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.

29 Jan2015
Manchester South
Concerns raised1
1. Failure to provide the doctor with access to the complete computerised system
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

John Michael Matthews · 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 Michael Matthews died from natural causes, with the medical cause recorded as aspiration pneumonia associated with haemorrhagic hydrocephalus and spontaneous subarachnoid haemorrhage. Concerns included triage without the ambulance Patient Report Form, a locum doctor’s inability to access the complete computerised system, failure to institute neurological observations, and an unnecessary and partly unexplained delay in obtaining a head CT scan.

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 provide the doctor with access to the complete computerised system
Wider context from the report
“2. The doctor having care of him in the E.D. was a locum doctor working his first (and only) shift at the hospital. That doctor told me that he could not find the PRF nor could he access the complete computerised system. ”
Source location
John Michael Matthews · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Jan2015
Surrey
Concerns raised1
1. Inadequacy of nursing records
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

Susanna Geraty · 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

Susanna Geraty, a previously fit and well 75-year-old woman, died after developing acute renal failure and hyperkalaemic cardiac arrest five days after surgery for a fractured tibia and fibula. The principal concerns were inadequate assessment, monitoring and recording of postoperative fluid balance, failure to respond promptly to family concerns or recognise her deteriorating condition, and an investigation report’s failure to consider dehydration as a possible cause of the acute renal failure.

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
Inadequacy of nursing records
Wider context from the report
“2. Inadequate nursing records ”
Source location
Susanna Geraty · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Jan2015
West Yorkshire (Western)
Concerns raised2
1. Failure to make accurate and complete doctors’ records
2. Failure to make complete and accurate 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

Phillip Roy 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

Phillip Roy Smith was diagnosed with a likely pancreatic carcinoma and underwent a percutaneous transhepatic cholangiogram with external drain insertion. He deteriorated overnight with severe pain, vomiting and a subsequent cardiac arrest, and died in intensive care on 15 March 2014 after treatment was withdrawn. The concerns included missing nursing and doctors’ records, undocumented observations, medication, blood gas results and fall details, and the junior doctor’s decision not to seek additional senior support despite concerns about Mr. Smith’s deterioration.

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 make accurate and complete doctors’ records
Wider context from the report
“(2) Standard of Doctors’ Records i) Junior Doctor’s involvement – neither the junior or middle grade doctors who reviewed Mr. Smith in the early hours of the 15th March 2014 made accurate records of their review and assessment of Mr. Smith. ii) Blood gasses assessment was undertaken by the junior doctor on his attendance around 1.30 a.m. but no record was made of this. ”
Source location
Phillip Roy Smith · 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 make complete and accurate nursing records
Wider context from the report
“(1) The Standard of Nursing Records i) On the evening of the 14th March 2014 observation were repeated 30 minutes after the standard observations were undertaken, but no record was made of these repeat observations. ii) Mr. Smith declined his evening medications, but this was not recorded. iii) Mr. Smith was given Tramadol at around 1.00 a.m. on the morning of the 15th March but this was not recorded. iv) Mr. Smith was found laid on the floor beside his bed in the early hours of the 15th March but full details of this event was not made by the nursing staff on duty. ”
Source location
Phillip Roy Smith · Prevention of Future Deaths report
Page 3 · concerns
Open source report
8 Jan2015
Manchester South
Concerns raised1
1. Failure to retrieve the correct resident file
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

George Hulme · 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

On 25 June 2014, George Hulme was assaulted by another resident at Bamford Grange Nursing Home, collapsed and required CPR. The wrong resident file, which recorded a DNR, was retrieved after he was incorrectly identified, and CPR ceased; concerns included inadequate resident identification systems, induction and room labelling for agency staff and emergency responders.

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 retrieve the correct resident file
Wider context from the report
“3) An incorrect file was retrieved resulting in a potentially inappropriate treatment of an unconscious resident. ”
Source location
George Hulme · Prevention of Future Deaths report
Page 1 · concerns
Open source report
22 Dec2014
Gateshead and South Tyneside
Concerns raised1
1. Failure to accurately record incidents affecting residents’ care and management
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

EDWIN THOMPSON · 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

Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and 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 accurately record incidents affecting residents’ care and management
Wider context from the report
“The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents. The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard. Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers. ”
Source location
EDWIN THOMPSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Dec2014
Manchester South
Concerns raised1
1. Failure to complete care notes contemporaneously with visits
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 1
1. Action
  Communicate expectations to all staff that repositioning documentation must be completed after each episode of care.
  Stated by Sunrise Senior Living UKStated completed
AI-generated summary

RHYS TUDOR WILLIAMS · 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

On 3 March 2014, RHYS TUDOR WILLIAMS was put to bed at Sunrise Senior Living and was found deceased between his bed and the wall at 1.40 am. The report raised concerns about inadequate staff training, incorrect bed positioning, failure to apply bed brakes, insufficient staffing and communication, pre-completed care notes, and possible delays in calling an ambulance.

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 complete care notes contemporaneously with visits
Wider context from the report
“8. Care notes were completed for the full period of the night shift of the 3rd to the 4th March 2014, at the beginning of that shift, i.e. before the visits had actually taken place. This was clearly unacceptable. Has anything been put in place to prevent this happening in the future? ”
Source location
RHYS TUDOR WILLIAMS · 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
Communicate expectations to all staff that repositioning documentation must be completed after each episode of care.

Verbatim wording from the response
“Repositioning charts used in the company are clear in that they require the team to complete once an episode of care has been given. The Director of Operations disclosed immediately and without request, prior to external scrutiny, that there appeared to be breach of process regarding this particular care note discrepancy. The individuals responsible were suspended, interviewed formally and the responsible person dismissed once this breach of process was confirmed. A communication has been sent to all staff outlining clearly the expectations of Sunrise when completing these forms.”

Source location
2014-0558-Response-by-Sunrise-Senior-Living
Page 3 · response
Published 15 December 2014
Open published response
5 Dec2014
Brighton and Hove
Concerns raised1
1. Poor documentation of referral-management decisions
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 1
1. Action
  Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
AI-generated summary

Paul Leslie HYDE · 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

Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

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 documentation of referral-management decisions
Wider context from the report
“(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”
Source location
Paul Leslie HYDE · 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
Extend the Breach Tool to record and monitor every referral, pending contact and triage outcome, with updated guidance and staff instruction.

Verbatim wording from the response
“The use of the Breach Tool has been extended and the system is now more robust. Medical Personal Assistants now complete this for all referrals, regardless of the triage decision. Team leads have oversight of the tool and it is a ‘live’ record of all pending contacts, whether by telephone or face to face with service users. All actions / outcomes from the clinical triage meetings are now recorded on the Breach Tool and these are closely monitored. The Breach Tool guidance has been reviewed and staff have received clear instruction on how to use the tool.”

Source location
2014-0527-Response-by-Sussex-Partnership-NHS
Page 1 · response
Published 5 December 2014
Open published response
24 Nov2014
North and West Cumbria
Concerns raised1
1. Lack of formal recording of sudden clinical interactions
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 4
1. Action
  Implement an electronic system to record details of advice provided to healthcare professionals at other hospitals.
  Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completed
2. Action
  Ensure the Cardiothoracic Surgical Team consistently uses the electronic system for external requests for medical opinions.
  Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completed
3. Action
  Include electronic-system recording requirements in the induction programme for newly recruited and rotating staff.
  Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated completed
1. Action
  Further develop the recording system to prompt documentation of key items, including radiological images viewed when providing an opinion.
  Stated by the Newcastle Upon Tyne Hospitals NHS Foundation TrustStated in progress
AI-generated summary

William Walter 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

William Walter Jackson was diagnosed with severe aortic disease and underwent aortic valve and ascending-aorta replacement surgery in June 2013. After becoming unwell in August, a CT scan showed haemorrhage in the descending aorta, but the report did not identify features of a contained rupture; he died on 4 September 2013. The concerns included the lack of a formal record of advice from the Freeman Hospital, uncertainty about whether the CT images were reviewed, and the potential risk to patients from how such advice was given.

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 formal recording of sudden clinical interactions
Wider context from the report
“(1) The CIC records showed that an A&E doctor had spoken to a Specialist Cardio Thoracic Registrar at the Freeman Hospital. Inquiries of the Freeman showed that there was no record/ recollection of this contact. (2) I understand there is no system at the Freeman to formally record sudden interactions. This means no traceable record and no means by which the Freeman doctor could be identified let alone recall the advice given. (3) The advice appears to have been given without the Freeman doctor actually seeing the CT scan. Has the images been reviewed it is possible that the true state of the deceased’s health would have been ascertained. (4) Independent of the issue of an enquiry being able to establish what advice was given at the time; there is a risk that the way such advice appears to have been given could place patients lives at risk. ”
Source location
William Walter Jackson · 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 an electronic system to record details of advice provided to healthcare professionals at other hospitals.

Verbatim wording from the response
“(i) Actions already taken:”

Source location
2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014
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
Ensure the Cardiothoracic Surgical Team consistently uses the electronic system for external requests for medical opinions.

Verbatim wording from the response
“• An electronic system is now in place within Cardiothoracic Surgery to record details of advice given when medical opinion is sought by a healthcare professional in another hospital.”

Source location
2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014
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 electronic-system recording requirements in the induction programme for newly recruited and rotating staff.

Verbatim wording from the response
“(ii) Further planned actions:”

Source location
2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014
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
Further develop the recording system to prompt documentation of key items, including radiological images viewed when providing an opinion.

Verbatim wording from the response
“(ii) Further planned actions:”

Source location
2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
Page 2 · response
Published 24 November 2014
Open published response
17 Nov2014
Manchester South
Concerns raised1
1. Failure to adequately record essential patient care in medical and nursing notes
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review current record-keeping training to reinforce clarity and completeness.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
2. Action
  Develop and pilot integrated health records across specialties to improve information sharing and prevent loss of vital information.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progress
AI-generated summary

Elsie Mallalie u · 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

Mrs Elsie Mallaliu fell at home on 12 August 2013, broke her hip, was admitted to hospital, and died four days later. The report raised concerns that she was moved to an inappropriate ward, where staff were not trained to use her high-flow oxygen, records and observations were inadequate, staffing pressures affected care, and antibiotics were not administered because the drip was not turned on. It also stated that she was considered “written off”, that a DNAR should not have been placed, and that escalation to ITU/HDU might have allowed treatment of the infection that led to her 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 adequately record essential patient care in medical and nursing notes
Wider context from the report
“3. The medical and nursing notes on ward 41 were woefully inadequate, and failed to record some of the most basic care which was, or ought to have been, given. ”
Source location
Elsie Mallalie u · 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
Review current record-keeping training to reinforce clarity and completeness.

Verbatim wording from the response
“Response The Trust’s internal investigation identified deficiencies in the record keeping in this case and is undertaking a review of its current training on record keeping standards. Such training will reinforce the need for clarity and completeness.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014
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
Develop and pilot integrated health records across specialties to improve information sharing and prevent loss of vital information.

Verbatim wording from the response
“There is also a proposal for integrated health records and for a pilot project to take place for each specialty within the Trust. A task and finish group is currently exploring this but to date ITU, Outreach and AMU began trialling integrated notes in November 2014. Integrated health records are now standard across most Trusts and should safeguard against vital information being lost as well as having a more universal and systematic approach to sharing information. Overall, it will provide a more transparent and robust approach throughout the Trust.”

Source location
2014-0501-Response-by-Tameside-Hospital-NHS-Trust
Page 2 · response
Published 17 November 2014
Open published response
31 Oct2014
Brighton and Hove
Concerns raised2
1. Failure to complete initial N.E.W.S. scoring
2. Failure to complete initial A & E assessment documentation
This report raised 13 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
  Continue educating staff to avoid inappropriate terminology describing patients’ condition on Emergency Department arrival.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
2. Action
  Provide further documentation training through departmental nurse induction and nurse development training days.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
3. Action
  Conduct regular audits to ensure Short Stay Ward and Clinical Decisions Unit proformas are used correctly.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
AI-generated summary

Maureen Annette ELLETT · 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

The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

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 complete initial N.E.W.S. scoring
Wider context from the report
“(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet. Acopia was recorded as the main diagnosis. None of the early A & E paperwork was completed. The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed. No Admission bloods were taken and in this respect there is no protocol or guidance concerning: a) that bloods should be taken when patients are admitted to A & E by Ambulance or b) who should take these bloods. ”
Source location
Maureen Annette ELLETT · 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 complete initial A & E assessment documentation
Wider context from the report
“(1) Initial A & E paperwork was flawed as no blood pressure or Glasgow Coma scales were recorded on the front sheet. Acopia was recorded as the main diagnosis. None of the early A & E paperwork was completed. The N.E.W.S. score from the first set of observations taken on arrival at A & E was not completed. No Admission bloods were taken and in this respect there is no protocol or guidance concerning: a) that bloods should be taken when patients are admitted to A & E by Ambulance or b) who should take these bloods. ”
Source location
Maureen Annette ELLETT · 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
Continue educating staff to avoid inappropriate terminology describing patients’ condition on Emergency Department arrival.

Verbatim wording from the response
“1. We agree that there were shortcomings in the record keeping when Mrs Ellett first arrived in the Emergency Dept. Since then, several changes have been made. Agreement has been reached with the South East Coast Ambulance NHS foundation Trust (SECAMB) that they will start calculating National Early Warning Scores (NEWS) and the triage nurse will note this when the patient arrives. We agree that the phrase is inappropriate and misleading, and should not be used to describe the condition of a patient on arrival to the Emergency department. We are continuing to educate staff about avoiding this term, while recognizing that it may be used by other people outside this Trust.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 1 · response
Published 31 October 2014
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
Provide further documentation training through departmental nurse induction and nurse development training days.

Verbatim wording from the response
“4. We have established that the triage nurse to whom you refer handed over to her colleague starting the next shift that there were several outstanding assessments to be completed and documented for Mrs Ellett. We deeply regret that this next member of staff, who had newly come on duty, did not complete these tasks as he should have done. We have not been able to take this up with him in the light of your comments as he had already left the Trust before Mrs Ellett’s inquest took place. Arrangements have been made for further training on documentation to be included in both the departmental nurse induction programme and also in the nurse development training days held in the department.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 2 · response
Published 31 October 2014
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 regular audits to ensure Short Stay Ward and Clinical Decisions Unit proformas are used correctly.

Verbatim wording from the response
“The nursing and medical staff in the Emergency Department, as well as the locum staff involved in the care of Mrs Ellett, and we ourselves have taken very seriously all the issues you have raised, and changes have been made to improve different aspects of the quality of care. As an over-arching step, individual named emergency consultants have recently been given responsibility for each of the Short Stay Ward and Clinical Decisions Unit, in order to provide visible senior medical leadership in each area and to seek ways of improving the quality of care. This will include regular audit to ensure proformas are being used correctly.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 4 · response
Published 31 October 2014
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
The failure to countersign the initial observations was considered a documentation oversight without adverse effect on clinical assessment.

Verbatim wording from the response
“10. The observations policy requires trained staff to review and countersign the findings, if taking the observations has been delegated to a health care assistant, however experienced that health care assistant may be. The agency staff nurse gave evidence to you that she had reviewed the first set of observations taken on the CDU and satisfied herself that the NEWS score was zero. What she failed to do, and acknowledged she should have done, was to countersign to indicate that she had carried out this check. We do not believe this documentation oversight at 21.55 had any adverse effect on Mrs Ellett’s clinical assessment, but we appreciate - as does the agency nurse herself - that detailed documentation of this kind is nevertheless important.”

Source location
2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
Page 4 · response
Published 31 October 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to provide the doctor with access to the complete computerised system

Concerns raised1

Inadequacy of nursing records

Concerns raised2

Failure to make accurate and complete doctors’ records

Failure to make complete and accurate nursing records

Concerns raised1

Failure to retrieve the correct resident file

Concerns raised1

Failure to accurately record incidents affecting residents’ care and management

Concerns raised1

Failure to complete care notes contemporaneously with visits

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 raised1

Poor documentation of referral-management decisions

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 raised1

Lack of formal recording of sudden clinical interactions

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

Concerns raised1

Failure to adequately record essential patient care in medical and nursing 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

Concerns raised2

Failure to complete initial N.E.W.S. scoring

Failure to complete initial A & E assessment documentation

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

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

Actions described in response 1

Actions described in response 1

Actions described in response 4

Actions described in response 2

Actions described in response 3

Respondent positions 1