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.

13 Nov2018
Staffordshire South
Concerns raised1
1. Poor record keeping affecting continuity of care
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.

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

Thomas Paul Arthur 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

Thomas Paul Arthur Jackson was found in a poorly state in his room at a secure unit within St George’s Hospital, Stafford, in the early hours of 25 August 2016 and was certified dead at 02.25 hours. The inquest recorded clozapine toxicity and pneumonia as causes of death, with treatment-resistant schizophrenia also noted; the substantive concern was the lack of a national policy for regular blood plasma monitoring of patients receiving clozapine.

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
Poor record keeping affecting continuity of care
Wider context from the report
“(1) During the hearing it was noted that on a number of occasions record keeping was poor. This can make continuity of care difficult and it can lead to matters being missed. I wonder if the Trust can take any action to improve this. ”
Source location
Thomas Paul Arthur JACKSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Nov2018
West London
Concerns raised1
1. Inadequate record keeping in the Practice
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 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

PATRICIA PRISCILLA CHAMBERS · 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

Patricia Chambers died by suicide on 11 May 2016 after jumping from the ninth-floor communal walkway of her residence, sustaining non-survivable injuries. The inquest identified deficiencies in her mental-health discharge process, communication and continuity of care, as well as inadequate GP record keeping and document control; the report remained concerned that information could be lost or ignored and pose a risk to future deaths.

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
Inadequate record keeping in the Practice
Wider context from the report
“I have since heard, through counsel, that the Trust has reflected on the evidence and the jury’s findings, and accepts that there is still concern in respect of: - The Discharge Medication Summary (the “Summary”) and the 7-Day Follow-Up, which need to be redrawn - Communication of the Summary to other parties (in particular the CMHT, the GP and Pharmacy) - Consistency of the Summary with C2, the Care Programme Approach Policy (which policy, I understand, is itself currently under review) - Compliance of the CPA with the Code of Practice (in particular paragraph 34.11 of the Code of Practice) - The appointment, training and supervision of the role of Primary Nurse on the Ward. The jury has found that your Practice’s record keeping was inadequate in 2016, and this was a contributory factor to Patricia Chambers’s death. In evidence, ████████ told the court that the Practice has an “admin team”, that records are computerised, and that communications are now made by email and no longer by fax. However, I remain concerned because ████████ disclosure of records to the inquest was most unsatisfactory. Documents were disclosed in a random, rather than a chronological, order. Important documents were missing from the disclosure, including in particular the Summary referred to above as well as communications to you from the consultant psychiatrist in the community, ████████ I am concerned that these were received but have been lost. Moreover, ████████ was unable to give any satisfactory explanation in evidence for the fact that documents were missing and disordered. I am concerned that the system in place for the collection, recording, saving and dissemination of information within the Practice is unsatisfactory, and that this could lead to information being lost and/or ignored, with a consequent risk that future deaths could occur unless action is taken. ”
Source location
PATRICIA PRISCILLA CHAMBERS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Oct2018
Berkshire
Concerns raised1
1. Failure to maintain full, accurate, and up-to-date hospital records about choking risk
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

Anne Roberts · 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

Anne Roberts died at Prospect Park Hospital, Reading, on 28 September 2017 after choking on a bolus of food consisting of a sandwich and chocolate brownie cake. The report raised concerns about bank-staff training, dissemination and recording of choking-risk information, management of patients eating in bedrooms, and frontline staff training on the interaction between mental disorders and choking risks.

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, accurate, and up-to-date hospital records about choking risk
Wider context from the report
“2. Concerns about the dissemination of information relating to risk of choking particularly with respect to ensuring that hospital records are full, accurate, and up to date. ”
Source location
Anne Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Oct2018
Manchester South
Concerns raised1
1. Unavailability of paper clinical notes to clinicians at appointments
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 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

Joseph James GRANTHAM · 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

Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.

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
Unavailability of paper clinical notes to clinicians at appointments
Wider context from the report
“3. At ENT appointments and neurosurgery appointments at the RMCH, Joseph was seen without the paper notes because they had not been made available to the clinicians seeing Joseph. ”
Source location
Joseph James GRANTHAM · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Oct2018
Liverpool and the Wirral
Concerns raised1
1. Failure to document important clinical findings
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.
AI-generated summary

Tom Cribley · 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

Tom Cribley attended Aintree hospital on 18 February 2017 with vomiting, diarrhoea and a rash, and was later diagnosed with meningococcal sepsis. The report identifies concerns including failures to document and escalate the rash and deteriorating observations, inadequate handovers and reassessment, delayed recognition of abnormal blood results, and delayed antibiotic treatment. Tom did not recover and died on 20 February 2017.

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 document important clinical findings
Wider context from the report
“A RCA revealed a number of failings by the Trust including in respect of some matters that had been previously raised by the Care Quality Commission and required action. The failings identified by the Trust and those found by the Jury included; inter alia failing to document important clinical findings for example the failure to document the rash that Tom presented with when he arrived at AED which was not recorded at triage. The failure to escalate the NEWS (National Modified Early Warning Score) in a timely manner to medical staff and to repeat observations hourly in accordance with the NEWS policy. The failure to complete a full “PIT STOP” review, the failure to review the initial diagnosis of gastroenteritis when Tom’s condition continued to deteriorate, the failure of clinical staff to handover clinical concerns to each other and to medical staff including face to face handovers, the failure to escalate monitoring and management appropriately in particular following receipt of the first set of grossly abnormal blood results, the failure to administer antibiotic therapy until 23.00 hrs this even when Tom’s condition continued to deteriorate and the rash that he presented with began to spread and appeared to change in both colour, size and location during which time Tom was becoming increasingly unwell, he had been a fit and well 28 year old prior to his attendance in AED. There was also an admitted failure to escalate appropriately and to convey the magnitude and severity of Tom’s condition and deterioration to the Critical Care Team, who described him as being “in extremis” when the Critical care doctor arrived shortly after 23.00hrs. The care and treatment from 2300hrs onwards on 18/02/2017 was regarded as wholly appropriate but sadly Tom did not recover and he died on 20/02/2017. Aintree University Hospital have put an action plan in place to address the failings identified within the RCA however such is the concern of the Coroner pertaining to the training needs of clinical staff (doctors and nurses) in respect of the identification and treatment of sepsis and meningococcal sepsis in particular that the Coroner requires a report and action plan which clearly identifies a systematic, consistent and comprehensive ongoing training programme which identifies not only the training plan that will be implemented across the Trust but also how the training plans implementation will be monitored in respect of consistency of approach, compliance and effectiveness. The Trust has produced a number of action plans on previous occasions following Care Quality Commission Reviews, however, some of the failings identified in the issues touching the death of Tom Cribley have also been identified on previous occasions. Robust monitoring and ownership of the training programme, implementation and review is required from the very top of the organisation up to and including the Trust Board. This leadership and ownership from the top will be fundamental to the achievement of meaningful and sustained improvements in the provision of education and training in this most challenging clinical area. ”
Source location
Tom Cribley · Prevention of Future Deaths report
Page 3 · concerns
Open source report
3 Oct2018
West Yorkshire Eastern
Concerns raised1
1. Failure to maintain contemporaneous nursing records of food and fluid intake
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 2
1. Action
  Address inconsistent nutrition and hydration record-keeping with the ward team and discuss it subsequently.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
2. Action
  Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
AI-generated summary

Theresa Maria BUTTON · 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

Theresa Maria BUTTON underwent a liver transplant, remained in hospital for approximately 15 weeks, suffered multiple complications including a stroke, developed pneumonia, and died on 7 December 2017. Concerns included staffing levels and whether limited nursing capacity affected implementation of treatment plans, nutritional care, communication with family members, and contemporaneous 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 maintain contemporaneous nursing records of food and fluid intake
Wider context from the report
“5. Contemporaneous nursing records were not always maintained; for example relating to food and fluid intake (even though nutrition was a matter of concern to the treating clinicians). ”
Source location
Theresa Maria BUTTON · 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
Address inconsistent nutrition and hydration record-keeping with the ward team and discuss it subsequently.

Verbatim wording from the response
“Prior to, and during the course of the inquest ████████ apologised that record keeping in relation to nutrition and hydration was not to a consistently high standard. This was addressed with the ward team at the time and has been discussed subsequently.”

Source location
2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 4 · response
Published 1 March 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
Complete Healthcheck auditing of ward J83 nutrition and hydration documentation and care standards.

Verbatim wording from the response
“The Trust has in place an audit process referred to as the ward/department Healthcheck. This provides a systematic overview of performance across a range of key areas that influence or reflect the standards of care, patient outcomes and experience of care delivered in the Trust. The data can be viewed at organisational, CSU and ward level, providing both a local and strategic picture. A copy of the completed Healthcheck for ward J83 over a 12 months period in relation to nutrition and hydration has been included with this letter. You will note that the ward results demonstrate a very high level of compliance across the key areas identified.”

Source location
2018-0333-Response-by-The-Leeds-Teaching-Hospitals-NHS-Trust
Page 5 · response
Published 1 March 2019
Open published response
26 Sep2018
Manchester West
Concerns raised1
1. Electronic clinical notes permitting alteration of author times
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.
Actions described in response 3
1. Action
  Appraise available electronic-record functionality and discuss it with users.
  Stated by Sir David DaltonStated planned
2. Action
  Incorporate a “date and time seen” field into new electronic-record documents.
  Stated by Sir David DaltonStated in progress
3. Action
  Issue all electronic-record users guidance for recording retrospective notes without changing authored times.
  Stated by Sir David DaltonStated completed
AI-generated summary

John Waite · 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

John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.

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
Electronic clinical notes permitting alteration of author times
Wider context from the report
“4. I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note. The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored. ”
Source location
John Waite · Prevention of Future Deaths report
Page 5 · 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
Appraise available electronic-record functionality and discuss it with users.

Verbatim wording from the response
“The Trust will appraise the functions available at the outset to discuss the functionality of EPR to all users. Staff already do not have the in-depth knowledge required to discuss the function available but the functionality is not routinely taught to our teams so many users are not aware of it. If the feedback from practitioners is that they believe this is the correct way to do it, the documents appeared at the times they had the patient, and this practice had spread through good intentions which were incorrectly applied.”

Source location
John-Waite-Response2
Page 3 · response
Published 26 September 2018
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
Incorporate a “date and time seen” field into new electronic-record documents.

Verbatim wording from the response
“We are already incorporating a “date and time seen” field into our new documents so that they are authored at the correct time, but with a field to show if the time seen differed from the documented time.”

Source location
John-Waite-Response2
Page 3 · response
Published 26 September 2018
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
Issue all electronic-record users guidance for recording retrospective notes without changing authored times.

Verbatim wording from the response
“We have issued an urgent bulletin to all EPR users with guidance on how retrospective notes should be made (i.e. authored time not to be changed but captured as time written and annotated notes then to incorporate ‘written in retrospect, at 9.15am’).”

Source location
John-Waite-Response2
Page 4 · response
Published 26 September 2018
Open published response
12 Sep2018
Warwickshire
Concerns raised1
1. Lack of contemporaneous records of telephone triage
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

Greg HUTCHINS · 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

Greg HUTCHINS committed suicide on 28 August 2017 in a hotel room after suffocating himself with a plastic bag and helium. Concerns included the lack of recollection and contemporaneous or subsequent records of a telephone triage, no update in the RIO system, uncertainty about the triage’s purpose, and limited rapid information sharing for people from outside the Birmingham area.

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
Lack of contemporaneous records of telephone triage
Wider context from the report
“(1) the staff member who conducted the telephone triage had no recollection of the triage whatsoever (2) no contemporaneous of the triage were made (3) no subsequent notes were made of the triage (4) no update regarding the triage was made in RIO system (5) the purpose of the telephone triage was unclear – it was described as not being a mental health assessment (6) Mr Hutchins was from outside the Birmingham area and I heard evidence that no national system exists for rapid information sharing ”
Source location
Greg HUTCHINS · Prevention of Future Deaths report
Page 1 · concerns
Open source report
30 Aug2018
West Yorkshire Eastern
Concerns raised1
1. Failure to record senior clinician advice in electronic notes
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.
Actions described in response 2
1. Action
  Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
2. Action
  Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.
  Stated by Leeds Teaching Hospitals NHS TrustStated completed
Respondent positions 1
1. Position
  Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.
  Stated by Leeds Teaching Hospitals NHS TrustUnable to act
AI-generated summary

Michael John Drewell · 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

Michael John Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.

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 senior clinician advice in electronic notes
Wider context from the report
“The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes. ”
Source location
Michael John Drewell · 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
Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.

Verbatim wording from the response
“I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

Source location
2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018
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
Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.

Verbatim wording from the response
“I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

Source location
2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018
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
Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.

Verbatim wording from the response
“In your Regulation 28 Report you highlight the fact that the junior doctor did not consult the hand-written medical records before prescribing the anticoagulant medication. I am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocol’ they either action this themselves personally, or leave clear unambiguous instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice.”

Source location
2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
Page 2 · response
Published 26 September 2018
Open published response
21 Aug2018
Manchester West
Concerns raised1
1. Failure to document advice given to patients
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.
Actions described in response 1
1. Action
  Put relevant safe-sleeping documentation in place.
  Stated by Bolton NHS Foundation TrustStated completed
AI-generated summary

Louie Francis Bradley · 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

Louie Francis Bradley died following breastfeeding in bed with his mother, who fell asleep. Concerns included advice to breastfeed in bed while side-by-side with the baby when the mother was fatigued, and incomplete documentation of key information and advice given to the patient.

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 document advice given to patients
Wider context from the report
“2. The standard Trust issue documentation was not (properly) completed with the omission of vital information such as mother’s name, GP Practice, address etc.; similarly advice allegedly given to patient was not documented. ”
Source location
Louie Francis Bradley · 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
Put relevant safe-sleeping documentation in place.

Verbatim wording from the response
“I have attached an Action Plan which details a number of improvements together with the relevant documentation which is now in place for your reference. I hope that my response has provided you and the family with the assurance that the Trust has taken appropriate action regarding safe sleeping advice and documentation.”

Source location
2018-0261-Response-by-Bolton-NHS-Trust
Page 1 · response
Published 25 September 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Poor record keeping affecting continuity of care

Concerns raised1

Inadequate record keeping in the Practice

Concerns raised1

Failure to maintain full, accurate, and up-to-date hospital records about choking risk

Concerns raised1

Unavailability of paper clinical notes to clinicians at appointments

Concerns raised1

Failure to document important clinical findings

Concerns raised1

Failure to maintain contemporaneous nursing records of food and fluid intake

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

Concerns raised1

Electronic clinical notes permitting alteration of author times

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

Concerns raised1

Lack of contemporaneous records of telephone triage

Concerns raised1

Failure to record senior clinician advice in electronic notes

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

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

Concerns raised1

Failure to document advice given to patients

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

Actions described in response 2

Actions described in response 3

Actions described in response 2

Respondent positions 1

Actions described in response 1