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
Inadequate wound assessment and record keeping
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.5
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Action
Operate a weekly Documentation Task and Finish Group with executive, Matron and Ward Manager oversight.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Maintain weekly documentation and risk-assessment audits across Division 2.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Continue the Stop the Clock and SBAR safety campaign in Acute Medicine to improve risk awareness and information transfer.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Action
Include record keeping alongside NEWS2 in core and clinical induction training.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Roll out standardised blue folders containing active nursing and medical records across acute medical wards, with wound documentation and bespoke staff training.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Failure to record enquiries about illicit drug misuse and patients’ responses
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
Discuss illicit-drug-use recording requirements and clarify that stopped intravenous drug use does not establish cessation of all illicit drug use.
Stated by West Timperley Medical Centre -
Action
Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
Stated by West Timperley Medical Centre -
Action
Contact identified patients to update records of their current illicit drug use.
Stated by West Timperley Medical Centre
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Concerns raised1
Poor quality of admission documentation
This report raised 9 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to maintain accurate records of contacts, decisions and risk assessments
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.4
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Action
Increase administrative support for Home Treatment Team multidisciplinary meetings so discussions and outcomes are recorded consistently.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Develop clear multidisciplinary-team standards and recording requirements through a quality-improvement project.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Develop and pilot mandatory clinical risk assessment and management training covering cumulative risk factors, suicide prevention and risk documentation.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Action
Improve care-planning and clinical-risk-assessment processes through a quality-improvement project.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Care and treatment concerns are largely for provider organisations to resolve.
Stated by NHS Birmingham and Solihull Integrated Care Board
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Position
Local NHS agencies are expected to address the report’s local concerns.
Stated by NHS England
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Concerns raised2
Failure to keep adequate patient records
Failure to maintain and provide complete patient 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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to document key patient-care events and sickness details
This report raised 13 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
Recruit two Quality Improvement Managers for West Sussex homes to support service improvements, care-record completion, mentoring and supervision.
Stated by Shaw Healthcare Limited -
Action
Continue improving care planning and daily assessment and evaluation records at Deerswood.
Stated by Shaw Healthcare Limited
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Concerns raised1
Suboptimal 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 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
Review and provide PROMPT documentation training for midwives and obstetricians, informed by documentation audit findings.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Conduct ongoing monthly documentation audits, produce quarterly Board reports, and share themes to inform multidisciplinary learning and training.
Stated by Northumbria Healthcare NHS Foundation Trust -
Action
Complete a documentation audit whose findings inform documentation training.
Stated by Northumbria Healthcare NHS Foundation Trust
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Concerns raised1
Failure to complete NEWS charts and partograms and maintain adequate records
This report raised 9 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 mandatory training on communication, record keeping, documentation and escalation, with compliance monitoring.
Stated by Cwm Taf Morgannwg University Local Health Board -
Action
Audit maternity record keeping, NEWS charts and risk-assessment completion, share findings and address identified deficiencies.
Stated by Cwm Taf Morgannwg University Local Health Board -
Action
Provide monthly clinical supervision for midwives focused on record-keeping standards.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Failure to make timely clinical records communicating patients’ condition and care
This report raised 9 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised4
Failure to record and communicate relevant presenting symptoms and prior clinical advice
Failure to record a differential diagnosis of DVT
Insufficient clinical documentation to resolve staff discrepancies
Failure to complete a body map
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.1
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Action
Audit ED staff compliance with documentation requirements and repeat the audit monthly.
Stated by the Shrewsbury and Telford Hospital NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The Trust was unaware of the suspected clot, and a painful leg alone was not necessarily indicative of a clot.
Stated by the Shrewsbury and Telford Hospital NHS Trust
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Position
Body maps apply to significant skin conditions and majors patients, not patients classified as minors.
Stated by the Shrewsbury and Telford Hospital NHS Trust
Data last updated 7 September 2026