Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
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
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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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.
Responses linked to these concernsEach 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
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Action
Place workflow, information coding and clinical correspondence availability concerns on the Health Informatics Group agenda within three months.
Stated by Royal College of General Practitioners -
Action
Ask the Health Informatics Group to examine inconsistent recording of NHS 111 reports and determine whether further escalation or membership communication is required.
Stated by Royal College of General Practitioners -
Action
Use this case to inform guidance, member communications and engagement with system partners on safe handling of clinical correspondence.
Stated by Royal College of General Practitioners
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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Position
ICBs, as GP contract commissioners, are responsible for monitoring compliance and taking action when practices breach contractual requirements.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach 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
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Action
Introduce a clinical history sheet requiring red-flag assessment and documented inspection of device implantation sites during device-check appointments.
Stated by Cardiff & Vale University LHB -
Action
Conduct monthly notes audits during the quarter following SOP presentation.
Stated by Cardiff & Vale University LHB -
Action
Require clinic entries to document clinical findings, implant-site observations, red flags, patient symptoms, device data, and associated tests.
Stated by Cardiff & Vale University LHB
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Action
Establish audits of notes-standard compliance and e-Advice usage and response times.
Stated by Cardiff & Vale University LHB -
Action
Implement the Fysicon electronic patient record to incorporate clinical notes and provide trend data for clinical decision-making.
Stated by Cardiff & Vale University LHB
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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.
Responses linked to these concernsEach 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
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Action
Conduct Trust-wide engagement events to review no-access clinical practice and reinforce comprehensive records and emergency-contact documentation.
Stated by Central London Community Healthcare NHS Trust
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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Position
Implemented improvements to no-access arrangements and the proportionate PSIRF response directly address the reported concerns and strengthen patient safeguards.
Stated by Central London Community Healthcare NHS Trust
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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.
Responses linked to these concernsEach 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
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Action
Deliver CEWT refresher training emphasizing documentation of nursing observations, escalations and responses.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Implement the National Paediatric Early Warning System across paediatric services, including revised escalation criteria and dedicated escalation records.
Stated by Mid and South Essex NHS Foundation Trust -
Action
Continue monthly documentation audits across Children’s ED and inpatient wards, with feedback and reminders addressing identified documentation deficiencies.
Stated by Mid and South Essex NHS Foundation Trust
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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.
Responses linked to these concernsEach 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
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Action
Introduce a mandatory post-fall care bundle and checklist requiring structured assessment, neurological observations, escalation triggers and clinical documentation.
Stated by Barts Health NHS Trust -
Action
Reinforce contemporaneous documentation and communication of inpatient falls and significant safety events during nursing and medical handovers.
Stated by Barts Health NHS Trust
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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Position
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach 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
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Action
Implement SYSTMOne templates requiring vital-sign and other observation recording during initial assessments and clinical reviews.
Stated by Metropolitan Police Service -
Action
Audit healthcare practitioners’ clinical documentation and provide feedback, guidance, and additional training where practice or records fall below the required standard.
Stated by Metropolitan Police Service
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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.
Responses linked to these concernsEach 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
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Action
Roll out digital markers for firearms certificate holders across all GP IT systems in England.
Stated by Department of Health and Social Care -
Action
Implement a digital firearms marker across GP surgeries to alert doctors about relevant conditions and prompt police notifications.
Stated by Home Office -
Action
Review whether and how to mandate the digital firearms marker in future.
Stated by Home Office
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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Position
Existing medical suitability controls, GP markers, and police-reporting arrangements are considered sufficient to address relevant-condition recording and reporting concerns.
Stated by Department of Health and Social Care
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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.
Responses linked to these concernsEach 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
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Action
Support provider organisations to adopt and safely implement electronic patient records, including improved interoperability and information sharing.
Stated by NHS England -
Action
Work with the Shared Care Records Programme to support wider access to relevant patient information.
Stated by NHS England -
Action
Publish a ten-year healthcare plan committing to a single, secure and authoritative patient record.
Stated by NHS England
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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.
Responses linked to these concernsEach 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
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Action
Lead the Frontline Digitisation Programme to support provider adoption and implementation of electronic patient record systems that improve information sharing.
Stated by NHS England -
Action
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.
Stated by NHS England
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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.
Responses linked to these concernsEach 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
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Action
Continue the Record Keeping Safety Improvement Programme to improve documentation through education and guidance.
Stated by Essex Partnership University NHS Foundation Trust
Data last updated 7 September 2026