Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

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First reported 13 Dec 2008•Latest report 26 Jun 2026

Definition

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

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care64

NHS England38

Care Quality Commission30

NHS Greater Manchester Integrated Care Board12

University Hospitals Sussex NHS Foundation Trust11

Essex Partnership University NHS Foundation Trust10

Greater Manchester Mental Health NHS Foundation Trust10

Stockport NHS Foundation Trust10

Tameside and Glossop Integrated Care NHS Foundation Trust10

Office of the Chief Coroner9

Recipient name withheld9

Sussex Partnership NHS Foundation Trust9

Barts Health NHS Trust8

East London NHS Foundation Trust8

Manchester University NHS Foundation Trust8

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.

1 May2024
Manchester South
Concerns raised1
1. Failure to document consultant clinical discussions
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Use an amended ICU daily review chart with a dedicated microbiology input section and documented real-time multidisciplinary decisions.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completed
Respondent positions 2
1. Position
  The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Existing consultant assignment and electronic patient-record processes are considered sufficient to coordinate multidisciplinary discussions and continuity of care.
  Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Jordan George James Fogg Howarth · 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

Jordan George James Fogg Howarth, a fit and healthy 25-year-old, was admitted to hospital on 3 April 2023 with an unexplained and deteriorating condition. He was not escalated for critical care review as required, and although a later review identified that he needed urgent ICU admission, this was delayed; he suffered a cardiac arrest on 6 April 2023 and could not be resuscitated. The principal concerns included inadequate coordination and continuity of care, failure to follow escalation policy, insufficient documentation of clinical decisions, and a lack of multidisciplinary discussion.

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 consultant clinical discussions
Wider context from the report
“2. In relation to ICU the evidence before the inquest was that the Critical Care Outreach Practitioner had identified that Jordan needed to be moved to ICU urgently. This view had then to be ratified by the ICU Consultant if he was to be accepted into ICU. There was no documentation from the ICU consultant setting out their rationale for not examining Jordan at that point and for declining to admit him at that point. All the documentation was in the Critical Care Practitioner’s notes. There was no evidence of any discussions between the medical consultant and the ICU consultant about the decision in the clinical notes. 3. The trust policy was that anyone who had a NEWS2 score of 5 and no ceiling of care should be referred to the CC Outreach team. The inquest heard evidence that this was not followed on a number of occasions and the fact it had been missed was not identified by more senior members of the nursing team. 4. The inquest heard oral evidence of conversations that it was told had taken place between consultants in a number of specialisms about Jordan. These were not documented in his notes. ”
Source location
Jordan George James Fogg Howarth · 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
Use an amended ICU daily review chart with a dedicated microbiology input section and documented real-time multidisciplinary decisions.

Verbatim wording from the response
“In response to this particular point the ICU team have updated and amended the daily review chart to include a specific section for microbiology input. All patients on ITU are”

Source location
Response from Tameside and Glossop Integrated Care
Page 1 · response
Published 9 May 2024
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
The hospital is responsible for considering the operational concerns and reporting the actions and improvements it will take.

Verbatim wording from the response
“Most of these issues are operational in nature and I note that you have rightly sent your report to the hospital in question (Tameside General Hospital). It will be important that they consider these issues and findings fully and write to you with the actions and improvements they will be taking to address your findings and prevent a recurrence of what happened to Mr Howarth.”

Source location
Response from Department of Health and Social Care
Page 2 · response
Published 9 May 2024
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
Existing consultant assignment and electronic patient-record processes are considered sufficient to coordinate multidisciplinary discussions and continuity of care.

Verbatim wording from the response
“The Trust follow the General Medical Council (GMC) guidance that supports the recommendation, that every patient admitted to hospital will have a named, identifiable clinician assigned to them. This will help to make sure care is properly coordinated. Mr Howarth’s care was reviewed by several consultants during his admission: ISGU ████████ each discussed and referred this gentleman’s care to other specialisms as required.”

Source location
Response from Tameside and Glossop Integrated Care
Page 5 · response
Published 9 May 2024
Open published response
25 Apr2024
Leicester City and South Leicestershire
Concerns raised1
1. Lack of documentation explaining or justifying care plan deviations
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Ash BANNISTER · 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

Ash Bannister, a 16-year-old who was gender neutral, died in a residential care home on 7 August 2021 after being found hanging. Principal concerns included the removal of Ash’s personal Ligature Risk Assessment without documented reasons, inadequate documentation and communication, inconsistent waking-night cover, failure to follow the support plan, staff training gaps, and an investigation process described as not fit for purpose.

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 documentation explaining or justifying care plan deviations
Wider context from the report
“I heard evidence to confirm there was no documentation created by United Children’s Services to detail the date on which Ash’s Ligature Risk Assessment was deemed to be no longer required or to explain the rationale behind the making of that decision. There is no documentation to explain or justify the deviation from Ash’s care plan on the morning that Ash died. Further, the Court heard evidence to confirm that there was little or no communication of Ash’s historic Child Sexual Exploitation risk between the two United Children’s Services care homes when Ash moved from The Oaks to The Laurels in July 2020. Lack of documentation and poor communication is a concern. ”
Source location
Ash BANNISTER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Apr2024
Swansea and Neath Port Talbot
Concerns raised1
1. Failure to record s.12 doctors’ assessment outcomes when patients are not admitted
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.
  Stated by Swansea CouncilStated planned
2. Action
  Discuss with the Health Board the requirement for doctors to record their views and conclusions on the AMHP assessment form.
  Stated by Swansea CouncilStated in progress
Respondent positions 3
1. Position
  Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.
  Stated by Swansea CouncilOutside remit
1. Position
  SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.
  Stated by Swansea CouncilRedirects responsibility
2. Position
  Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.
  Stated by Welsh GovernmentRedirects responsibility
AI-generated summary

Nicholas Kim Harrison · 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

Nicholas Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.

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 s.12 doctors’ assessment outcomes when patients are not admitted
Wider context from the report
“It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur. ”
Source location
Nicholas Kim Harrison · Prevention of Future Deaths report
Page 4 · 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
Amend the AMHP assessment form to capture consultation views, reasons for non-consultation, earlier analysis, and doctors' individual views and detention-criteria conclusions.

Verbatim wording from the response
“vi. The AMHP assessment form is to be updated to include an additional section for the recording of the views of relevant others or reasons for not consulting with them, and AMHPs are to be directed/instructed to complete this section in as much detail as possible.”

Source location
Response from City and County of Swansea
Page 4 · response
Published 9 May 2024
Open published response
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
Discuss with the Health Board the requirement for doctors to record their views and conclusions on the AMHP assessment form.

Verbatim wording from the response
“xi. The AMHP assessment form is to be amended so that the section referencing the doctors involved in the assessment process prompts the detailed recording of the doctors' individual views as to the individual's case and criteria for detention. The Council's Head of Adult Services has opened dialogue with Swansea Bay University Health Board's (hereafter "SBUHB") Service Group Director of Mental Health and Learning Disabilities with regard to the requirement for doctors to record their views/conclusions on the AMHP assessment form.”

Source location
Response from City and County of Swansea
Page 4 · response
Published 9 May 2024
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
Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.

Verbatim wording from the response
“It is not within the Council's remit to respond to all of the matters of concern set out by His Majesty's Coroner in the Report, and it is appropriate that the Council responds to the first and second matters of concern. I shall address each in turn:”

Source location
Response from City and County of Swansea
Page 1 · response
Published 9 May 2024
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
SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.

Verbatim wording from the response
“This is a matter of concern for SBUHB and NHS Wales to primarily address, but the Council wishes to comment specifically in relation to access to its systems by Section 12 doctors.”

Source location
Response from City and County of Swansea
Page 5 · response
Published 9 May 2024
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
Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.

Verbatim wording from the response
“I note the report has been sent to the UHB and the City and County of Swansea for a response and action and I expect them to provide responses within your timescale that address the concerns raised. I am issuing a separate Welsh Government response to ensure lines of accountability are clear. I take the concerns raised in the report very seriously and I would like to set out the actions being taken.”

Source location
Response from Welsh Government
Page 1 · response
Published 9 May 2024
Open published response
17 Apr2024
Northumberland
Concerns raised1
1. Inaccurate recording of cannula events and siting in medical records
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Audit Ward 1 cannula care-plan compliance to identify documentation gaps.
  Stated by Northumbria Healthcare NHS Foundation TrustStated completed
2. Action
  Highlight cannula documentation requirements and difficult-access escalation at ward safety huddles.
  Stated by Northumbria Healthcare NHS Foundation TrustStated planned
3. Action
  Establish a clearer escalation process for staff managing difficult intravenous access.
  Stated by Northumbria Healthcare NHS Foundation TrustStated planned
1. Action
  Conduct weekly reaudits of cannula care-plan documentation to drive improvement.
  Stated by Northumbria Healthcare NHS Foundation TrustStated in progress
2. Action
  Create a Trust safety message covering difficult access, cannula documentation, partial-dose recording and eMeds amendments.
  Stated by Northumbria Healthcare NHS Foundation TrustStated in progress
3. Action
  Disseminate the safety message and videos Trustwide through multiple media, the intranet, email bulletin and digital newsletter.
  Stated by Northumbria Healthcare NHS Foundation TrustStated planned
AI-generated summary

Eleanor Smith Deceased · 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

Eleanor Smith suffered an unwitnessed fall, sustaining a left femoral neck fracture, and underwent surgical repair. She developed an infection postoperatively and died in hospital on 24 September 2023. The principal concerns were a significant delay in administering intravenous antibiotics, whether the antibiotics were effectively administered, and whether the medical records accurately documented cannula placement and medication administration.

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
Inaccurate recording of cannula events and siting in medical records
Wider context from the report
“1. It was the concern of the family throughout the investigation that there was a delay in the administration of IV antibiotics and the antibiotics were not administered effectively. The Trust accepted that there was a significant delay in the administration of antibiotics of a period of 24 hours but that it was unlikely that the delay affected the outcome. The family gave evidence that they were present until around 21.00 hours on 23 September 2023 and described difficulties experienced by staff on 23 September 2023 in the siting of a canula. There was an attempt for the canula to be placed in one arm, then the other and was eventually sited in the foot. It was the position of Trust that from 17.56 hours on 23 September 2023 there was a working cannula and prescribed medication was administered. I accepted the evidence of the family and I am concerned that the medical records did not accurately record the events and siting of the canula. I am further concerned as to whether prescribed medication on this occasion being antibiotics were effectively administered and what checks there are to ensure the effective administration of medicines. ”
Source location
Eleanor Smith Deceased · Prevention of Future Deaths report
Page 3 · 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
Audit Ward 1 cannula care-plan compliance to identify documentation gaps.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
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
Highlight cannula documentation requirements and difficult-access escalation at ward safety huddles.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
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
Establish a clearer escalation process for staff managing difficult intravenous access.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
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 weekly reaudits of cannula care-plan documentation to drive improvement.

Verbatim wording from the response
“This suggests regular use of the care plans but does not provide assurance that all cannulas are being correctly documented. We therefore conducted a one-day point prevalence audit of Ward 1 to assess compliance on 12 May 2024. The audit showed that on the day in question only 58% of patients with a cannula had a fully completed and up to date care plan. We have put an action plan in place to address this on Ward 1 and across the Trust. The action plan includes highlighting the issue at the ward safety huddles, a clearer escalation process for staff in the event of difficult intravenous access and weekly reaudit to drive improvement.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
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
Create a Trust safety message covering difficult access, cannula documentation, partial-dose recording and eMeds amendments.

Verbatim wording from the response
“We are in the process of creating a safety message (see attached text and video) that will highlight:”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
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
Disseminate the safety message and videos Trustwide through multiple media, the intranet, email bulletin and digital newsletter.

Verbatim wording from the response
“The safety message and videos will be disseminated Trustwide via multiple media platforms, along with being shared on the Trust's intranet site and will also be sent to all staff by way of an email bulletin and on the communication digital newsletter. This will be sent separate to the normal safety message processes.”

Source location
Response from Northumbria Healthcare
Page 3 · response
Published 29 April 2024
Open published response
2 Apr2024
South Yorkshire (Eastern)
Concerns raised1
1. Poor and inconsistent clinical record keeping on the ward
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Implement two behaviour charts in frailty areas, make them readily identifiable for multidisciplinary review, and audit completion.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completed
2. Action
  Train frailty teams to use and complete the new behaviour charts.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated completed
3. Action
  Roll out behaviour-chart training across the Trust.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated planned
1. Action
  Audit use of the Nerve Centre documentation mechanism.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated planned
2. Action
  Audit referral, multidisciplinary review-visit, and outcome documentation quarterly.
  Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation TrustStated planned
AI-generated summary

Robert Fuller · 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

Robert Fuller was admitted to Doncaster Royal Infirmary with increased confusion and later suffered an assault by another patient, causing him to fall and sustain a traumatic brain bleed. He subsequently deteriorated and died on 22 July 2022; the inquest concluded that he died from natural causes, with pathology confirming that the assault-related injuries did not cause or contribute to his death. Concerns included poor record keeping, inadequate communication with the family after the incident, and the lack of a system for agency staff to access and communicate reminders, policies and procedures.

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 and inconsistent clinical record keeping on the ward
Wider context from the report
“1. There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded. There was either no or poor documentation of other professionals entering the ward and evaluating patients, and the outcome of such assessments not being recorded. Some of the documentation was also described as not fit for purpose within the frailty unit due to the needs of the patients. This insufficient record keeping prevented any patterns of challenging behaviour to be assessed and managed accordingly putting other patients, staff and visitors at risk of harm. ”
Source location
Robert Fuller · 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
Implement two behaviour charts in frailty areas, make them readily identifiable for multidisciplinary review, and audit completion.

Verbatim wording from the response
“In April 2024, we reviewed and implemented two new behaviour charts in our frailty areas.”

Source location
Response from DBTH
Page 2 · response
Published 4 April 2024
Open published response
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
Train frailty teams to use and complete the new behaviour charts.

Verbatim wording from the response
“The Trust’s Person Centred Care Practitioner and Named Practitioner Safety in Care have carried out training on the use of and completion of the charts for our frailty teams. There is a plan to roll this out Trust-wide over the course of the upcoming year.”

Source location
Response from DBTH
Page 2 · response
Published 4 April 2024
Open published response
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
Roll out behaviour-chart training across the Trust.

Verbatim wording from the response
“The Trust’s Person Centred Care Practitioner and Named Practitioner Safety in Care have carried out training on the use of and completion of the charts for our frailty teams. There is a plan to roll this out Trust-wide over the course of the upcoming year.”

Source location
Response from DBTH
Page 2 · response
Published 4 April 2024
Open published response
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
Audit use of the Nerve Centre documentation mechanism.

Verbatim wording from the response
“Within our Trust, we use Nerve Centre for documentation. There have been challenges to our external colleagues being able to access Nerve Centre and therefore unable to record entries in the patient’s electronic notes. I am able to assure you this has now been rectified and the older persons’ mental health team (OPMH) and mental health liaison (MHL) teams are able to record entries alongside Trust staff. This improves the Multi-Disciplinary Team’s ability to see other entries on a patient care record and aids communication. An audit of”

Source location
Response from DBTH
Page 2 · response
Published 4 April 2024
Open published response
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
Audit referral, multidisciplinary review-visit, and outcome documentation quarterly.

Verbatim wording from the response
“Further measures include staff recording referrals and subsequent visits by the MDT members in our clinical notes. Record keeping is a Trust priority under the Patient Safety Incident Response framework. Additionally care planning and documentation is a strategic priority within the Trust Nursing Midwifery and AHP Quality Strategy. A quarterly audit is scheduled in relation to the referral documentation, review visits by external professionals and documentation of the process and outcome by our Ward Team on a quarterly basis.”

Source location
Response from DBTH
Page 3 · response
Published 4 April 2024
Open published response
6 Mar2024
Herefordshire
Concerns raised1
1. Deficiencies in the quality and completion of residence care documentation
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Support senior care staff through weekly documentation discussions and regularly review and audit resident notes.
  Stated by Credenhill Court Rest HomeStated completed
2. Action
  Advance-email weekly ward-round resident lists to the GP surgery and record visiting clinicians’ actions in care plans.
  Stated by Credenhill Court Rest HomeStated completed
3. Action
  Implement written daily handover sheets and add completed handovers to residents’ daily records.
  Stated by Credenhill Court Rest HomeStated completed
1. Action
  Review and audit care plans monthly or when required.
  Stated by Credenhill Court Rest HomeStated completed
2. Action
  Carry out daily audits of written daily notes and continue supporting staff to maintain documentation quality.
  Stated by Credenhill Court Rest HomeStated planned
AI-generated summary

John Patrick MacGREGOR · 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

John Patrick MacGREGOR fell at a care home on 2 April 2023 and was not admitted to hospital until 13 April 2023, by which time he was profoundly unwell. He was treated for a hydropneumothorax, fractures and infection, but deteriorated and was placed on an end-of-life pathway; concerns included the quality and completion of care-home documentation and procedures for escalation or non-escalation after a 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
Deficiencies in the quality and completion of residence care documentation
Wider context from the report
“Evidence was heard regarding: (a) The quality of residence care documentation and its completion. (b) Procedures regarding escalation or non-escalation following a fall and subsequent medical intervention ”
Source location
John Patrick MacGREGOR · 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
Support senior care staff through weekly documentation discussions and regularly review and audit resident notes.

Verbatim wording from the response
“• Senior care staff have been supported through weekly discussions to ensure they are confident in documenting the needs of each resident, they are able to capture everything on a day to day basis and any concerns raised are being addressed and documented. The notes are being regularly reviewed and audited.”

Source location
Response from Credenhill Court
Page 1 · response
Published 14 March 2024
Open published response
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
Advance-email weekly ward-round resident lists to the GP surgery and record visiting clinicians’ actions in care plans.

Verbatim wording from the response
“• I have reviewed our weekly ward round and a list of residents that need to be seen are emailed to the GP surgery 24 hours in advance. Once the residents have been seen we now receive a record of actions taken by the GP/ECP that visited. These actions are then added to the individual resident’s health notes within their care plan and any omissions can be identified.”

Source location
Response from Credenhill Court
Page 1 · response
Published 14 March 2024
Open published response
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
Implement written daily handover sheets and add completed handovers to residents’ daily records.

Verbatim wording from the response
“• In addition to our verbal handover and residents information board on display to all care staff in the office, to facilitate and capture more extensive notes for the daily records we have implemented a written daily handover sheet that care staff will complete and this will then be added to each residents daily records.”

Source location
Response from Credenhill Court
Page 2 · response
Published 14 March 2024
Open published response
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 and audit care plans monthly or when required.

Verbatim wording from the response
“• Care plans continue to be regularly reviewed and audited monthly or when required.”

Source location
Response from Credenhill Court
Page 2 · response
Published 14 March 2024
Open published response
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
Carry out daily audits of written daily notes and continue supporting staff to maintain documentation quality.

Verbatim wording from the response
“• I will carry out daily audits of the daily notes that have been written and continue to support staff to ensure that the quality of our written documentation is upheld.”

Source location
Response from Credenhill Court
Page 2 · response
Published 14 March 2024
Open published response
29 Feb2024
Nottinghamshire
Concerns raised1
1. Failure of clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Conduct and share monthly care-planning audits to identify and correct discrepancies.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
2. Action
  Develop and pilot ward safety huddles before rolling them out across adult mental health wards.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
3. Action
  Move adult mental health inpatient care planning to the Dialog+ tool.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
1. Action
  Review and update risk and safety forms and audits to reflect current guidance.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
2. Action
  Ratify the updated Clinical Risk and Safety Policy incorporating current risk-assessment and safety-planning guidance.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
3. Action
  Launch and evaluate an improved multidisciplinary-team record template for risk-assessment and care-planning discussions.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
AI-generated summary

Daniel Mark Edward 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

Daniel Mark Edward Tucker was detained under the Mental Health Act and admitted to hospital following self-harm and suicidal thoughts, but was discharged on 22 April 2022 despite ongoing concerns about his mental state and risk. He ingested a lethal quantity of a substance later that evening and died. The report identifies concerns about risk assessment and care planning, named-nurse allocation, staff skills in engaging patients, emergency response to confirmed ingestion, and the accessibility of online suicide forums.

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 clinical and nursing staff to complete and utilise ward-specific risk assessments and care plans
Wider context from the report
“1. A continuing practice/culture of minimising the importance of a ward specific risk assessment and care plan I am concerned that, notwithstanding the existence of a clear, appropriate policy and significant commendable actions by the Trust since Daniel’s death to address this issue, there remain clinical and nursing staff who do not fully recognise or accept the importance of completing and utilising the required risk assessment and care plan. This suggests there may be a persisting training or cultural issue. The inquest heard evidence that there was (and remains) a clear and robust policy in place which most staff were aware of. This requires a care plan and risk assessment be initiated upon a patient’s admission, completed within 72 hours of admission and updated as necessary during admission. Further, since Dan’s death, the Trust has gone to considerable and commendable lengths to ensure that care plans and risk assessments are in place in every case and to reinforce the requirements of this guidance within the Nursing team; that team hold primary (but not sole) responsibility for creating and updating the risk assessment and care plan document. I also heard that a recent audit found that all current patients had an appropriate care plan in place. The Ward Manager agreed this is “a basic and fundamental part” of any patient’s care. In spite of all of this, an experienced ward nurse and two psychiatrists (a consultant and a registrar) involved in Dan’s care seemed to minimise the practical importance of the required process and documentation, the latter both suggesting they would not routinely consult it. ”
Source location
Daniel Mark Edward TUCKER · Prevention of Future Deaths report
Page 3 · 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 and share monthly care-planning audits to identify and correct discrepancies.

Verbatim wording from the response
“The Trust expectation remains that care plans and risk assessments are individualised and fully updated following the 72-hour assessment period. Throughout a person’s admission care plans and risk assessments are expected to be kept contemporaneous and accessible to all staff to support a patients care. At the inquest evidence was provided about how an improvement in care planning had been demonstrated and the oversight of this is a continual process to ensure this is maintained. A monthly audit is completed which is shared within”

Source location
Response from Nottinghamshire Healthcare
Page 1 · response
Published 6 March 2024
Open published response
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
Develop and pilot ward safety huddles before rolling them out across adult mental health wards.

Verbatim wording from the response
“Regarding risk assessments this is also a feature of the rapid improvement work with clear emphasis in the understanding of risk within the clinical areas. A key element of this is the introduction of safety huddles which is within the pilot stage within AMH before roll out to all wards. These safety huddles support the team to reflect on the dynamic risks within the ward ensuring risk is well understood and shared amongst the team to ensure effective robust plans are in place.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 6 March 2024
Open published response
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
Move adult mental health inpatient care planning to the Dialog+ tool.

Verbatim wording from the response
“The oversight of care planning is a feature of the Trust rapid improvement programme. This is a Trust board supported priority focus to improve the quality within adult mental health (AMH) service inpatients wards. With regards care planning the emphasis of this work has been the engagement of our patients regarding their experience of care planning. Secondly the Trust is looking to move to an alternative care planning tool through the Dialog+ model. This is an evidence-based tool which has received positive feedback in their evaluations. AMH’s Head of Nursing colleagues are heavily involved in supporting the implementation plans. Additionally, an allocated worker model is in the implementation phased at Highbury Hospital.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 6 March 2024
Open published response
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 and update risk and safety forms and audits to reflect current guidance.

Verbatim wording from the response
“Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. Nottinghamshire Healthcare’s Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope good practice and share learning. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified early May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 6 March 2024
Open published response
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
Ratify the updated Clinical Risk and Safety Policy incorporating current risk-assessment and safety-planning guidance.

Verbatim wording from the response
“Trust guidance relating to risk assessment, formulation and safety planning has been reviewed in line with NICE guidelines and the latest updates from NHSE and suicide prevention evidence and literature. Nottinghamshire Healthcare’s Trust Lead for Self-harm and Suicide Prevention is leading this work and has met with NHSE and other leaders in suicide prevention to scope good practice and share learning. Updated guidance is reflected in the Trust’s new Clinical Risk and Safety Policy (due to be ratified early May 2024) and guidance documents relating to psychosocial assessment, formulation, and safety planning in relation to suicidality, including self-harm have been developed.”

Source location
Response from Nottinghamshire Healthcare
Page 2 · response
Published 6 March 2024
Open published response
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
Launch and evaluate an improved multidisciplinary-team record template for risk-assessment and care-planning discussions.

Verbatim wording from the response
“The need for clear risk assessment and care planning lead to the review of MDT records and an improved template to capture discussions and plans in a more meaningful manner has been completed by AMH Clinical Directors. This has been launched and is due for full evaluation in July 2024.”

Source location
Response from Nottinghamshire Healthcare
Page 3 · response
Published 6 March 2024
Open published response
28 Feb2024
Essex
Concerns raised1
1. Failure to record medication tapering regimes in clinical notes
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
2. Action
  Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.
  Stated by Mid and South Essex NHS Foundation TrustStated completed
3. Action
  Conduct a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.
  Stated by NHS EnglandStated planned
Respondent positions 1
1. Position
  Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Chloe Anne Tapp · 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

Chloe Anne Tapp, a 20-year-old with epilepsy and other medical conditions, suffered seizures and respiratory and cardiac arrest on 7 October 2021 and died in hospital on 8 October 2021. The principal concerns included delays transferring her to adult neurology, a telephone consultation despite her being non-verbal, an incorrect and inadequately documented medication tapering regime, and unanswered attempts to obtain clarification. Broader concerns were raised about staffing shortages, unsafe backlogs and difficulties responding to patients and carers within the neurology department.

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 medication tapering regimes in clinical notes
Wider context from the report
“No note was made of the tapering regime for the medication change in Chloe’s notes. ”
Source location
Chloe Anne Tapp · Prevention of Future Deaths report
Page 3 · 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
Communicate and reinforce the requirement that medication tapering regimes are recorded in notes and scanned into electronic patient records.

Verbatim wording from the response
“It is our usual practice to record tapering regimes in patient notes, and this is the expected standard as set out in our clinical record keeping standards policy. The regime was recorded in the letter to Chloe’s GP dated 8 September 2021, however the related table drawn up by the Consultant should have been included in Chloe’s notes.”

Source location
Response from Mid and South Essex NHS
Page 2 · response
Published 6 March 2024
Open published response
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
Audit neurology clinic records for record-keeping compliance and conduct quarterly reviews for divisional governance assurance.

Verbatim wording from the response
“To ensure adherence to the expected standards we have completed an audit of neurology clinic records during February and March 2024.The results of this audit showed overall good compliance with dictation, headers, footers, and onward referrals. Small deviations that were picked up were fed back to the team and actioned. Audit reviews will continue quarterly to provide assurance to the divisional governance meeting. These are in addition to the Trust wide record keeping audits.”

Source location
Response from Mid and South Essex NHS
Page 3 · response
Published 6 March 2024
Open published response
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 a GIRFT review visit to Mid and South Essex NHS Foundation Trust’s neurology department.

Verbatim wording from the response
“Having considered your Report and the concerns raised, a GIRFT visit to Mid and South Essex NHS Foundation Trust has been arranged to review the specific situation within their Neurology department.”

Source location
Response from NHS England
Page 2 · response
Published 6 March 2024
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
Many concerns about Chloe’s care fall within the NHS Foundation Trust’s remit rather than NHS England’s national programme or policy remit.

Verbatim wording from the response
“In your Report you raise concerns over pressures being placed on neurology departments and that there was a recognised shortage of neurologists amid an increase in demand. This response focuses on the concerns raised relevant to NHS England national programme or policy. Many of your concerns around the quality of care delivered to Chloe sit within the remit of Mid and South Essex NHS Foundation Trust, and I note that you have also addressed your Report to them.”

Source location
Response from NHS England
Page 1 · response
Published 6 March 2024
Open published response
26 Feb2024
West Sussex, Brighton and Hove
Concerns raised2
1. Failure to maintain timely and sufficient clinical notes of events and treatment
2. Failure to identify when clinical notes are based on assumption rather than first-hand knowledge
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Disseminate accurate, contemporaneous record-keeping requirements through maternity, Trust-wide, professional, governance and board communications.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Require the labour ward coordinator to check staff documentation completion during shift checkout.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
3. Action
  Complete an audit assessing retrospective entries and maternity record-keeping quality and prevalence.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
1. Action
  Continue retrospective-entry and maternity-record audits through the service annual audit plan.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
AI-generated summary

Alissa Claire NORTON · 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

Alissa Claire Norton died on 22 April 2022 at Royal Sussex County Hospital from hypoxic ischaemic encephalopathy caused by chorioamnionitis to which she was exposed before birth. The report raises concerns that most notes about her events and treatment were completed retrospectively, with limited contemporaneous documentation and some entries based on assumption rather than first-hand knowledge.

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 timely and sufficient clinical notes of events and treatment
Wider context from the report
“2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter. 3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her. 4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the notes. ”
Source location
Alissa Claire NORTON · 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 identify when clinical notes are based on assumption rather than first-hand knowledge
Wider context from the report
“2. The evidence that I heard was that the majority of the notes which were adduced in evidence as to the events and treatment of Alissa were completed retrospectively on the next day (19 April 2022) by the midwife who cared for Mrs Norton. There were very limited notes completed by the midwife caring for Alissa at the time or at any time thereafter. 3. Therefore, there was limited documented information available to treating clinicians following Alissa’s birth as to the events and treatment which had been provided to her. 4. The inquest heard that some of the notes completed retrospectively were based on assumption rather than first hand knowledge. This was not clear in the notes. ”
Source location
Alissa Claire NORTON · 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
Disseminate accurate, contemporaneous record-keeping requirements through maternity, Trust-wide, professional, governance and board communications.

Verbatim wording from the response
“1. Sharing of a ‘message of the week’ within maternity on 4th March 2024 and a global message to all Trust staff on 5th April 2024 regarding the importance of accurate and contemporaneous record keeping, adhering to the Nursing and Midwifery Council (NMC) and General Medical Council (GMC) codes of conduct.”

Source location
Response from University Hospitals Sussex
Page 1 · response
Published 28 February 2024
Open published response
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
Require the labour ward coordinator to check staff documentation completion during shift checkout.

Verbatim wording from the response
“4. Action as part of the shift ‘check out’ that the labour ward coordinator checks that all staff have completed their documentation before leaving the shift.”

Source location
Response from University Hospitals Sussex
Page 1 · response
Published 28 February 2024
Open published response
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
Complete an audit assessing retrospective entries and maternity record-keeping quality and prevalence.

Verbatim wording from the response
“5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.”

Source location
Response from University Hospitals Sussex
Page 2 · response
Published 28 February 2024
Open published response
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
Continue retrospective-entry and maternity-record audits through the service annual audit plan.

Verbatim wording from the response
“5. An audit of maternity records to assess the quality and prevalence of retrospective entries and record keeping as a whole has been completed. The retrospective notes audit will be an ongoing audit as an addition to the service annual audit plan. The results will be shared within the Quality and safety meetings and newsletters during April and May 2024.”

Source location
Response from University Hospitals Sussex
Page 2 · response
Published 28 February 2024
Open published response
16 Feb2024
Derby and Derbyshire
Concerns raised1
1. Inadequate clinical record-keeping of material risk information
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.
  Stated by Cygnet Health Care LimitedStated completed
2. Action
  Conduct three-monthly audits of record triangulation to ensure information is cross-referenced across record streams.
  Stated by Cygnet Health Care LimitedStated completed
3. Action
  Audit records of patients subject to sections 37/41 and reinforce record-keeping standards through staff supervision.
  Stated by Derbyshire Healthcare NHS Foundation TrustStated completed
1. Action
  Implement a strategic programme to raise investigation standards and improve record keeping.
  Stated by Derbyshire ConstabularyStated in progress
2. Action
  Reinforce the importance of record keeping through senior-management messaging and force-wide communications.
  Stated by Derbyshire ConstabularyStated completed
AI-generated summary

Sobia Tabasim Khan · 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

Sobia Tabasim Khan, aged 37, was murdered shortly after moving from Bradford to Derby to live near a man subject to a restricted hospital order and supervision by multiple agencies. The inquest concluded that her death was an unlawful killing and identified concerns including failures to act on information about the relationship, inadequate supervision and risk assessment, over-reliance on self-reporting, poor record-keeping, and insufficient scrutiny of the man’s discharge and recall.

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 clinical record-keeping of material risk information
Wider context from the report
“h. Record-keeping. This was a thread that ran through the case and applied both to the clinical notes but also the notes of meetings, such as MAPPA, which are necessarily a summary but which did not always include sufficient information to enable those reviewing them to understand what had been discussed and what actions taken. In terms of clinical records, whilst basic, mundane matters such as his sleeping habits and appetite were recorded, much of what mattered was not. The paucity of records and the poverty of their quality meant that ████████ was not aware of the history of manipulation and the other factors which indicated an ample need for reassessment. In terms of the SOTP, whereas there was a conflict of evidence as to why the group programme was not available at Cygnet hospital, the keeping of proper records would have ensured that there was a ready answer if needed. The discharge meetings were poorly recorded, with the spousal assault risk assessment not having featured at all. There were repeated instances of witnesses not being able to remember, understandably, what had happened with respect to certain events. There was no excuse for professional witnesses to be put in this embarrassing position. The MoJ are reliant on what they are told in writing, but given that there is a culture of poor record-keeping, until and unless that record-keeping is improved to an acceptable level, they have to be more pro-active and more prepared to question things. ”
Source location
Sobia Tabasim Khan · Prevention of Future Deaths report
Page 3 · 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
Require all staff to complete a report-writing and record-keeping skills workbook during Cygnet induction.

Verbatim wording from the response
“1. All staff complete a report writing and record keeping developmental Skill workbook as part of their Cygnet induction.”

Source location
Response from Cygnet
Page 3 · response
Published 22 February 2024
Open published response
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 three-monthly audits of record triangulation to ensure information is cross-referenced across record streams.

Verbatim wording from the response
“2. Cygnet audits on triangulation of records completed 3 monthly to ensure cross referencing of information in different streams of records.”

Source location
Response from Cygnet
Page 3 · response
Published 22 February 2024
Open published response
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
Audit records of patients subject to sections 37/41 and reinforce record-keeping standards through staff supervision.

Verbatim wording from the response
“The Trust conducts ongoing record keeping audits of the medical records of all patients who are subject to a s.37/41 to ensure that they meet the standards required. This audit process is reinforced by a robust supervision process for all nurses / AHPs working with those patients.”

Source location
Response from Derbyshire Healthcare NHS Foundation Trust
Page 3 · response
Published 22 February 2024
Open published response
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
Implement a strategic programme to raise investigation standards and improve record keeping.

Verbatim wording from the response
“Improving investigations is a key strategic priority and we have a comprehensive programme of activity to raise standards and improve record keeping, led by our Head of Crime, Detective Chief Superintendent ████████. The importance of record keeping has been reiterated as part of key messaging to frontline officers, staff, and supervisors through their senior management teams and force wide communications.”

Source location
Response from Derbyshire Constabulary
Page 3 · response
Published 22 February 2024
Open published response
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
Reinforce the importance of record keeping through senior-management messaging and force-wide communications.

Verbatim wording from the response
“Improving investigations is a key strategic priority and we have a comprehensive programme of activity to raise standards and improve record keeping, led by our Head of Crime, Detective Chief Superintendent ████████. The importance of record keeping has been reiterated as part of key messaging to frontline officers, staff, and supervisors through their senior management teams and force wide communications.”

Source location
Response from Derbyshire Constabulary
Page 3 · response
Published 22 February 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to document consultant clinical discussions

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of documentation explaining or justifying care plan deviations

Concerns raised1

Failure to record s.12 doctors’ assessment outcomes when patients are not admitted

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Inaccurate recording of cannula events and siting in medical records

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.6

Concerns raised1

Poor and inconsistent clinical record keeping on the ward

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

Concerns raised1

Deficiencies in the quality and completion of residence care documentation

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

Actions described in response 1

Respondent positions 2

Actions described in response 2

Respondent positions 3

Actions described in response 6

Actions described in response 5

Actions described in response 5