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.

8 Apr2019
Blackpool and the Fylde
Concerns raised2
1. Failure to retain and make clinical records available
2. Poor and illegible clinical record keeping
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

Tina Tait · 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

Tina Tait underwent elective ovarian cystectomy surgery on 8 May 2018 and subsequently experienced complications, including a colon perforation and later deterioration. She became unresponsive and died on 16 June 2018. The principal concern was the quality, legibility, accessibility and retention of clinical records, which delayed and compromised internal death reviews and could affect continuity of care and the learning of lessons.

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 retain and make clinical records available
Wider context from the report
“I bear in mind that the quality of record keeping is an issue I have raised with the hospital trust previously. In October 2017 I sent to the Trust a letter of concern written in accordance with paragraph 37 of the Chief Coroner’s Guidance No. 5 (Reports to prevent future deaths). That letter was in relation to investigations conducted at this court into the deaths of WB and NM. The letter was felt to be necessary after the inquest into WB’s death had to be conducted in the absence of documentation which the Trust was unable to locate. In May 2017 this court received from the Trust a Sudden Untoward Incident Review into the death of NM which had been completed in the absence of some of the hospital records which could not be located. I was concerned that an improvement in relation to record keeping was essential because having access to quality documentation minimises the chance of, for example, an untoward clinical incident review being delayed or remaining incomplete; it avoids the risk that a coroner’s inquest is delayed. Also, and importantly in my view, it is obviously important that records are readily available to assist a coronial inquiry or indeed an internal hospital review not least in order to ensure any lessons which need to be learnt can be learnt and for this to be achieved as effectively as possible an accurate record of events should be available. In addition to the quality of some of the records relating to Mrs Tait’s care in hospital, the Trust’s internal review was delayed because the clinical records could not be located for some time resulting in a delay before witness statements could be compiled and the Sudden Untoward Incident Review completed the impact of which was the inquest had to be vacated from the original court slot allocated to it and re-listed. Other investigations have been affected by similar issues: a further investigation into the death of JS ultimately proceeded in the absence of hospital records which reportedly went missing after the death and could not be found. In deciding to write this letter I take into account that in response to my letter in October 2017 [see above] I received a response from the Trust dated 4th December 2017 which explained that the point was made that “it is worth noting that the Trust has somewhere in excess of 500,000 sets of patient records and that non-availability is a rare event”. The letter went on to helpfully explain that the Executive Directors had approved a business case for the introduction of an electronic document management system which would mean paper records would be immediately accessible to attending clinicians. Unfortunately, having monitored the situation since then I remain concerned that the Trust’s procedures in terms of accessibility but also to quality of clinical records pose a risk of future deaths if those procedures are jeopardising the likelihood of the correct lessons arising from a death investigation being learnt. ”
Source location
Tina Tait · 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
Poor and illegible clinical record keeping
Wider context from the report
“The concern I have is that there is a risk of future deaths because the opportunity to learn valuable lessons following a death is being compromised by issues pertaining to the quality of record keeping. Issues have arisen in relation to the quality of accessible clinical records [as in this inquest concerning Tina Tait] but also in relation to retention and storage of those records [other investigations – see below] to the extent that the effectiveness of sudden untoward incident reviews conducted by the Trust has been compromised perhaps due to the consequential delay [inevitably leading to lessons being learnt later than they may otherwise have been] or because the quality of the review has been affected [missing documentation leading to internal reviews having to be concluded in the absence of records]. Following Tina Tait’s death the hospital trust undertook a sudden untoward incident review. This led to a report being compiled and that document was included in the inquest evidence. One of the authors of that report, ████████ ████████(Clinical Matron) gave extremely helpful evidence at the inquest and was an impressive witness. However within the report a learning point was identified namely that the documentation in the case records had been found to be “at times poor and illegible”. [Other learning points included the need for improved handover / continuity of care, learning in relation to the recognition of a deteriorating patient and correct use of the Early Warning Score chart with appropriate escalation.] Professionals such as Amanda Langton tasked with investigating deaths clearly need to be provided with all of the necessary information to be able to produce an effective review which ensures the right lessons are learnt and the risk of future deaths minimised accordingly. I am concerned that ████████ having found herself trying to review this matter in the face of poor and illegible records is a reminder that unless this type of issue is not addressed then risks will occur as a consequence. Medical professionals who take over the care of patients from other staff at handover need to be able to familiarise themselves with accessible and legible records. When this does not happen the quality of the care received by patients can be affected. It seems to me that issues persist as regards the quality of record keeping within the Trust and that it would be remiss of me not to raise that concern at this time. ”
Source location
Tina Tait · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Apr2019
Surrey
Concerns raised2
1. Failure to make notes in the radiography suite
2. Failure to document patient vulnerabilities for radiographer use
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 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

Mrs Alice Doris Dixon · 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

Alice Doris Dixon attended St Peter’s Hospital for investigation of anaemia and shortness of breath and suffered an anaphylactic shock during a CT scan involving injected contrast dye. She was admitted to intensive care, later treated palliatively, and died from the consequences of the shock. Concerns included inadequate support and communication during consent, incomplete and unclear consent documentation, lack of clinical assessment immediately before the scan, missing information about vulnerabilities, and difficulty observing or hearing her breathing difficulties during the scan.

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 make notes in the radiography suite
Wider context from the report
“8. No notes were made in the radiography suite. ”
Source location
Mrs Alice Doris Dixon · 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
Failure to document patient vulnerabilities for radiographer use
Wider context from the report
“10. There was no note to assist the radiographer with any vulnerabilities Mrs Dixon had (including cranial hearing and understanding difficulties and issues that she was not able to lie flat) ”
Source location
Mrs Alice Doris Dixon · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Mar2019
Norfolk
Concerns raised2
1. Failure to routinely include or read ambulance notes in clinical records
2. Poor clinical record keeping
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

Brian Robert HAVARD · 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

Brian Robert Havard attended the Emergency Department with chest pain and vomiting, was discharged with a diagnosis of musculoskeletal pain, then collapsed in the car and died while being taken back to hospital. The concerns included failure to review ambulance records, inadequate senior review arrangements, and poor record keeping.

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 routinely include or read ambulance notes in clinical records
Wider context from the report
“3. Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read. ”
Source location
Brian Robert HAVARD · Prevention of Future Deaths report
Page 1 · 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
Poor clinical record keeping
Wider context from the report
“3. Record keeping generally appeared to be poor and thus the doctors who attended at inquest had little documentation with which to refresh their memories and the ambulance notes do not appear to be routinely included in these notes and or read. ”
Source location
Brian Robert HAVARD · Prevention of Future Deaths report
Page 1 · concerns
Open source report
18 Mar2019
Norfolk
Concerns raised1
1. Failure to maintain full and contemporaneous electronic records
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.
Actions described in response 5
1. Action
  Instruct all clinical services to review record-keeping and partner-agency communication practices.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated completed
2. Action
  Review working practices for record keeping and communication with partner agencies across clinical services.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
3. Action
  Provide management assurance on actions taken to improve record keeping and partner-agency communication.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
1. Action
  Deliver a learning session on clinicians’ regulatory, legal and professional responsibilities for record keeping and communication.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
2. Action
  Monitor intervention effectiveness through audit, user feedback and quality and safety reviews.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Operational managers are responsible for reviewing record-keeping and partner-agency communication practices and providing assurance of improvement actions.
  Stated by Norfolk and Suffolk NHS Foundation TrustRedirects responsibility
AI-generated summary

Ellie Jane LONG · 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

Ellie Long was receiving community treatment from the Eating Disorder Service and had diagnoses of Anorexia Nervosa and Depression. She was found hanging in her bedroom on 10 December 2017 and died in hospital on 12 December 2017. The principal concerns were incomplete record keeping and disclosure, and inadequate communication and information sharing with external agencies including her GP and school.

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 maintain full and contemporaneous electronic records
Wider context from the report
“1. Record keeping and Auditing of Record keeping a) Not all records were properly recorded on Lorenzo. Further, personal handwritten notes were made of some meetings which were not then reflected in the electronic records. Some of these notes only came to light during the inquest hearing. It is, of course, imperative that all staff recognise their obligations in respect of keeping full and contemporaneous electronic records and that full disclosure of all relevant documents is made in a timely fashion before the inquest commences. This avoids potential delay in the inquest process and further distress to the family. b) Some action has been taken by NSFT in this respect, not least in that the team is now better resourced staff-wise. Further action has been and is being taken to ensure staff appreciate the importance of full record keeping. An audit of the records has been undertaken to ensure full compliance with record keeping requirements but this will only continue until 100% compliance has been achieved. c) Concern remains in that staff do change over time and matters raised now do not necessarily remain at the forefront of an individual’s mind, especially when under time pressure. Good record keeping is an integral part of any good service and must be second nature to all staff. It must be fully appreciated by all as “a vital component in the management of risk”. Further, record keeping has been raised elsewhere as a matter of concern within NSFT. d) I have concern that full record keeping and disclosure requirements will not remain a priority. ”
Source location
Ellie Jane LONG · Prevention of Future Deaths report
Page 1 · 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
Instruct all clinical services to review record-keeping and partner-agency communication practices.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Review working practices for record keeping and communication with partner agencies across clinical services.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Provide management assurance on actions taken to improve record keeping and partner-agency communication.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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 a learning session on clinicians’ regulatory, legal and professional responsibilities for record keeping and communication.

Verbatim wording from the response
“Supporting this is a learning session to be delivered by the Head of Patient Safety and Safeguarding and the Legal Services Manager. The session will have a specific focus on the regulatory, legal and professional responsibilities each clinician holds with respect to record keeping and communication.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
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
Monitor intervention effectiveness through audit, user feedback and quality and safety reviews.

Verbatim wording from the response
“The Trust will gain assurance these interventions are working through a number of indicators. This will include audit, user feedback and the outcomes of quality and safety reviews. To support an effective assurance system, the Trust is implementing a new governance structure enabling a combined and tiered approach that will provide the culture and conditions for improvement.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 2 · response
Published 14 June 2019
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
Operational managers are responsible for reviewing record-keeping and partner-agency communication practices and providing assurance of improvement actions.

Verbatim wording from the response
“All clinical services have been instructed to review their working practice in respect of record keeping and communication with partner agencies. Responsibility for this rests with the operational managers who will provide assurance of the actions taken to improve performance.”

Source location
2019-0090-Response-by-Norfolk-and-Suffolk-NHS-Trust
Page 1 · response
Published 14 June 2019
Open published response
26 Feb2019
Manchester South
Concerns raised1
1. Absence of a requirement for structured narrative nursing records for each shift
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

Mr Geoffrey Jackson · 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 Geoffrey Jackson died at Trafford General Hospital on 6 November 2018 following congestive cardiac failure and ischaemic heart disease, with left hip replacement and hospital-acquired pneumonia also recorded. He had an unwitnessed fall after required falls-risk assessments were not completed, although there was no evidence that the fall contributed to or materially hastened his death. Concerns included continuing omissions in falls-risk assessments and nursing records that lacked structured narrative accounts of patients’ conditions.

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
Absence of a requirement for structured narrative nursing records for each shift
Wider context from the report
“2. A further matter of concern arose from the manner in which nursing records are made at Trafford General Hospital, with an emphasis on proforma care plans which simply require signing and dating by nurses, observation charts, and sheets upon which variance from the care plans can be recorded. It is a matter of concern that the absence of any requirement upon the nurse looking after a patient for a given shift to make a structured narrative record of what transpires over that period represents a missed opportunity to capture nuanced changes in a patient’s condition, and communicate these to others. ”
Source location
Mr Geoffrey Jackson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Feb2019
Bedfordshire and Luton
Concerns raised1
1. Failure to make proper and crucial clinical notes under staffing pressures
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.

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

Gwyneth Ann EDWARDS · 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

Gwyneth Ann EDWARDS was admitted to Bedford Hospital on 7 December 2017 and deteriorated after Hydrocortisone and Desmopressin were not dispensed. She developed severe hypernatraemia and died on 14 December 2017 while receiving end-of-life care; the stated cause of death included bronchopneumonia and hypernatraemia, with failure to administer Desmopressin and maintain appropriate fluids. Concerns included gaps in weekend transfer arrangements, NEWS scores not being acted upon, an unverified Mobile Medic review marked complete, staff unfamiliarity with Desmopressin storage, and staffing pressures affecting monitoring and record-keeping.

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 make proper and crucial clinical notes under staffing pressures
Wider context from the report
“(5) Witnesses who had not recorded their actions or who had not undertaken NEWS scoring, explained that they were too busy, and indicated there was not enough staff. It is of concern that monitoring, as envisaged by NEWS, cannot take place if there is insufficient staff and it is of concern that proper and crucial notes are not being made due to staffing pressures. ”
Source location
Gwyneth Ann EDWARDS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Jan2019
London (East)
Concerns raised2
1. Failure to maintain up-to-date coded records of asthma history and hospital correspondence
2. Lack of a coordinated record of asthma-related attendances
This report raised 22 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 integrated care models connecting services and information for children and young people.
  Stated by NHS EnglandStated planned
AI-generated summary

Sophie Holman · 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

Sophie Holman, a 10-year-old girl with chronic asthma, died on 13 December 2017 after collapsing during a severe asthma attack while being taken to hospital. The report identifies concerns about inadequate long-term management, fragmented records, failure to recognise the cumulative severity and risks of her asthma, lack of a coordinated asthma action plan and safety-netting, and missed opportunities for specialist referral.

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 maintain up-to-date coded records of asthma history and hospital correspondence
Wider context from the report
“In the primary care practice there was: a) No clear agreed practice protocol for managing asthma b) The medical records did not contain an up to date summary of current and past problems; in particular correspondence from hospitals following treatment for asthma attacks was not Read Coded. As a result clinicians consulted could not readily see the evidence of this girls chronic poorly controlled asthma c) A failure to recognise the risks of future poor outcome such as: i. Excess salbutamol prescriptions after the publication of the NRAD in May 2014. The child was prescribed 28, 22, 30 and 16 of these inhalers in 2014, 2015, 2016 and 2017 by her general practice ii. Failure to recognise the only 5 of the required preventer inhalers were collected in Sophie’s final year of life d) No clear supervision of junior doctors and nurses delegated to provide asthma care e) Failure to objectively assess severity and progress when treating acute asthma attacks as per the UK BTS/SIGN asthma guidelines f) Failure to recognise that absence of symptoms and distress does not exclude the presence of a severe attack, as highlighted in the UK BTS/SIGN asthma guidelines g) Failure to follow up after attacks as detailed in the NICE Quality Statement of 25, 2013 h) No clear evidence of detailed specific safety netting advice and over-reliance on prescription of unlicensed, non-specific based high dose salbutamol ‘weaning plans’ which may have masked recognition of deteriorating signs due to a requirement for excess reliever medication in Sophie’s final fatal attack – which may have led the parents to seek help earlier than 24 hours after leaving the surgery i) Potentially dangerous advice on occasions: in particular when a nurse sent the child home and advised mother to administer reliever treatment with a nebuliser at home for an asthma attack j) No evidence of provision of a written Personalised Asthma Action Plan for recognition of uncontrolled asthma and attacks and any action to be taken by the family and how and when to obtain medical assistance k) There was only one example where one of the 16 general practitioners who treated this child arranged a post-attack follow-up review soon after attacks l) No attempt to increase the medication dose for three and a half years despite at least 14 recurring asthma attacks ”
Source location
Sophie Holman · 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
Lack of a coordinated record of asthma-related attendances
Wider context from the report
“2) There was: a. No coordinated record of these occasions b. No analysis of the frequency or circumstances of these events c. No analysis of the underlying chronic asthma condition d. No appreciation of the risk factors for future attacks and death due to asthma in this child e. No long-term management plan for the care of this child despite innumerable attendances for attacks and failure of the parents to bring the child on occasions for routine hospital and practice appointments f. No evidence of provision of a written personal acute asthma self-management plan recommended in the UK BTS/SIGN asthma guidelines g. No evidence that the family were informed of the risks of poor outcome evidence in this child’s history h. No evidence that anyone considered referring this child as recommended in the NRAD, to a respiratory specialist or severe asthma service for investigation, characterisation of the nature and phenotype of this child’s asthma so that a long-term management and treatment plan could be formulated and implemented i. No clear understanding or awareness by the health professionals caring for Sophie of the current UK asthma guidelines, the recommendations of the NRAD or of the prescribing advice in the British National Formulary for the management of asthma ”
Source location
Sophie Holman · Prevention of Future Deaths report
Page 3 · 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 integrated care models connecting services and information for children and young people.

Verbatim wording from the response
“NHS England published the NHS Long Term Plan² in January 2019. Within the plan we committed to focusing on the health and care of children and young people, and to launch a ‘Children and Young People’s (CYP) Transformation Board’. As part of this we will work to develop new models of integrated care that will bring together services and connect vital information for children and young people. We are particularly keen to focus on continuing healthcare needs and from autumn 2019 we will roll out CYP clinical networks for long-term conditions focusing on asthma, epilepsy and diabetes. These CYP networks will link to primary care networks³ whilst focusing specifically on the needs of children, young people and their families and the improvement of services by sharing best clinical practices and supporting the integration of paediatric skills across services.”

Source location
2019-0035-Response-by-NHS-England
Page 2 · response
Published 26 May 2019
Open published response
23 Jan2019
Lincolnshire
Concerns raised1
1. Failure to date and sign recorded emergency pre-alerts
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.

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

Gail Bailey · 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

Gail Bailey, who was nine weeks pregnant, developed abdominal discomfort while on holiday on 5 August 2017. An ambulance was called but arrived after a delay, and she was declared deceased at Boston Pilgrim Hospital later that evening. The report raised concerns about emergency communication and preparedness, including pre-alert calls that were not dated or signed and the apparent lack of advance warning to obstetric and gynaecology 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 date and sign recorded emergency pre-alerts
Wider context from the report
“C) I received evidence from Mr Bailey that upon arrival at hospital the clinicians appeared not to be ready for his wife's arrival. D) I received evidence from Mr ████████, consultant in the Accident and Emergency Unit at Boston Pilgrim Hospital, that ████████, a Specialty Doctor in Emergency medicine present at the time had noted in the medical records that he, together with other doctors had attempted to resuscitate Mrs Bailey who had presented to A & E in a collapsed state around 21.00 hours and had noted that "a cardiac arrest call-out had also been initiated in or around the time of the patients' arrival to Pilgrim." E) I received evidence from the locum registrar for the labour ward, ████████ that "[My understanding at that time was that] no Obstetrician and gynaecologist was forewarned about this patients arrival to the A & E department." F) The ED records confirmed that two pre alert calls were recorded but not dated nor signed. G) Whilst the severity of Mrs Bailey's condition meant that in the particular circumstances of this case the treatment Mrs Bailey received at hospital neither caused nor contributed to her death, the apparent breakdown in communication does raise an area of concern in relation to future emergency admissions. ”
Source location
Gail Bailey · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Jan2019
Manchester South
Concerns raised2
1. Lack of detail in GP and ANP consultation notes
2. Failure to document the extent and issues considered during medication reviews
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 7
1. Action
  Document follow-up plans and dosage advice whenever medication is started.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
2. Action
  Provide and document advice on non-pharmacological treatments when prescribing analgesia.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
3. Action
  Share learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.
  Stated by NHS Greater Manchester Integrated Care BoardStated planned
1. Action
  Require medication reviews to record the medicines and content reviewed, with follow-up appointments when reviews are incomplete.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
2. Action
  Make prescribers aware that EMIS can set review dates for individual medicines.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
3. Action
  Liaise with EMIS to request medication-review fields and prompts, while assessing current functionality to improve recording.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
4. Action
  Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.
  Stated by NHS Greater Manchester Integrated Care BoardStated in progress
Respondent positions 1
1. Position
  Detailed consultation records are the responsibility of individual clinicians rather than a limitation of the GP computer system.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jacqueline Marie Elliott · 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

Jacqueline Marie Elliott, who had a long-standing history of back pain, was found deceased at home on 9 August 2018. Post-mortem and toxicology findings identified reduced liver function and significant toxicity from a combination of drugs. Concerns included inaccurate prescription records, insufficient clinical notes and medication-review detail, prescribing of 100 tramadol tablets despite a recorded history of non-compliance and self-medication, and a lack of continuity of care.

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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 detail in GP and ANP consultation notes
Wider context from the report
“2. The notes made by GPs and the ANP who had seen her/had telephone consultations lacked detail and so it was difficult to assess what information had been provided previously and what advice she had been given; ”
Source location
Jacqueline Marie Elliott · 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
Failure to document the extent and issues considered during medication reviews
Wider context from the report
“3. There was no detail provided in the notes at the inquest of the extent or issues considered during the medication reviews that were recorded as having taken place; ”
Source location
Jacqueline Marie Elliott · 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
Document follow-up plans and dosage advice whenever medication is started.

Verbatim wording from the response
“Actions agreed with the CCG and in progress”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 4 · response
Published 23 May 2019
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
Provide and document advice on non-pharmacological treatments when prescribing analgesia.

Verbatim wording from the response
“Actions agreed with the CCG and in progress”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 4 · response
Published 23 May 2019
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 learning on medication follow-up, dosage advice and non-pharmacological pain treatment with GPs through training and newsletters.

Verbatim wording from the response
“1. When medication is started document the plan for follow-up/review and any advice given relating to the dose to take.”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 4 · response
Published 23 May 2019
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 medication reviews to record the medicines and content reviewed, with follow-up appointments when reviews are incomplete.

Verbatim wording from the response
“The medication review date is primarily set to ensure that repeat medication gets reviewed at regular intervals. As previously stated this should also include a review of any medication on the acute list. A medication review may be a review of the medical notes or a review with the patient in a telephone consultation or face to face.”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 5 · response
Published 23 May 2019
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
Make prescribers aware that EMIS can set review dates for individual medicines.

Verbatim wording from the response
“For individual medicines that require an earlier review prescribers should be made aware of the facility to set a review date for that individual medicine (rather than authorisations which are less specific and can be overridden)”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 5 · response
Published 23 May 2019
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
Liaise with EMIS to request medication-review fields and prompts, while assessing current functionality to improve recording.

Verbatim wording from the response
“2. In the EMIS system a medication review is usually recorded by clicking on the medication review date at the bottom of the medication screen. This only allows recording of the read code for medication review and has no facility for recording the details of the review. The only way to record details of the review is to open”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 5 · response
Published 23 May 2019
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
Audit practices against repeat-prescribing and medication-review standards to support and maintain safety improvements.

Verbatim wording from the response
“As a CCG we will offer advice to all GPs and Non-Medical Prescribers around these actions, this will be in the role of an enabler by providing appropriate tools and information/education. Our Medicines Optimisations team will continue to support practices to achieve and maintain the changes through an ongoing system of audit, against the Gold Standard Repeat Prescribing guidelines and medication review.”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 6 · response
Published 23 May 2019
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
Detailed consultation records are the responsibility of individual clinicians rather than a limitation of the GP computer system.

Verbatim wording from the response
“It is important to note that full and accurate record keeping is the responsibility of the clinician. A lack of detailed records of consultations is related to the quality of record keeping by individual GPs and not to the GP clinical computer system capability.”

Source location
2019-0016-Response-by-Trafford-CCG-and-Department-of-Health-and-Social-Care
Page 9 · response
Published 23 May 2019
Open published response
4 Jan2019
Manchester North
Concerns raised2
1. Failure to record and make psychology records accessible to psychologists
2. Inadequate documentary record keeping of care-plan meetings
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.
Actions described in response 5
1. Action
  Inform prison psychology staff how to request access to patients’ NHS clinical records.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
2. Action
  Audit psychology staff access, records viewed, and clinical entries documented in the system.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
3. Action
  Require the funded psychologist to document every patient interaction in the patient’s clinical record.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
1. Action
  Implement and embed the national Challenge Support Intervention Plan with multidisciplinary engagement, information-sharing, and effective record-keeping requirements.
  Stated by HM Prison and Probation ServiceStated in progress
2. Action
  Operate weekly multidisciplinary meetings at HMP Manchester to manage complex and challenging prisoners and maintain decision-making records.
  Stated by HM Prison and Probation ServiceStated completed
Respondent positions 1
1. Position
  Medical confidentiality requirements prevent combining mental health and psychology records, so information sharing must use existing multidisciplinary forums.
  Stated by HM Prison and Probation ServiceUnable to act
AI-generated summary

Mr Nicky Raymond Reilly · 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 Nicky Raymond Reilly, also known as Mr Mohamed Saeed-Alim, was an inmate at HMP Manchester after spending six years at Broadmoor High Security Hospital. He was found hanging by a ligature in his cell on 19 October 2016 and was pronounced deceased at 14.43. The report raised concerns about the lack of continuation of the Care Program Approach, incomplete multidisciplinary records and coordination, limited psychological input and record keeping, insufficient staff training, separation of mental health and psychology records, and medication-refusal processes.

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 and make psychology records accessible to psychologists
Wider context from the report
“The Court received a copy of the psychology records kept by ████████ which the Court heard were the only Psychology records available. It was evident to the Court that there was little to no recording of information within the Psychology department. NR’s psychology medical records were at best, woeful. Moreover, as they were not kept in the Psychology department they were not available access to any other Psychologists. ”
Source location
Mr Nicky Raymond Reilly · 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
Inadequate documentary record keeping of care-plan meetings
Wider context from the report
“The Court heard evidence in respect of the quarterly meetings held by the CMG in respect of managing NRs care plan. The quality of documentary record keeping in respect of these meetings was limited. The absence of important multi-disciplinary attendees and lack of requirement of formal reports meant there was no-one who could provide full, accurate, informed information regarding NR, upon which decisions regarding his care could be made. ”
Source location
Mr Nicky Raymond Reilly · 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
Inform prison psychology staff how to request access to patients’ NHS clinical records.

Verbatim wording from the response
“Where a prisoner is receiving input from the prison psychology team access to the NHS record can be requested by the psychologist responsible for delivering that input to the patient, subject to the normal consent being given. The prison psychology team have been informed of how they can gain access to the patient's clinical record. Where such access is given, it is expected that the psychologist will document their involvement with the patient in the clinical record, to inform the multi-disciplinary healthcare team of the input that is being provided. Psychology access to the system will allow them to see the current package of care that is being delivered by medical and mental health services.”

Source location
2019-0014-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 1 · response
Published 24 May 2019
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
Audit psychology staff access, records viewed, and clinical entries documented in the system.

Verbatim wording from the response
“An audit of psychology access to the system, patients viewed and documented entries made, will be conducted by the Head of Healthcare. Mental Health and psychology staff now attend the weekly Complex Case meeting, which are minuted, where those prisoners with complex needs are reviewed by the multi-disciplinary team. This allows a multi-disciplinary approach to care planning and a forum for the sharing of information. HMP Manchester has just received funding from NHS England from the 1st April 2019, to increase mental health services within the prison. Part of this funding will be used to fund a psychologist, employed by Greater Manchester Mental Health Trust, to provide psychoeducationally informed, evidence based specialist support for all those assessed as requiring interventions to address mental health, personality disorder, and support for individuals with learning disabilities.”

Source location
2019-0014-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 2 · response
Published 24 May 2019
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 the funded psychologist to document every patient interaction in the patient’s clinical record.

Verbatim wording from the response
“As a GMMH employee this psychologist will be expected to document all patient interactions within the patient's system clinical records.”

Source location
2019-0014-Response-by-Greater-Manchester-Mental-Health-NHS-Trust
Page 2 · response
Published 24 May 2019
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
Implement and embed the national Challenge Support Intervention Plan with multidisciplinary engagement, information-sharing, and effective record-keeping requirements.

Verbatim wording from the response
“Whilst recognising the significance of the introduction of the new national case management model, Challenge Support Intervention Plan (CSIP), which replaced the MCBS policy on 1 February this year and is currently being implemented and embedded across the prison estate, you have expressed concern that some of the issues covered during the inquest may still be relevant. You have specifically referred to poor record keeping, the lack of multi-disciplinary attendees and the lack of requirement for formal reports.”

Source location
2019-0014-Response-by-HM-Prison-and-Probation-Service
Page 1 · response
Published 24 May 2019
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
Operate weekly multidisciplinary meetings at HMP Manchester to manage complex and challenging prisoners and maintain decision-making records.

Verbatim wording from the response
“HMP Manchester has been holding a weekly multi-disciplinary meeting to manage complex and challenging prisoners since April 2018, and CSIP was introduced in June 2018. The purpose of the weekly meeting is assist the Residential function by providing multi-disciplinary case management for prisoners who require additional resources over and above their CSIP or ACCT Intervention, Support or Care plans. Departments who do not attend are expected to provide written submissions to the meeting. The meetings are chaired by a Senior Manager from the Residential and Safety function, and minutes are kept to ensure an ongoing record of decision-making is maintained.”

Source location
2019-0014-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 24 May 2019
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
Medical confidentiality requirements prevent combining mental health and psychology records, so information sharing must use existing multidisciplinary forums.

Verbatim wording from the response
“You have referred to mental health and psychology services record-keeping operating separately, with clinical records being held on SystmOne to which psychologists do not have access. While I recognise that this separation does carry the risk that information is not effectively shared, I must respect the medical in-confidence issues that make this necessary, and I expect all staff working in prisons to use the many forums available to them to work in a multi-disciplinary, collaborative way to ensure that decisions about prisoners are made with all available information.”

Source location
2019-0014-Response-by-HM-Prison-and-Probation-Service
Page 2 · response
Published 24 May 2019
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to retain and make clinical records available

Poor and illegible clinical record keeping

Concerns raised2

Failure to make notes in the radiography suite

Failure to document patient vulnerabilities for radiographer use

Concerns raised2

Failure to routinely include or read ambulance notes in clinical records

Poor clinical record keeping

Concerns raised1

Failure to maintain full and contemporaneous electronic 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.5

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

Concerns raised1

Absence of a requirement for structured narrative nursing records for each shift

Concerns raised1

Failure to make proper and crucial clinical notes under staffing pressures

Concerns raised2

Failure to maintain up-to-date coded records of asthma history and hospital correspondence

Lack of a coordinated record of asthma-related attendances

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 date and sign recorded emergency pre-alerts

Concerns raised2

Lack of detail in GP and ANP consultation notes

Failure to document the extent and issues considered during medication reviews

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.7

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

Actions described in response 5

Respondent positions 1

Actions described in response 1

Actions described in response 7

Respondent positions 1