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
Distinct published reports
Individual concerns
568
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
780
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.
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
NHS trust265
Healthcare site91
Ministerial department73
Executive non-departmental public body44
Private limited company32
Health and social care service regulator30
Integrated care board26
Type not available24
Local health board21
Residential care home17
Multi-service care provider15
Nursing home15
Health professional body14
Independent healthcare provider12
Coronial office9
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.
Cardiff and the Vale of Glamorgan
Concerns raised1
Failure to keep investigative test and scan results with patients' medical 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 concerns
Each 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
Action
Review systems and processes for storing ECG investigations.
Stated by Cardiff & Vale University LHBStated completedThe respondent said that this action was complete when they made their response on 7 October 2015.
Action
Review ECG machines for MUSE connectivity and improved patient identification.
Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 7 October 2015.
Action
Review MUSE usage and supporting infrastructure capacity for increased ECG activity.
Stated by Cardiff & Vale University LHBStated plannedThe respondent said that this action was planned when they made their response on 7 October 2015.
Blackburn, Hyndburn and Ribble Valley
Concerns raised1
Failure of medical records to sufficiently highlight a previous diagnosis of a potentially life-threatening condition
Responses linked to these concerns
Each 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
Action
Provide GP case summaries through EMIS Web in urgent, emergency and planned admission records.
Stated by East Lancashire Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 30 September 2015.
Action
Pilot daily problem lists to document ongoing clinical concerns during ward rounds and assessments, with evaluation before rollout to other areas.
Stated by East Lancashire Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The records do not substantiate autonomic dysreflexia; autonomic instability is considered the more accurate diagnosis.
Stated by East Lancashire Hospitals NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised2
Failure to record advice on medical treatment and care
Failure of Lakeside Unit clinical notes to identify actions, times and clinicians
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.
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
Action
Direct clinicians to fully record specialist clinical advice, including colleagues’ names, grades and contact details.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
Action
Review the clinical-record audit process and consider policy changes based on audit recommendations.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 September 2015.
Action
Develop a standardised transfer proforma recording medical background, referral reasons and prior discussions for transfer between the Trusts.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 September 2015.
Action
Develop a standardised transfer proforma for inclusion in care records between the two trusts.
Stated by North West Boroughs Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 28 September 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Documenting external referral discussions contemporaneously is difficult because calls occur during clinical duties and patients often lack accessible Trust records.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
The health professional seeking advice is responsible for ensuring a full and accurate record of the clinical advice received.
Stated by Wrightington, Wigan and Leigh Teaching Hospitals NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local providers are responsible for reviewing local systems concerning X-ray reporting, electronic viewing and patient-note recording.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Local-level services are responsible for implementing the recording of clinical information in patient notes.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to record declined interventions
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 concerns
Each 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
Action
Share investigation learning with New Park House and recommend improvements to recording practices.
Stated by Stoke-on-Trent City CouncilStated completedThe respondent said that this action was complete when they made their response on 14 July 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The investigation found no evidence that the pressure-sore management plan was inadequately followed or that records had been falsified.
Stated by Stoke-on-Trent City CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to keep proper and sufficient resident care notes
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.
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
Action
Supervise staff on recording residents’ welfare and monitor records through daily senior-team checks and weekly Home Manager reviews.
Stated by MERIDIAN HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 20 August 2015.
Action
Train staff on care-plan documentation and review care plans after admissions, changes in needs, and at least monthly.
Stated by MERIDIAN HEALTHCARE LIMITEDStated completedThe respondent said that this action was complete when they made their response on 20 August 2015.
Avon
Concerns raised1
Failure to record admission information in computerised Rio notes
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Review Place of Safety staffing levels through the Safer Staffing initiative to support timely observations and information recording.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 24 July 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The RIO entry was made shortly after the incident, although documentation was delayed while staff managed the traumatic incident and debrief.
Stated by Avon and Wiltshire Mental Health Partnership NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester North
Concerns raised1
Incomplete or inaccurate nursing records and associated documentation
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.10
Action
Review Ward T7 documentation against Trust standards and conduct monthly nursing-metrics audits of record keeping.
Stated by Pennine Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2015.
Action
Recruit registered nurses to Ward T7 and provide induction competency observations covering documentation and related clinical tasks.
Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
Action
Conduct weekly Ward T7 documentation audits with immediate feedback on risk assessments, care plans and reassessments.
Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
Action
Implement scenario training on completing the Purpose T tool for early pressure-ulcer detection and management.
Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
Action
Run Nursing Care Indicators audits and respond to reduced results through corrective action.
Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
Action
Use Nursing Metrics across the Trust to audit nursing-documentation quality in case notes.
Stated by Pennine Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 15 July 2015.
Action
Continue developing and governing nursing documentation through the Nursing Documentation Group and Nursing and Midwifery Board, including wider professional documentation.
Stated by Pennine Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2015.
Action
Secure Trust Development Agency support and carry out a Trust-wide documentation standardisation project.
Stated by Pennine Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2015.
Action
Implement the EVOLVE electronic case-note system, beginning with a pilot of nursing assessments, care plans, referrals and specified risk documentation.
Stated by Pennine Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 15 July 2015.
Action
Introduce Ward Accreditation to monitor ward-team nursing-care quality, including record keeping and patient assessments.
Stated by Pennine Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 July 2015.
Manchester North
Concerns raised1
Failure to document discharge risk-factor assessments in clinical 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.
Manchester South
Concerns raised1
Failure to maintain complete and accessible medical and nursing records
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.
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
Action
Maintain and use a hospital-wide documentation standards audit, recording variances and sharing results through peer review.
Stated by BMI The Alexandra HospitalStated completedThe respondent said that this action was complete when they made their response on 7 August 2015.
Action
Complete hospital-wide training on documentation and the legal aspects of patient records.
Stated by BMI The Alexandra HospitalStated in progressThe respondent said that this action was in progress when they made their response on 7 August 2015.
Action
Deliver education sessions to clinical staff on completing patient care pathways.
Stated by BMI The Alexandra HospitalStated plannedThe respondent said that this action was planned when they made their response on 7 August 2015.
Action
Deliver Royal College of Nursing presentations to nursing staff on documentation standards.
Stated by BMI The Alexandra HospitalStated plannedThe respondent said that this action was planned when they made their response on 7 August 2015.
Action
Notify relevant nursing staff that notes must record observations taken after patients are removed from oxygen.
Stated by BMI The Alexandra HospitalStated plannedThe respondent said that this action was planned when they made their response on 7 August 2015.
Brighton and Hove
Concerns raised2
Failure to complete clinical notes
Failure to record nursing observations and NEWS
This report raised 17 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Introduce integrated documentation for all clinical staff treating patients on Twineham ward.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 June 2015.
Action
Develop and deliver a Twineham ward training package on accurate documentation and the consequences of poor documentation.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 June 2015.
Action
Strengthen senior medical review requirements, including consultant reviews, daily review of sick patients, junior attendance and documentation of discussions.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 June 2015.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
