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 properly record handovers in medical notes
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.
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
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Action
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust -
Action
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS 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
A shared handover visible in both Trusts’ electronic systems is impracticable because their electronic patient records have limited interoperability.
Stated by Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure to maintain reliable 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.
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
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Action
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
Stated by Nursing and Midwifery Council -
Action
Refer concerns about care at Westmorland Court and inaccurate healthcare records to the Employer Link Service and New Referrals team for enquiries.
Stated by Nursing and Midwifery Council
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Concerns raised1
Lack of provision on the Accident & Emergency Record Card to record medication prescription and administration
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.2
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Action
Use ARK medication administration charts with dedicated recording fields for immediate doses and antibiotic administration times.
Stated by Welsh Government -
Action
Implement electronic prescribing and medicines administration systems across Welsh hospitals, with timestamped prescribing and administration records and medication task lists.
Stated by Welsh Government
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Concerns raised1
Failure to fully utilise care notes for recording injuries and incidents
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.5
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Action
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
Stated by Sheffcare -
Action
Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.
Stated by Sheffcare -
Action
Issue updated guidance and brief managers on completing body maps and photographing injuries or marks.
Stated by Sheffcare
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Action
Complete a quality-assurance systems review for linked care plans, risk assessments, falls escalation and care-note updating.
Stated by Sheffcare -
Action
Introduce management checks and sampling of the Person-Centred Care system and daily care notes to strengthen record-keeping oversight.
Stated by Sheffcare
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Concerns raised1
Inadequate nursing records
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.
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
Administer and update medications through Cerner scanners, with senior-nurse observations and governance monitoring of wristband and medication-administration compliance.
Stated by East Lancashire Hospitals NHS Trust -
Action
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
Stated by East Lancashire Hospitals NHS Trust -
Action
Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
Stated by East Lancashire Hospitals NHS Trust
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Action
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
Stated by East Lancashire Hospitals NHS Trust
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Concerns raised2
Delays in recording family-provided clinical timelines
Inaccurate or incomplete discharge summaries failing to record diagnostic uncertainty
This report raised 9 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 Integrated Care Board is expected to respond to concerns about the specific care provided.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to document key clinical decisions and treatment stages contemporaneously
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.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.
Stated by Barts Health NHS Trust -
Action
Update ITU induction materials to require contemporaneous documentation or justified retrospective entries.
Stated by Barts Health NHS Trust -
Action
Provide staff training on mental-capacity assessment and deprivation-of-liberty safeguards.
Stated by Barts Health NHS Trust
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Action
Require on-call consultants to confirm remote access to the electronic healthcare record.
Stated by Barts Health NHS Trust -
Action
Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.
Stated by Barts Health NHS 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
The primarily local concerns are for Barts Health NHS Foundation Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to maintain accurate resident-specific care and dietary 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
Reinforce accurate record-keeping and require staff to check records after using the software’s repeat functionality.
Stated by Haddon Court Limited
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
Existing staff reminders, record-checking practices and other measures are considered robust enough to ensure accurate care records.
Stated by Haddon Court Limited
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Position
Further software changes cannot be undertaken directly; the matter has been raised with and can only be influenced through the provider.
Stated by Haddon Court Limited
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Concerns raised1
Failure of medical records to make important information immediately visible and accessible to relevant clinicians
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
Convene a multidisciplinary cross-specialty group led by the Chief Pharmacist to review Major (level 2) drug interactions for potential prescriber alerts.
Stated by County Durham and Darlington NHS Foundation Trust
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Concerns raised1
Failure to record the reason for a missed appointment and whether an assessment was undertaken
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 Trust disputes that a cancelled appointment lacked rationale and says assessment remained within the applicable 18-week timeframe.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Data last updated 7 September 2026