Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
- 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
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 474 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked responses
- Cornwall Partnership NHS Foundation Trust
- Royal Cornwall Hospitals NHS Trust
Stated actions 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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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Review the inter-hospital transfer form to document escalation plans, ensure consistent handover records, and prompt sharing of relevant medical-management details.
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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
Establish a task-and-finish group to review inter-hospital transfer-form design and take forward resulting developments.
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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Cornwall Partnership NHS Foundation Trust and Royal Cornwall Hospitals NHS Trust
A shared handover visible in both Trusts’ electronic systems is impracticable because their electronic patient records have limited interoperability.
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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.
Linked response
- Nursing and Midwifery Council
Stated actions 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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Nursing and Midwifery Council
Continue the fitness-to-practise investigation into the registered nurse and decide whether to progress or close the case for public-protection reasons.
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Nursing and Midwifery Council
Refer concerns about care at Westmorland Court and inaccurate healthcare records to the Employer Link Service and New Referrals team for enquiries.
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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.
Linked response
- Welsh Government
Stated actions 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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Welsh Government
Use ARK medication administration charts with dedicated recording fields for immediate doses and antibiotic administration times.
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Welsh Government
Implement electronic prescribing and medicines administration systems across Welsh hospitals, with timestamped prescribing and administration records and medication task lists.
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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.
Linked response
- Sheffcare
Stated actions 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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Sheffcare
Roll out refresher training on pre-admission assessments, detailed care notes, falls documentation and escalation, using anonymised scenarios and monthly monitoring.
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Sheffcare
Discuss falls, documentation and escalation requirements with staff through huddles, supervision and management briefings.
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Sheffcare
Issue updated guidance and brief managers on completing body maps and photographing injuries or marks.
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Sheffcare
Complete a quality-assurance systems review for linked care plans, risk assessments, falls escalation and care-note updating.
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Sheffcare
Introduce management checks and sampling of the Person-Centred Care system and daily care notes to strengthen record-keeping oversight.
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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.
Linked response
- East Lancashire Hospitals NHS Trust
Stated actions 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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East Lancashire Hospitals NHS Trust
Administer and update medications through Cerner scanners, with senior-nurse observations and governance monitoring of wristband and medication-administration compliance.
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East Lancashire Hospitals NHS Trust
Standardise clinical-risk handovers by using Cerner tasks and embedding Patient e-Obs trend review during nursing handover.
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East Lancashire Hospitals NHS Trust
Enable nursing staff to accompany doctors on ward rounds and use the daily multidisciplinary meeting to escalate concerns and immediate actions.
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East Lancashire Hospitals NHS Trust
Arrange simulation-based deterioration training for community-ward staff, including assessment, escalation, handover, documentation and gastrointestinal-bleeding scenarios.
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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.
Linked response
- Department of Health and Social Care
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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Department of Health and Social Care
The Integrated Care Board is expected to respond to concerns about the specific care provided.
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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.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
Stated actions 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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Barts Health NHS Trust
Deliver an A&E induction programme covering mental capacity, contemporaneous documentation, emergency medicines, sedation and escalation.
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Barts Health NHS Trust
Update ITU induction materials to require contemporaneous documentation or justified retrospective entries.
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Barts Health NHS Trust
Provide staff training on mental-capacity assessment and deprivation-of-liberty safeguards.
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Barts Health NHS Trust
Require on-call consultants to confirm remote access to the electronic healthcare record.
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Barts Health NHS Trust
Update rapid-tranquilisation guidance to require senior, clearly documented decision-making when its criteria cannot be followed.
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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Department of Health and Social Care
The primarily local concerns are for Barts Health NHS Foundation Trust to address.
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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.
Linked response
- Haddon Court Limited
Stated actions 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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Haddon Court Limited
Reinforce accurate record-keeping and require staff to check records after using the software’s repeat functionality.
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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Haddon Court Limited
Existing staff reminders, record-checking practices and other measures are considered robust enough to ensure accurate care records.
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Haddon Court Limited
Further software changes cannot be undertaken directly; the matter has been raised with and can only be influenced through the provider.
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Concerns raised1
Failure of medical records to make important information immediately visible and accessible to relevant clinicians
Linked response
- County Durham and Darlington NHS Foundation Trust
Stated actions 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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County Durham and Darlington NHS Foundation Trust
Convene a multidisciplinary cross-specialty group led by the Chief Pharmacist to review Major (level 2) drug interactions for potential prescriber alerts.
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Concerns raised1
Failure to record the reason for a missed appointment and whether an assessment was undertaken
Linked response
- Cumbria, Northumberland, Tyne and Wear 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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Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
The Trust disputes that a cancelled appointment lacked rationale and says assessment remained within the applicable 18-week timeframe.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026