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.
Manchester South
Concerns raised1
Failure to maintain sufficiently detailed clinical documentation
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.
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
Deliver documentation training and complete Ward 6 competency assessments, senior sign-off, and regular clinical-record audits with feedback on omissions.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020.
Manchester South
Concerns raised1
Inaccurate or lacking recording of clinical observations and NEWS scores
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.
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
Action
Reinforce accurate NEWS2 completion and documentation through staff communication and regular supervision.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Action
Audit five randomly selected NEWS2 charts monthly to oversee compliance with documentation standards.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Action
Provide rolling NEWS2 training covering accurate scoring, escalation, clinical deterioration and sepsis recognition.
Stated by Pennine Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2020.
Manchester South
Concerns raised1
Poor quality of written medical notes
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Although record keeping could have been better, the medical notes contained sufficient documentation to form a clinical view.
Stated by NHS Greater Manchester Integrated Care BoardDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Black Country
Concerns raised2
Failure to record or report resident deterioration and drowsiness
Failure to record the timing and findings of resident observations
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.
North East Kent
Concerns raised1
Substandard obstetric record keeping
This report raised 19 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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust is responsible for setting out and implementing actions to address the identified maternity-service safety risks.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South London
Concerns raised1
Failure to document clinical formulation or impression
This report raised 7 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
Conduct reflective-practice sessions focused on assessment, risk documentation, record keeping and formulation, with impact monitoring.
Stated by Oxleas NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 March 2020.
Manchester South
Concerns raised1
Incomplete digitisation preventing professionals from accessing each other's notes
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.
Stated by NHS Greater Manchester Integrated Care BoardOutside remitThe respondent said that this matter was outside its role or authority.
Inner North London
Concerns raised1
Failure to document treatment-plan changes and prescribing decisions
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.
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
Reinforce requirements for significant clinical decisions to be documented in patient records and for clinical notes to meet best-practice standards.
Stated by Barts Health NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 January 2020.
Action
Audit note keeping regularly at monthly morbidity and mortality meetings to drive and maintain improvement.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 January 2020.
Manchester City
Concerns raised2
Absence of timely, full and accurate clinical record keeping
Failure to identify participating healthcare staff and verify completeness of System One records
This report raised 19 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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The healthcare provider is responsible for responding separately to concerns about clinical issues.
Stated by HM Prison and Probation ServiceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Manchester West
Concerns raised2
Failure to maintain accurate and adequate care records
Failure to maintain contemporaneous documentation of Dieticians or Falls Team referrals
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.9
Action
Continue quality-assurance monitoring through support visits, scrutiny of records and care plans, and follow-up of referral effectiveness.
Stated by Wigan Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2019.
Action
Recommend that the provider source training for all staff on effective record keeping, dementia and nutrition.
Stated by Wigan Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Monitor the provider’s uptake of recommended training and its impact on service-user experiences.
Stated by Wigan Borough CouncilStated in progressThe respondent said that this action was in progress when they made their response on 29 December 2019.
Action
Highlight three possible regulatory breaches concerning record keeping, staff training and support, and provider quality monitoring.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 29 December 2019.
Action
Conduct a further comprehensive inspection within 12 months to verify that the provider has addressed the identified breaches.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 29 December 2019.
Action
Operate a weekly and monthly weight-monitoring and weight-loss escalation system linked to Caredocs and care plans, including dietetic, GP and SALT referrals.
Stated by Rosewood Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Audit weight-loss records weekly and monthly, cross-reference them with care plans and record resulting actions.
Stated by Rosewood Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Maintain person-centred Caredocs care plans identifying individual needs, with Home Manager and Regional Manager care-plan audits.
Stated by Rosewood Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Action
Operate an accidents and incidents system linked to Caredocs and care plans, with falls triage, clinical referrals, family updates and required safeguarding or regulatory notifications.
Stated by Rosewood Healthcare GroupStated completedThe respondent said that this action was complete when they made their response on 29 December 2019.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Existing weight-monitoring, care-plan, auditing and staff-training arrangements are considered sufficient to address inaccurate records and poor record keeping.
Stated by Rosewood Healthcare GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing falls, incident monitoring and referral procedures are considered sufficient to address concerns about dietician and falls-team referrals.
Stated by Rosewood Healthcare GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
