Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
Not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
- Reports
- 474
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to ensure availability of patient observation 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 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
Implement the Cerner Millennium electronic patient record across the remainder of the hospital.
Stated by Wirral University Teaching Hospital NHS Foundation Trust
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Concerns raised1
Gaps 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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Incomprehensive and inefficient hospital notes
Failure of the electronic system to reveal notes of a previous admission
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The hospital record system links both hospital numbers, while searching with the NHS number displays all associated records.
Stated by Stockport NHS Foundation Trust
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Concerns raised1
Failure to record respiratory and pulse rates
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of adequate records of medication discussions
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.3
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Action
Document the full clinical plan and management in records when starting patients on addictive medication.
Stated by Roundwell Medical Centre -
Action
Conduct six-monthly reviews for patients receiving long-term benzodiazepines or opiates and document the clinical plan and management discussed.
Stated by Roundwell Medical Centre -
Action
Design a bespoke Addictive Medication Review template to ensure reviews are documented and completed correctly.
Stated by Roundwell Medical Centre
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Concerns raised1
Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians
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.
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
A mental health assessor may reasonably reach a different conclusion from the GP because risk changes rapidly and requires current assessment.
Stated by South West London and St George'S Mental Health NHS Trust
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Concerns raised1
Failure to maintain complete, accurate and timely clinical records
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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 appropriately record post-fall checks in clinical 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 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 appropriately record patients’ medical conditions and blood test readings in clinical notes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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Action
Address staff competency in accurate, timely clinical-note recording through supervision and additional training.
Stated by North West Boroughs Healthcare NHS Foundation Trust -
Action
Introduce practitioner-level care-quality-record audits led by ward leadership teams.
Stated by North West Boroughs Healthcare NHS Foundation Trust -
Action
Conduct records audits and re-audits, communicate identified improvements, and action them through team managers.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Action
Circulate Trust-wide Managers Briefing Notes reinforcing clinical information-recording requirements.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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
Existing processes and systems ensure clinical records are maintained in accordance with Trust policies and procedures.
Stated by North West Boroughs Healthcare NHS Foundation Trust
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Concerns raised1
Failure of contemporaneous record keeping to support clinical recollections
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 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.2
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Position
Concerns about the GP’s decisions and actions should be addressed by Pennine Care NHS Trust and York House Surgery.
Stated by Department of Health and Social Care
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Position
NHS England’s Performers Screening Group will determine whether specific action is needed regarding the GP’s clinical behaviour.
Stated by Department of Health and Social Care
Data last updated 7 September 2026