Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

First to latest report 13 Dec 2008 — 26 Jun 2026

Reports that mention this concern
474
Times this concern has been raised
568
Stated actions linked to this concern
780

What this concern includes

Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.

What is 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 and published responses 474 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Exeter & Great Devon

    AI-generated summary

    Polly Elisabeth Jane CARPENTER · 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

    Polly Elisabeth Jane Carpenter, who had a history of psychotic depression and repeated suicide attempts, left an inpatient psychiatric unit on 5 May 2011 and deliberately sat on a railway track, where she was struck by a train and died. The concerns included weaknesses in recording risk assessments, observations and nurse allocation, limited staff awareness of current risk, and inadequate security of unit windows, which contributed to her absconding.

    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 maintain a permanent record of nursing tasks performed

    Wider context from the report

    “(4) The decision not to formally record levels of observations and nurse allocation to do them on the RIO record remains a cause for concern. From the Evidence heard it is quite clear there can be no audit of a system which is not routinely recorded and some participants remain worryingly vague about the tasks they may/may not have performed. This does not support the view that being in hospital means that a regular robust system of care and attention is given to patients who desperately need the help for which they have been admitted. It is hoped that provision of a permanent record, would allow a culture of individual responsibility to flourish in the minds of all the nursing staff, so patients are looked after in the fullest sense of the word. ”

    Source location

    Polly Elisabeth Jane CARPENTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Surrey

    AI-generated summary

    Chrylin Angela Maria Norrell-Goldsmith · 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

    Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

    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 retain complete primary source data within the Phoenix Programme

    Wider context from the report

    “3. Retention of Primary Source Data within the Phoenix Programme Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One record. ”

    Source location

    Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Manchester South

    AI-generated summary

    Agnes Mary Hannan · 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

    Agnes Mary Hannan, who had autoimmune hepatitis with cirrhosis, attended Tameside General Hospital several times with severe abdominal pain before being admitted. She was diagnosed with Superior Mesenteric Vein Thrombosis causing bowel infarction and died on 21 September 2013. The report identified concerns about delayed diagnosis, inadequate monitoring and hydration, poor communication and handover, incomplete records, lack of multidisciplinary involvement, and insufficient communication with her family about her condition and end-of-life care.

    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

    Use of unexplained initials and abbreviations in hospital notes

    Wider context from the report

    “5. Throughout the hospital notes for this patient, there is widespread use of initials and abbreviations. On at least one occasion in court, none of the medical/nursing staff present could explain to me what the abbreviation in the notes meant. ”

    Source location

    Agnes Mary Hannan · 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

    Inadequacy of medical and nursing notes

    Wider context from the report

    “3. There was extremely poor communication between hospital staff and the patient (and her family), and between and amongst hospital staff. There was evidence of a lack of handover between staff, and this was exacerbated by the fact that the medical and nursing notes were frequently inadequate. ”

    Source location

    Agnes Mary Hannan · 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 record-keeping training to reinforce communication, careful handover and avoidance of unclear abbreviations.

    Verbatim wording from the response

    “Response The Trust promotes safe handover of patient care by providing protected time, to enable handover of all relevant patient information, both at the beginning and end of shifts. The Trust is currently undertaking a review of its current training on record keeping standards which will include an emphasis on the importance of good communication between staff and the importance of careful handover.”

    Source location

    2014-0573-Response-by-Tameside-Hospital-NHS-Trust
    Page 2 · response
    Published 27 October 2014

    Open published response

  4. Manchester South

    AI-generated summary

    Mark Hancock · 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

    Mark Hancock had a history of severe clinical depression and was receiving treatment at the Priory Hospital. On 12 February 2014, he was found at his parents’ house with serious self-inflicted wounds after concerns about his deteriorating presentation had been escalated but hospital admission did not occur because no bed was available. The report identified concerns about poor or absent records, the lack of a documented risk assessment, insufficient reassessment after concerns were escalated, and the absence of a procedure for admission when no bed was available.

    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 maintain a complete, accessible multidisciplinary patient record

    Wider context from the report

    “- The quality of the records kept in relation to the deceased was poor and in some circumstances non-existent. No records were kept of the Multi-Disciplinary Team Meetings. - The Consultant notes were brief and are not kept on the Care Notes system. Such a diverse practice means that there is no overall record of a patient so that all those who have involvement with a patient do not have all relevant, pertinent information available to them. ”

    Source location

    Mark Hancock · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Sunderland

    AI-generated summary

    Leonard Henry Hudson · 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

    Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

    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 nursing and care-record documentation

    Wider context from the report

    “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted. Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor. Mr Hudson ought to have been referred to the foot protection team in a more timely manner. The nursing documentation was not as comprehensive as it ought to have been. The classification of Mr Hudson’s heel injuries was “variable”. From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: - 1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this; 2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist; 3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis; 4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy; 5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; 6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding. However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention. I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths. ”

    Source location

    Leonard Henry Hudson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. West London

    AI-generated summary

    Brian Christopher Dalrymple · 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

    Brian Christopher Dalrymple died at Colnbrook Immigration Removal Centre on 31 July 2011 after a fatal rupture associated with extreme hypertension, which he declined to have treated and monitored for most of his detention. The report raised concerns that indicators of his deteriorating mental health were not recognised or communicated to healthcare staff, that medical practitioners lacked necessary knowledge, that medical visits to segregated detainees were inadequate, and that clinical records were not comprehensive or accessible.

    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

    Absence of a comprehensive and accessible computerised clinical record for each detainee

    Wider context from the report

    “(5) The absence of a comprehensive and accessible (computerised) clinical record relating to each detainee at IRCs Harmondsworth and Colnbrook. ”

    Source location

    Brian Christopher Dalrymple · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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

    No practicable steps can be taken concerning Harmondsworth working practices because management responsibility transferred to Mitie.

    Verbatim wording from the response

    “As the Contract for the management of Harmondsworth IRC passed to Mitie on 01st September 2014, there is of course no practicable steps GEO can take in relation to the working practices at Harmondsworth.”

    Source location

    2014-0410-Response-by-The-GEO-Group-UK-Ltd
    Page 1 · response
    Published 18 September 2014

    Open published response

  7. Manchester South

    AI-generated summary

    Joyce Nelson · 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

    Joyce Nelson fell at home on 7 March 2014 and fractured her pelvis in several places. The report raises concerns about delays in medical assessment, documentation and imaging results at the Emergency Department, and that she was to be discharged despite having a multi-fractured pelvis; it states that the delays were linked to reported shortages of emergency medicine doctors and radiologists.

    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 imaging results

    Wider context from the report

    “2. Chest and hip X-rays were carried out but the results were not documented by the doctor who was simply too busy to do so. ”

    Source location

    Joyce Nelson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  8. Inner North London

    AI-generated summary

    Thomas Charles 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

    Thomas Charles Taylor, a diabetic man aged 54, died in the Royal Free Hospital after a delay in administering insulin following the loss of his medical notes and drug chart. Concerns included unclear ward leadership, the absence of a protocol for lost notes and drug charts, inadequate escalation when blood sugar checks were refused, and delayed clinical monitoring after significant hyperglycaemia.

    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

    Delays and lack of focus in locating missing clinical records

    Wider context from the report

    “2. There was no protocol for the loss of notes and drug chart. Attempts by the ward staff to locate these were not prompt, focused or sustained. The notes and chart were later found simply in a drawer on the ward. ”

    Source location

    Thomas Charles TAYLOR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Inner North London

    AI-generated summary

    Irshad ALI · 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

    Irshad Ali was admitted to hospital for drainage of ascites, fell unwitnessed on the ward on 25 March 2014, and later returned with a massive head injury. He died six weeks later following a consequent chest infection. Concerns included missing records of intentional rounding and neurological observations, required pre-discharge checks not being completed, and communication problems around his discharge.

    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 intentional rounding checks

    Wider context from the report

    “1. The nursing staff should have checked on Mr Ali every two hours through the night, but there was no record of intentional rounding on 24/25 March. There was a record of the night before and a record of the night after, but not the night that Mr Ali fell. The chart appears to have gone missing. ”

    Source location

    Irshad ALI · 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

    Conduct monthly senior nursing audits of medical-record filing, with spot checks of intentional-rounding compliance and correct filing.

    Verbatim wording from the response

    “During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 29 August 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

    Intentional rounding occurred despite the missing chart, which resulted from medical notes being filed incorrectly.

    Verbatim wording from the response

    “During the investigation, senior qualified nursing staff contacted the nurse allocated to care for Mr Ali on the night of 24/15 March 2014, who confirmed that the intentional rounding did take place. The intentional rounding chart for this night remains missing. Evidence has been adduced that this is because the medical notes had been filed incorrectly. This will be dealt with by a monthly senior nursing audit of the integrity of the filing of patients’ notes and spot checks for intentional rounding compliance and correct filing of medical notes.”

    Source location

    2014-0387-Response-by-Barts-Health-NHS-Trust
    Page 1 · response
    Published 29 August 2014

    Open published response

  10. Brighton and Hove

    AI-generated summary

    MARTIN ARNOLD HILL · 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

    MARTIN ARNOLD HILL arrived at A & E on 28 March 2014 after approximately three days of confusion, abdominal pain and vomiting, with raised inflammatory markers. The concerns included delayed antibiotics, failures to refer him to the Critical Care Outreach Team when his NEWS was elevated, inadequate withdrawal treatment, failures in managing constipation, poor handover and communication, and serious omissions in the Medical Administration Record.

    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 maintain accurate clinical notes

    Wider context from the report

    “(4) When Mr. HILL arrived in A & E it was found that he was suffering from constipation with impacted faeces in his bowel. He was written up for an enema and the Doctor who saw him directed that he should be given laxatives. The latter were never written up for him and the former was never given. In the event, careful study of the notes showed that he opened his bowels for the first time on the evening of the 28th March 2014 but this information was not apparently noted by the Doctors who were still talking about constipation over the next 24 – 36 hours. This shows poor patient handover and poor communication between the shifts and poor note taking. ”

    Source location

    MARTIN ARNOLD HILL · Prevention of Future Deaths report
    Page 2 · 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 maintain complete and legible Medical Administration Records

    Wider context from the report

    “(5) There are serious omissions on the Medical Administration Record. I was told that it was believed that no Senior Pharmacist reviewed the MAR charts over a weekend. Given the importance of medicating patients correctly, it would seem advisable that there should be a review, if indeed it is the practice that records are not reviewed. It seems that in this particular case the charts are particularly poorly written and perhaps those involved with this patient would benefit from a discussion with the Chief Pharmacist. ”

    Source location

    MARTIN ARNOLD HILL · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026