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
Lack of contemporaneous record keeping in the Emergency Department
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Reinforce contemporaneous record keeping through twice-daily Emergency Department huddle discussions with nursing and medical staff.
Stated by Royal Berkshire NHS Foundation Trust -
Action
Provide new Emergency Department staff with induction education on electronic records, NEWS alerts and observation prompts.
Stated by Royal Berkshire NHS Foundation Trust
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Concerns raised1
Failure to record and highlight patients' current or former smoking status in an immediately accessible manner
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
Clarified how clinicians should check and document smoking status using the patient care history during consultations.
Stated by Ringmead Medical Group
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
Immediate visibility of smoking status when opening patient notes was not feasible because of IT issues affecting more than 42,000 patients.
Stated by Ringmead Medical Group
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Concerns raised1
Inadequate clinical notation by advanced nurse practitioners failing to explain the patient’s presentation for escalation of care
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 and audit Advanced Nurse Practitioner documentation with staff, discussing learning points and improvements against required standards.
Stated by the Clatterbridge Cancer Centre NHS Foundation Trust -
Action
Provide clinical documentation training based on GMC guidance to staff undertaking advanced clinical practice roles.
Stated by the Clatterbridge Cancer Centre NHS Foundation Trust
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Concerns raised2
Inaccurate recording of clinical communications in case notes
Inadequate nursing documentation of vomiting, pain and pain scores
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Implement an electronic patient record and scan historical records into it, including electronically signed, dated and timed clinical notes.
Stated by South Tees Hospitals NHS Foundation Trust -
Action
Mandate pain assessments at every set of physiological observations through the electronic observation system.
Stated by South Tees Hospitals NHS Foundation Trust -
Action
Incorporate objective pain assessment tools and visual alerts for patients reporting moderate-to-severe pain.
Stated by South Tees Hospitals NHS Foundation Trust
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Action
Monitor compliance with timely pain assessments and reassessments on an ongoing basis.
Stated by South Tees Hospitals NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Records frequently recorded no pain, and reported scores may have reflected chronic rather than postoperative pain.
Stated by South Tees Hospitals NHS Foundation Trust
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Concerns raised2
Failure to record escalation of omitted critical medicines in the notes
Incomplete clinical and nursing documentation
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Lancashire Teaching Hospitals NHS Foundation Trust is the appropriate organisation to respond to concerns one to seven.
Stated by NHS England
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Concerns raised1
Inconsistent staff performance in completing welfare-check 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.3
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Action
Deliver and continue welfare-check, risk-management, complex-needs and related At Risk training for resident-facing and Conway House staff.
Stated by Sapphire Independent Housing -
Action
Review the welfare-check spreadsheet every Friday and recruit an administration assistant to provide qualitative oversight and sample testing.
Stated by Sapphire Independent Housing -
Action
Formulate and use a written contractor induction package covering the conduct and recording of welfare checks.
Stated by Sapphire Independent Housing
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 existing spreadsheet is considered adequate for recording welfare checks, so its format will be maintained rather than replaced.
Stated by Sapphire Independent Housing
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Concerns raised1
Lack of a unified record-keeping system for sharing patient information
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
Achieve national read-only interoperability between Shared Care Records across England.
Stated by NHS England
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
NHS England is best placed to address the absence of a unified record-keeping system across NHS providers.
Stated by Surrey and Borders Partnership NHS Foundation Trust and Surrey County Council
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Concerns raised1
Failure to record suicidal ideation identified during emergency department care
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
Update Emergency Department digital triage to ask all patients about mental health or self-harm within 15 minutes of arrival.
Stated by Frimley Health NHS Foundation Trust -
Action
Store Emergency Department triage and mental health assessment forms electronically in the patient record, with Psychiatric Liaison access.
Stated by Frimley Health NHS Foundation Trust
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Concerns raised1
Failure of the clinical record to present information as a continuous chronological running record
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to provide psychology clinicians with access to clinical notes across hospitals and county locations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Enable Adult Community Psychological Services clinicians to access PARIS, MOBIUS, and Health Information Exchange records.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Embed a clinical information-sharing mechanism through a joint forum incorporating formal handover of required inpatient and community information.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Commission a unified electronic medical records system.
Stated by Essex Partnership University NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Relevant clinical records are accessible to inpatient and community psychological staff through existing electronic systems and the Health Information Exchange.
Stated by Essex Partnership University NHS Foundation Trust
Data last updated 7 September 2026