
Conduct Trust-wide engagement events to review no-access clinical practice and reinforce comprehensive records and emergency-contact documentation.
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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Central London Community Healthcare NHS Trust
Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.
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Concerns raised1
Incomplete documentation of nursing observations and escalations
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Mid and South Essex 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.3
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Mid and South Essex NHS Foundation Trust
Deliver CEWT refresher training emphasizing documentation of nursing observations, escalations and responses.
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Mid and South Essex NHS Foundation Trust
Implement the National Paediatric Early Warning System across paediatric services, including revised escalation criteria and dedicated escalation records.
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Mid and South Essex NHS Foundation Trust
Continue monthly documentation audits across Children’s ED and inpatient wards, with feedback and reminders addressing identified documentation deficiencies.
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Concerns raised1
Failure to record falls
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
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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Barts Health NHS Trust
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
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Barts Health NHS Trust
Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
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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Department of Health and Social Care
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
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Concerns raised1
Failure to assess and record the clinical picture before and after prescribing
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Metropolitan Police Service
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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Metropolitan Police Service
Implement SYSTMOne templates requiring vital-sign and other observation recording during initial assessments and clinical reviews.
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Metropolitan Police Service
Audit healthcare practitioners’ clinical documentation and provide feedback, guidance, and additional training where practice or records fall below the required standard.
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Concerns raised1
Failure to require General Practitioner practices to record firearms licence holdings in medical records
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Department of Health and Social Care
- Home Office
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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Department of Health and Social Care
Roll out digital markers for firearms certificate holders across all GP IT systems in England.
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Home Office
Implement a digital firearms marker across GP surgeries to alert doctors about relevant conditions and prompt police notifications.
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Home Office
Review whether and how to mandate the digital firearms marker in future.
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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Department of Health and Social Care
Existing medical suitability controls, GP markers, and police-reporting arrangements are considered sufficient to address relevant-condition recording and reporting concerns.
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Concerns raised1
Failure to make previous altered gastric anatomy apparent in clinical notes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- 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
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NHS England
Support provider organisations to adopt and safely implement electronic patient records, including improved interoperability and information sharing.
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NHS England
Work with the Shared Care Records Programme to support wider access to relevant patient information.
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NHS England
Publish a ten-year healthcare plan committing to a single, secure and authoritative patient record.
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Concerns raised1
Failure to make previous gastric surgery and altered anatomy apparent in clinical notes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- 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
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NHS England
Lead the Frontline Digitisation Programme to support provider adoption and implementation of electronic patient record systems that improve information sharing.
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NHS England
Continue working across the health and care system and with the Shared Care Records Programme to support greater integration and access to relevant patient information.
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Concerns raised2
Incomplete, inaccurate and inconsistent care records
Inconsistent and contradictory observation records
This report raised 29 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.1
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Essex Partnership University NHS Foundation Trust
Continue the Record Keeping Safety Improvement Programme to improve documentation through education and guidance.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026