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
Poor recording of vomiting episodes
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 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
Complete a root cause analysis investigation into the failures concerning doctor contact, vomiting records, and family communication.
Stated by the Dudley Group NHS Foundation Trust
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Concerns raised1
Inaccurate and incomplete nursing notes and falls records
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.
Stated by Swansea Bay University Local Health Board
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Concerns raised2
Failure to record clinically relevant discussions and diagnostic information in medical notes
Failure to record clinical attendance and examination in medical notes
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.
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
Brief all medical staff on the requirement to record patient events completely and contemporaneously in medical records.
Stated by Barts Health NHS Trust
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Concerns raised1
Failure to record the rationale and patient consent for a change of GP
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Require providers to document discussions and information received from residents, record potential changes in care plans and clinical systems, and update records promptly.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board -
Action
Contact care homes to recommend policies and documentation standards for staff signing on behalf of residents who can consent but cannot physically sign.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board -
Action
Issue standard practice application forms to membership practices, including a section for signing on behalf of another person.
Stated by NHS Leicester, Leicestershire and Rutland Integrated Care Board
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Action
Require care homes to confirm patients’ awareness, consent and appropriate next-of-kin notification when capable residents change GP practice.
Stated by Northfield Medical Centre
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
There is usually no need to record the rationale for changing a patient's registered GP in the medical record.
Stated by Hazelmere Medical Centre
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Position
Care homes are responsible for confirming patient awareness, consent and, where appropriate, next-of-kin notification when facilitating GP practice changes.
Stated by Northfield Medical Centre
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Concerns raised1
Failure to record objections to sharing confidential medical information
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.
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
Require Care Coordinators to assess risk-based information sharing with Personal Assistants and document this in wellbeing care plans.
Stated by Pennine Care NHS Foundation Trust -
Action
Disseminate and deliver a briefing on Personal Assistant involvement in care planning and information-sharing records.
Stated by Pennine Care NHS Foundation Trust -
Action
Discuss adding Personal Assistant care-planning and information-sharing guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
Stated by Pennine Care NHS Foundation Trust
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Concerns raised1
Failure to effectively use Read Codes to flag significant patient-care risk factors
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 concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Deliver refresher training so CNWL staff can use SystmOne risk indicators and set the high-risk icon on patient records.
Stated by Central and North West London NHS Foundation Trust -
Action
Review SystmOne use across Surrey sites and make it a standing item in local Clinical Quality Meetings.
Stated by Central and North West London NHS Foundation Trust -
Action
Develop a SystmOne training package covering system functionality and READ codes, and incorporate homepage login requirements into the Standard Operating Procedure.
Stated by Central and North West London NHS Foundation Trust
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Concerns raised1
Failure to sign and date handwritten clinical notes
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 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, infrequent, disjointed and incomplete clinical record keeping
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to complete turning charts
This report raised 15 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
Failings in 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026