Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
Not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
- Reports
- 474
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to maintain complete medical records of required checks
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Addition of diagnoses to clinical correspondence without examining the patient
Failure to record consultant assessment and review of clinical results
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record observations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Audit October AMU fall-patient documentation for compliance with neurological observation requirements and identify improvement and support needs.
Stated by Swansea Bay University Local Health Board
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Concerns raised1
Failure to record mandatory monthly care 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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Provide monthly supervision for all care coordinators, covering care-plan delivery, reviews, CPA status and record-keeping, with regular compliance audits.
Stated by East London NHS Foundation Trust -
Action
Review internal monitoring processes to identify gaps in CPA reviews and regular contact.
Stated by East London NHS Foundation Trust -
Action
Provide teams with live activity reports and weekly performance prompts covering CPA patients.
Stated by East London NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
The London Borough of Tower Hamlets is handling formal processes addressing the care coordinator’s conduct, with Trust support.
Stated by East London NHS Foundation Trust
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Position
Implemented CMHT systems are considered sufficient to address concerns about monitoring care coordinators.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to record routine resident checks
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Record residents’ hourly or two-hourly nightly checks on signed night-check sheets.
Stated by Care First Class (UK) Limited -
Action
Monitor staff records and address issues arising from record completion.
Stated by Care First Class (UK) Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Registered Provider remains responsible for ensuring monitoring checks are conducted and accurately recorded.
Stated by Care Quality Commission
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Concerns raised1
Poor record keeping by doctors and nurses
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inaccurate falls-risk documentation
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Audit documentation on service users’ falls and mobility.
Stated by Fairfield View Care Centre -
Action
Audit care plans and daily records daily and weekly for accurate risk assessments and fall documentation.
Stated by Fairfield View Care Centre -
Action
Provide care-planning training covering accurate risk assessments, service-user needs, documentation and involvement in care planning.
Stated by Fairfield View Care Centre
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Concerns raised1
Failure to maintain complete, sufficient and consistent nursing records, handovers, risk assessments and care plans
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to involve and record discussions with the primary surgeon before remounting the valve
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Inadequate record keeping during MDT meetings
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026