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 Aug2018
Manchester North
Concerns raised1
1. Inadequate and incomplete record keeping
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.
Actions described in response 1
1. Action
  Implement and embed the electronic care-planning system to improve real-time recording and structured care documentation.
  Stated by Persona Care And Support LimitedStated in progress
AI-generated summary

Dr Donald Clegg · 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

Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.

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 and incomplete record keeping
Wider context from the report
“5. Record keeping was inadequate and in parts, incomplete. Record keeping is vital in keeping service users safe. ”
Source location
Dr Donald Clegg · 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
Implement and embed the electronic care-planning system to improve real-time recording and structured care documentation.

Verbatim wording from the response
“5. Record keeping was inadequate and in parts incomplete Record keeping in social care has become an increasingly significant part of the role in recent years and as a result during 2017 we investigated a number of electronic care planning systems and in autumn 2017 purchased and began implementation of our chosen system Access Mobizio. Roll-out to Elmhurst took place in February 2018. It is now the case that all care planning is in the majority digital within short stay. The system allows real time recording, voice recording and more structured prompts which all contribute to improved record keeping. The QA Framework includes audits and spot checks of care records to assess the quality and accuracy of these. We have identified that there is still further work to do with staff to continue to embed the approach and to drive a culture of improved record keeping.”

Source location
2018-0269-Response-by-Persona
Page 3 · response
Published 25 October 2018
Open published response
1 Aug2018
Inner South London
Concerns raised4
1. Failure to record chest examination findings
2. Delays in recording consultation notes
3. Failure to record swallow test findings
1. Failure to record reported non-adherence to lithium medication
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

Nigel Handscomb · 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

Nigel Handscomb was admitted to University Hospital Lewisham after being diagnosed with pneumonia and possibly having suffered a stroke. He was not reviewed by a doctor for 48 hours, opportunities to escalate his care were missed, and he later suffered a cardiac arrest; the inquest concluded that natural causes, including aspiration pneumonia, bronchopneumonia and severe ketoacidosis, involved neglect. Concerns included incomplete and inaccurate GP records, delayed recording, and missing information about examinations, medication and swallowing difficulties.

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 chest examination findings
Wider context from the report
“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”
Source location
Nigel Handscomb · 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
Delays in recording consultation notes
Wider context from the report
“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”
Source location
Nigel Handscomb · 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
Failure to record swallow test findings
Wider context from the report
“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”
Source location
Nigel Handscomb · 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
Failure to record reported non-adherence to lithium medication
Wider context from the report
“During your evidence to the inquest it became clear that the notes you had made of your consultation with Mr Handscomb were incomplete and inaccurate. Although in this case I accepted that this did not cause or contribute to the death I am concerned that, if repeated, it may do so in other cases. The inquest was told that GP records will now be more readily available to hospitals and will therefore inform their decision making processes. (1) Your records were made several hours after the consultation. (2) You did not record that you had carried out a chest examination, or the result of this examination. (3) You did not record that Mr Handscomb had told you that he had not taken his lithium medication for several days. This was of particular importance in view of the possibility that his symptoms might be the result of lithium toxicity. (4) You did not record that you carried out a swallow test and that Mr Handscomb could not swallow. (5) You prescribed medication and recorded that it should be taken once a day in the morning. This was the instruction recorded on the medication packet. Your evidence was that you told Mr Handscomb to take the medication that afternoon. This was not recorded. ”
Source location
Nigel Handscomb · Prevention of Future Deaths report
Page 1 · concerns
Open source report
26 Jul2018
Manchester North
Concerns raised1
1. Poor or non-existent record keeping
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

Astonn Mitchell-Male · 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

Astonn Mitchell-Male, who had schizophrenia/psychosis and was living in supported accommodation, was found deceased on 1 November 2016 after police and ambulance services had been delayed in responding to a welfare concern the previous evening. The jury found that he died from multiple self-inflicted stab and incise wounds on or around the evening of 31 October 2016 following a deterioration in his mental state. Concerns included the absence of a Trust policy on medication monitoring and compliance, and poor or non-existent record keeping affecting patient safety.

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 or non-existent record keeping
Wider context from the report
“2. There was evidence to show that record keeping was poor and at some points non-existent. Records are a vital form of communication about the patient's condition and care provision. As such, poor compliance goes to the issue of patient safety. ”
Source location
Astonn Mitchell-Male · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Jul2018
Manchester South
Concerns raised1
1. Failure to document conversations with other clinicians
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

Robert Thomas Wrinch · 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

Robert Thomas Wrinch deteriorated with severe back pain and reduced mobility associated with an undiagnosed metastatic spinal malignancy, and developed bronchopneumonia. The report raised concerns about delays and inadequate tracking in pathology sample processing and reporting, reliance on paper reports, inconsistent departmental tracking systems, incompatible information technology systems between trusts, and pathology backlogs linked to shortages of pathologists.

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 conversations with other clinicians
Wider context from the report
“1. The Inquest heard evidence that the pathology department at the Trust had no system for tracking samples. As a result, it was unclear when samples had been received and analysis had taken place. There was no documentation of conversations with other clinicians and so, it was difficult to be clear about the chronology of events. Transmission dates of the sample to another Trust were unclear. It was also difficult to know on what date the report of the pathologists findings had been issued to the treating clinician. It was unclear if these issues are specific to the pathology department of the Trust or more widespread. ”
Source location
Robert Thomas Wrinch · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Jul2018
Manchester (West)
Concerns raised1
1. Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time
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

Mohamed Rahman · 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

Baby Mohamed Rahman was born at 01:45 on 17 February 2018 after an elective feticide procedure and was confirmed dead at 02:48 that day. The principal concerns were that fetal asystole was not unequivocally confirmed before discharge, that the mother and professionals were unprepared for the birth, and that documentation and guidance about confirming fetal demise and explaining the procedure to parents required consideration.

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 contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time
Wider context from the report
“2. The Consultant Obstetrician giving evidence confirmed the need to formally record the exact time at which fetal heart activity ceased at the interval scan which should be at least 20 minutes later with the interval fetal heart check for a full 2 minutes to avoid more transient than permanent asystole. Following the case involving baby Mohammed written Fetal Medicine Guidelines were amended (copy attached). The Consultant Obstetrician agreed that it would be good practice to contemporaneously document the time of insertion and withdrawal of needle and the time at which the fetal heartbeat was monitored on ultrasound. ”
Source location
Mohamed Rahman · Prevention of Future Deaths report
Page 2 · concerns
Open source report
18 Jul2018
Newcastle upon Tyne
Concerns raised1
1. Lack of written guidance on robust recording by first aid staff of patients attended and action taken
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

Ellie Mae Knowles · 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 Mae Knowles attended a dance music event on 5 November 2016, consumed MDMA, became unwell, and later died due to methylenedioxymethamphetamine toxicity. The report identified concerns about event search procedures, record-keeping, staffing and future planning of similar events, including the continued existence of a licence for such events at the premises.

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 written guidance on robust recording by first aid staff of patients attended and action taken
Wider context from the report
“Although oral evidence of remedial action and change in practice was provided by Shindig Events Ltd, the Coroner remained concerned as detailed below: (1) No evidence was provided of written guidance/direction for Shindig Events Ltd employees and/or those with whom they subcontract of standards required in respect of: a. Numbers and qualifications of first aid staff to be provided at dance music events b. Robust recording by first aid staff of patients attended and action taken c. Numbers of security staff required at dance music events d. Scrutiny of the licence to operate status of security staff e. Extent of search of ticket holders required to be undertaken by security staff f. Robust system for recording items (including controlled drugs) seized at search and safe storage of those items ”
Source location
Ellie Mae Knowles · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Jul2018
Blackpool and the Fylde
Concerns raised2
1. Insufficient recording and care planning of patient leave, including its rationale, benefits and risks
2. Failure to document and clearly formulate patient risks in the medical records
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Consider amending the Leave Policy to include additional requirements for care planning regular patient leave.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated planned
2. Action
  Pilot leave diaries in secure services to assess whether they improve the quality of post-leave documentation.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated in progress
3. Action
  Write to consultants and ward managers reiterating the need to document the rationale, risks and benefits for each patient accessing leave.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated planned
1. Action
  Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated planned
2. Action
  Include the actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.
  Stated by Lancashire & South Cumbria NHS Foundation TrustStated planned
AI-generated summary

Adam James Carter · 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

Adam James Carter died on 10 September 2017 after absconding from The Harbour mental health facility during escorted leave and falling from the fifth floor of a car park. The principal concern was inadequate record keeping about Adam’s risks, leave arrangements, leave authorisation and assessment before leave, which could affect staff decisions about patient safety.

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
Insufficient recording and care planning of patient leave, including its rationale, benefits and risks
Wider context from the report
“The concern relates to record keeping. During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following: • Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: - aggression and violence; - self harm; - suicidal behaviour; - absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. • He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave. • He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion). • He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records. If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health. It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result. I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”
Source location
Adam James Carter · 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
Failure to document and clearly formulate patient risks in the medical records
Wider context from the report
“The concern relates to record keeping. During his independent review of this matter, a Consultant Psychiatrist identified some discrepancies within the medical records including the following: • Although he felt that the therapeutic team had an understanding of the extent to which Adam posed a risk of: - aggression and violence; - self harm; - suicidal behaviour; - absconding; He did not feel that these risks were documented or clearly formulated in the medical notes. • He stated that there was very little detail in the documentation as regards Adam’s use of leave nor of care planning of his leave. The rationale for leave having been granted was not recorded nor were the benefits and risks associated with leave. • He was unable to find a record of an assessment of Adam’s clinical state by nursing staff immediately before the period of escorted ground leave on 10th September 2017 as required by trust policy (although he did not feel that this would have any bearing on the decision to afford Adam leave on this occasion). • He could not find a copy of the Leave Authorisation that granted Adam leave and felt that documentation of leave fell short of the guidance laid out in the Trust policy for the authorisation of section 17 leave of absence. Clearly the quality of record keeping is important in the context of a detained mental health patient. Adam had spent some time in a Psychiatric Intensive Care Unit and then a number of days on an acute inpatient ward prior to the events of 10th September 2017. The level of risk such a patient poses as regards issues such as the risk of self harm and absconding are fundamental to the care provided. Plans were being made for Adam to be discharged and into the community rather than back to his parents’ home and he was being afforded the opportunity to build towards that discharge by granting him leave which was an important step in progressing towards that goal. However, such decisions need to be made appropriately and informed by how the risk a patient poses is viewed at that time. It is vital that the basis for such decisions is clear from the records. If this does not happen then I have a concern that future deaths may result – inevitably patients such as Adam are cared for by a team consisting of different staff performing different shifts. Staff taking over the care of a patient such as Adam ought not to have to rely on the verbal information provided to them and handover of that patient’s care but need to have the opportunity to read the records and to remind themselves how the risk their patient poses is viewed by for example the relevant Consultant Psychiatrist, and why he or she has been granted leave. The court heard that escorted grounds leave was granted to Adam but that nursing staff had discretion as regards whether that leave went ahead and they may exercise such discretion subject to how Adam presented, his behaviour on the ward etc. If they cannot access accurate and informative records, such staff may make decisions that are not in the interests of their patients. Leave may proceed on a basis not felt to be safe. Leave may be declined because the staff member – unable to access the relevant information – decides to err on the side of caution and declines leave to the detriment of that patient’s progress and the condition of his / her mental health. It seems to me that if an independent consultant psychiatrist has conducted a review and identified these issues in relation to records it should inevitably prompt a concern on my part that unless I write a report such as this one future deaths may result. I therefore raise the concern. I cannot be prescriptive about what action should be taken and I make no recommendations but simply raise the issue. At the conclusion of the inquest, I indicated to the Properly Interested Persons that I proposed to write to the Department of Health by way of a report in accordance with the provisions of paragraph 7 of Schedule 5 of the Coroners and Justice Act 2009. ”
Source location
Adam James Carter · 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
Consider amending the Leave Policy to include additional requirements for care planning regular patient leave.

Verbatim wording from the response
“Leave that is given regularly to a patient is already discussed and agreed in the context of the Multi Disciplinary Team, and should be documented in the clinical record, however some points around how this is care planned are not currently included in our Leave Policy and so the Mental Health Law Manager will consider a minor amendment to the policy by 28 September 2018.”

Source location
2018-0226-Response-by-Lancashire-Care-NHS-Trust
Page 2 · response
Published 23 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
Pilot leave diaries in secure services to assess whether they improve the quality of post-leave documentation.

Verbatim wording from the response
“How leave went for the patient should already be documented and discussed in the wider MDT forum; in addition a pilot of “leave diaries” is currently taking place in our secure services, if it is found to increase the quality of post leave documentation this will later be rolled out to all wards.”

Source location
2018-0226-Response-by-Lancashire-Care-NHS-Trust
Page 2 · response
Published 23 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
Write to consultants and ward managers reiterating the need to document the rationale, risks and benefits for each patient accessing leave.

Verbatim wording from the response
“The Clinical Director will write to consultants and ward managers about these actions by 14 September 2018 and reiterate the importance of documenting the rationale, risks and benefits for each individual accessing leave.”

Source location
2018-0226-Response-by-Lancashire-Care-NHS-Trust
Page 2 · response
Published 23 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
Prompt nursing teams to reassess patients’ risks and mental state immediately before leave and document the decision in clinical records.

Verbatim wording from the response
“Once leave has been agreed by the Multi Disciplinary Team, the nursing team on each ward will be prompted to fully consider the patients risks and state of mind immediately prior to the patient taking this leave, and reminded to document their up to date decision in the clinical record.”

Source location
2018-0226-Response-by-Lancashire-Care-NHS-Trust
Page 1 · response
Published 23 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
Include the actions’ impact in a clinical audit, then review findings and provide feedback through team clinical supervision.

Verbatim wording from the response
“The impact of the above actions will be included in a clinical audit in January 2019. Matrons and ward managers will then review the findings from these audits and feed the results back during clinical supervision with their teams.”

Source location
2018-0226-Response-by-Lancashire-Care-NHS-Trust
Page 2 · response
Published 23 September 2018
Open published response
25 Jun2018
Coventry
Concerns raised1
1. Failure to transcribe information provided by patients or families for clinical teams
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.

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

Vanessa Ferkova and Sylvia Daniel · 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

Vanessa Ferkova, aged 2, died after presenting to a walk-in centre with fever and vomiting, developing a rash, and later suffering cardiac arrest; the report states she died from meningococcus septicaemia. Sylvia Daniel, aged 73, presented with symptoms including neck pain, was diagnosed with an ear infection, and was found deceased the following morning; the report states she died from acute meningitis. Concerns included delays and deficiencies in initial assessment and registration, failure to transcribe or retain information provided by families, and an unsafe non-clinical triage and flagging process.

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 transcribe information provided by patients or families for clinical teams
Wider context from the report
“2. I am concerned that some information provided by Mrs Daniel’s family was not transcribed by the reception team, meaning that it was not available in written form to the clinical team as part of the initial ‘paper’ triage process and at the later formal consultation. ”
Source location
Vanessa Ferkova and Sylvia Daniel · Prevention of Future Deaths report
Page 3 · concerns
Open source report
19 Jun2018
Staffordshire South
Concerns raised1
1. Inadequate availability of nursing records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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

Derek Reginald Smith · 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

Derek Reginald Smith, who was bedbound and unable to manage his care needs, died at home on 21 December 2017 from aspiration pneumonia. He had developed a severe pressure sore, and the report raised concerns about limited communication between district nurses, family members and possibly carers, as well as the availability of nursing records and delays in treatment decisions.

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 availability of nursing records
Wider context from the report
“It became apparent at the inquest that there was very little communication between the District Nursing team who attended Mr Smith and family members (and possibly little communication with the attending carers as well). There was also an issue regarding the availability of nursing records as well. It may be that Mr Smith’s death could not be prevented but there could have been opportunities for helpful interventions by the family and earlier decision making regarding Mr Smith’s treatment. Suitable communication could well be a significant factor in other cases. I wonder if systems could be changed to ensure better communication between the District Nursing team, family members and other agencies involved. ”
Source location
Derek Reginald Smith · Prevention of Future Deaths report
Page 1 · concerns
Open source report
12 Jun2018
Surrey
Concerns raised2
1. Inadequate clinical documentation for care continuity
2. Lack of meaningful documentation in hospital notes
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.
Actions described in response 4
1. Action
  Introduce Care View on the Acute Medical Unit to communicate high-risk patients and their management plans.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated planned
2. Action
  Review how compliance with the Health Record Content policy is monitored.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated in progress
3. Action
  Conduct twice-yearly audits of the 14 Health Record Content policy standards, including arrangements for future and ongoing care.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated planned
1. Action
  Circulate the prevention-of-future-deaths concerns to all Trust consultants and remind them of documentation accountabilities and Royal College of Physicians standards.
  Stated by Epsom and St Helier University Hospitals NHS TrustStated completed
AI-generated summary

Rita Taylor · 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

Rita Taylor was admitted to hospital with severe hyponatraemia in the context of diabetes insipidus and a pituitary adenoma, and died on 15 August 2017 after developing central pontine myelinolysis. The principal concerns were failures to appropriately monitor and manage her sodium levels and diabetes insipidus, including omission of desmopressin, inadequate fluid-balance assessment, insufficient documentation, and lack of a coherent management plan.

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 clinical documentation for care continuity
Wider context from the report
“6. The documentation throughout Mrs Taylor’s admission until transfer to the high dependency unit was inadequate with no record of assessment or a coherent management plan in place to ensure appropriate care and continuity of that care for succeeding physicians to consider or to follow. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 5 · 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 meaningful documentation in hospital notes
Wider context from the report
“1. The failure to appropriately manage Mrs Taylor’s hyponatraemia by the on call consultant physician on the 31st July 2017 on the grounds that it was not his sphere of expertise. No contact was considered or made to someone who may have been able to assist leaving Mrs Taylor to languish overnight with no management plan in place and a lack of any meaningful documentation in her hospital notes. ”
Source location
Rita Taylor · Prevention of Future Deaths report
Page 4 · 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
Introduce Care View on the Acute Medical Unit to communicate high-risk patients and their management plans.

Verbatim wording from the response
“Care View, an electronic handover system which allows high risk patients and their management plans to be communicated more effectively is also to be introduced to AMU.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 3 · response
Published 23 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
Review how compliance with the Health Record Content policy is monitored.

Verbatim wording from the response
“Response - The Trust is reviewing how we monitor compliance with our Health Record Content policy which outlines the record keeping standards for Trust staff. There are 14 standards set out within this policy which have been taken from the guidance provided by the Royal College of Physicians. There will be a twice annual audit of the 14 standards set out within the policy which will include an assessment of the requirement to include ‘clear evidence of the arrangements made for future and ongoing care’. The Joint Medical Director and Deputy Chief Executive has also circulated a copy of the concerns raised in the Report to Prevent Future Deaths to all consultants within the Trust and has reminded them of their accountabilities around the documentation of management plans and reminded them of the standards for documentation set by the Royal College of Physicians.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 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
Conduct twice-yearly audits of the 14 Health Record Content policy standards, including arrangements for future and ongoing care.

Verbatim wording from the response
“Response - The Trust is reviewing how we monitor compliance with our Health Record Content policy which outlines the record keeping standards for Trust staff. There are 14 standards set out within this policy which have been taken from the guidance provided by the Royal College of Physicians. There will be a twice annual audit of the 14 standards set out within the policy which will include an assessment of the requirement to include ‘clear evidence of the arrangements made for future and ongoing care’. The Joint Medical Director and Deputy Chief Executive has also circulated a copy of the concerns raised in the Report to Prevent Future Deaths to all consultants within the Trust and has reminded them of their accountabilities around the documentation of management plans and reminded them of the standards for documentation set by the Royal College of Physicians.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 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
Circulate the prevention-of-future-deaths concerns to all Trust consultants and remind them of documentation accountabilities and Royal College of Physicians standards.

Verbatim wording from the response
“Response - The Trust is reviewing how we monitor compliance with our Health Record Content policy which outlines the record keeping standards for Trust staff. There are 14 standards set out within this policy which have been taken from the guidance provided by the Royal College of Physicians. There will be a twice annual audit of the 14 standards set out within the policy which will include an assessment of the requirement to include ‘clear evidence of the arrangements made for future and ongoing care’. The Joint Medical Director and Deputy Chief Executive has also circulated a copy of the concerns raised in the Report to Prevent Future Deaths to all consultants within the Trust and has reminded them of their accountabilities around the documentation of management plans and reminded them of the standards for documentation set by the Royal College of Physicians.”

Source location
2018-0225-Response-by-Epsom-and-St-Helier-University-Hospitals-NHS-Trust
Page 4 · response
Published 23 September 2018
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Inadequate and incomplete record keeping

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 raised4

Failure to record chest examination findings

Delays in recording consultation notes

Failure to record swallow test findings

Failure to record reported non-adherence to lithium medication

Concerns raised1

Poor or non-existent record keeping

Concerns raised1

Failure to document conversations with other clinicians

Concerns raised1

Failure to contemporaneously document needle insertion and withdrawal times and ultrasound fetal heartbeat monitoring time

Concerns raised1

Lack of written guidance on robust recording by first aid staff of patients attended and action taken

Concerns raised2

Insufficient recording and care planning of patient leave, including its rationale, benefits and risks

Failure to document and clearly formulate patient risks in the medical 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

Concerns raised1

Failure to transcribe information provided by patients or families for clinical teams

Concerns raised1

Inadequate availability of nursing records

Concerns raised2

Inadequate clinical documentation for care continuity

Lack of meaningful documentation in hospital 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.4

Actions described in response 1

Actions described in response 5

Actions described in response 4