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. Liverpool

    AI-generated summary

    Charles Gavin BRADLEY · 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

    Charles Gavin Bradley fell unwitnessed in the Assessment Unit at Arrowe Park Hospital on 21 February 2013 and sustained head injuries that proved fatal. The investigation and inquest identified inadequate record-keeping and communications, including failures concerning his transfer and unclear recording of the fall.

    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 of transfer communications and record-keeping

    Wider context from the report

    “During the investigation and inquest into Mr Bradley’s death it was found that the record-keeping and communications at Arrowe Park Hospital were inadequate, ineffective making them unsafe. This was evidenced by findings that though Leeds Teaching Hospital had effective records as to the arrangements for the transfer of Mr Bradley to Arrowe Park on the 21st February 2013, when Mr Bradley arrived at Arrowe Park they were not expecting him. This is likely to have caused added worry and stress to his rehabilitation plan. It is further evidenced by the inadequate recording of his fall on the 21st February 2013. From the evidence it was unclear as to whether it was witnessed or not, was it in a bathroom and if so why was there mention of a filing cabinet near he lay? In other cases the matters reported could result in fatalities. Documentation, recordkeeping and communications are core basic skills for all who work in healthcare. Neither the HEALTH aspect nor the CARE aspect of a health care service can be delivered without these basic skills. It would be helpful to see a cross Trust action plan with regard to the improving documentation, record-keeping and communication in the response to this report ”

    Source location

    Charles Gavin BRADLEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. London (West)

    AI-generated summary

    Neil James Carter · 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

    Neil James Carter took his own life on 20 November 2012 by jumping in front of a train while he was an inpatient at Priory Hospital Roehampton. The report identified repeated failures to perform basic nursing observations, inadequate staffing and skill mix, poor ward layout and discipline, management failures, and deliberate falsification of the nursing record. The inquest concluded that these failures led to missed opportunities to realise he was missing, search for him early, and offer life-saving interventions.

    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

    Deliberate falsification of nursing records

    Wider context from the report

    “(3) There was a deliberate falsification of the nursing record. ”

    Source location

    Neil James Carter · 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

    Use information about alleged nursing-record falsification to inform planning and delivery of the next inspection.

    Verbatim wording from the response

    “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 8 · response
    Published 5 March 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

    No evidence of deliberate nursing-record falsification was identified during inspections.

    Verbatim wording from the response

    “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 8 · response
    Published 5 March 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

    Deliberate record falsification is difficult to identify through routine monitoring or inspections unless reported by staff, patients or relatives.

    Verbatim wording from the response

    “The Commission has seen no evidence of deliberate falsification during the course of our inspections. It is extremely worrying that such evidence was presented. It is also a very difficult thing for the Commission to identify either in regular monitoring or at an inspection visit unless it had been brought to our attention by staff, patients or relatives. Nevertheless, this information will inform the planning and delivery of the next inspection visit of The Priory Hospital Roehampton.”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 8 · response
    Published 5 March 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

    Alleged deliberate record falsification may require referral to the relevant professional regulatory body, such as the NMC or GMC.

    Verbatim wording from the response

    “The Commission would also respectfully suggest that if it has not been done so already this may be a matter which would require referral to the relevant professional regulatory body, whether NMC, GMC or otherwise.”

    Source location

    2014-0103-Response-by-Care-Quality-Commission
    Page 8 · response
    Published 5 March 2014

    Open published response

  3. Avon

    AI-generated summary

    Ms. Kimberley Parsons · 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

    Ms. Kimberley Parsons, who had a history of mental health problems and suicidal ideation, was found hanging in her room at Sycamore Ward on 16 March 2014 after repeated self-harm during her admission. She was transferred to intensive care but died from her injuries on 24 March 2014. Concerns included serious patient-safety deficiencies at Hillview Lodge, including incomplete observation records, shortcomings in resuscitation equipment and training, and deficiencies in care planning and pathways for patients with emotionally unstable personality disorder.

    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 proposed treatment discussions

    Wider context from the report

    “(1) The suggestion made to Ms. Parsons, a person with a history of self-harming and who remained at high risk of self-harming, that she could be assisted with self-harming was not an approach to patient care and treatment which was supported by any reference to the results of any research published in a peer-reviewed professional journal. Therefore if this is a bona fide approach to treatment in a high risk patient then the Trust should be able to justify that this is a recognised and generally accepted practice by reference to the published literature and/or results of published research. (2) If the Trust cannot provide evidence to support this treatment being a recognised and generally accepted practice then the Trust must establish proper procedures for the introduction and use of novel treatments including the obtaining of any necessary ethical approvals. (3) This discussion with regard to ‘assisted self-harming’ was not discussed by the nurse with the consultant psychiatrist nor was any record made of the discussion. The Trust should undertake a proper review of any training with respect to these matters so as to ensure any discussions with regard to proposed treatment are had with the full knowledge and agreement of the consultant in charge and that those discussions are properly recorded. ”

    Source location

    Ms. Kimberley Parsons · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    Stephen John PALMER · 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

    Stephen John Palmer’s death was the subject of an inquest, but the supplied text does not describe the circumstances of the death. Principal concerns included delays in assessment and review, inappropriate transfer to an Acute Medical Unit, failure to recognise deterioration, suboptimal clinical management, inadequate preparation and arrangements for urgent surgery, and failure of the CT scanning service.

    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 ward round documentation

    Wider context from the report

    “(7) There was a completely inadequate Ward Round Note made at the hurried ward round between 08:30 and 08:40 hours. This left the Nursing Staff in the Acute Medical Unit unable to look after this surgical patient efficiently. ”

    Source location

    Stephen John PALMER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. North Northumberland

    AI-generated summary

    Jack Basil Lynn · 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

    Jack Basil Lynn, who lived alone and received daily care visits, was found unresponsive at home on 15 October 2013 after a morning visit during which the carer did not check his wellbeing. The concerns were that there was no continuous medication communication sheet and that no safety or wellbeing check was made during the allocated visit, creating a potential risk to future residents despite the inquest finding that Mr Lynn died from natural causes.

    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 medication communication sheet as a continuous record of medications

    Wider context from the report

    “Arrangements put in place for daily prompting with medication did not include keeping a medication communication sheet at Mr Lynn’s home address as a continuous record of his medications. This would have allowed for a more reliable check by visiting carers or family members as it would have clearly indicated whether medications were being taken regularly. ”

    Source location

    Jack Basil Lynn · 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

    Encourage clients to keep medication charts in communication folders and advise on the requirement where carers provide medication-related services.

    Verbatim wording from the response

    “We will encourage all of our clients to have medication charts in their communication folder and in the case of not wishing to have one we will advise that if a carer is involved in any service concerning medication it is company policy to have them in the folder.”

    Source location

    2014-0066-Response-by-Nightingales-Home-Help-Service
    Page 1 · response
    Published 18 February 2014

    Open published response

  6. Surrey

    AI-generated summary

    Keith Ronald Martin · 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

    Keith Ronald Martin attended A&E with chest pain and left-arm tingling, but there were delays in triage, investigations, treatment and senior review. He later deteriorated with a myocardial infarction, was transferred for emergency treatment, and died after the infarction was described as incompatible with life. The concerns included failure to appreciate and act promptly on his symptoms and raised troponin, unclear chest-pain management protocols, and inadequate documentation.

    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 effective clinical documentation

    Wider context from the report

    “9. An overall lack of effective documentation ”

    Source location

    Keith Ronald Martin · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Surrey

    AI-generated summary

    Lillian Rose Robinson · 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

    Lillian Rose Robinson was admitted to Brockhurst Care Home, transferred to Upper Halliford nursing home after deteriorating, and died from bronchopneumonia on 28 December 2012. The substantive concerns were communication about mental-capacity assessments, unqualified carers evaluating capacity in patients with mild or moderate dementia, and poor note-taking and continuity of 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

    Poor note taking in patient care records

    Wider context from the report

    “Poor note taking and continuity of patient care notes ”

    Source location

    Lillian Rose Robinson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Gwent

    AI-generated summary

    DESGRAE REGINA TUCKER · 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

    Desgrae Regina Tucker was admitted with abdominal pain, underwent gall bladder removal surgery, was discharged home, and died at home six days later. Concerns included inadequate recording and consideration of anti-embolic stockings and no anti-coagulant medication being prescribed on 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

    Lack of recording of anti-embolic stocking use in patient notes

    Wider context from the report

    “(1) The lack of recording in the patient's notes as to whether the patient was wearing the anti-embolic stockings prescribed. (2) No consideration given as to whether the patient should be discharged home with anti-embolic stockings. (3) No anti-coagulant medication prescribed to the patient upon discharge. ”

    Source location

    DESGRAE REGINA TUCKER · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  9. Berkshire

    AI-generated summary

    Mrs Nutbeam · 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 Nutbeam was struck by a car and later underwent debridement surgery for an infected leg wound. She vomited and aspirated during the procedure and subsequently died; the principal concerns were failures to transfer information about her vomiting between hospitals and to record or communicate vomiting symptoms before surgery, together with whether pre-operative questioning should routinely address recent vomiting.

    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 vomiting symptoms in nursing notes

    Wider context from the report

    “(2) Despite clear evidence from the family that Mrs Nutbeam was vomiting on the ward shortly before her debridement procedure, there is no reference in the nursing notes and this information was not made known to the Anaesthetist nor Surgeon. The fact that she was vomiting prior to a surgical procedure should have been a matter of serious concern. ”

    Source location

    Mrs Nutbeam · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester South

    AI-generated summary

    Barbara White · 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

    Barbara White presented to Tameside Hospital with symptoms consistent with biliary colic, deteriorated after 9 December 2012, and died on 2 January 2013 despite intensive care intervention. Concerns included a 12-hour lack of clinical and nursing observations, an incorrectly recorded PARS score, staff shortages and inadequate escalation, and insufficient handover information about outstanding investigations.

    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 sufficient information in medical records after staff handover

    Wider context from the report

    “4. There was a lack of information in the patient’s medical records following the handover from the day staff to the night staff. Following the review of Mrs White on the 9th December when further tests had been requested there was a lack of any further clinical consideration and no escalation to a consultant. At the Inquest I heard evidence from Dr ████████ who was the SHO on duty during the night and who had received the handover from the day staff. Her evidence was that she had no recollection of Mrs White being mentioned at the handover and was unaware that there were outstanding investigations. ”

    Source location

    Barbara White · 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 accurately record PARS scores

    Wider context from the report

    “2. At 6 am Mrs White’s PARS score was recorded as 2 when this should have been 5 which if correctly recorded would have led to medical intervention. ”

    Source location

    Barbara White · Prevention of Future Deaths report
    Page 1 · 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