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
Poor quality of clinical record keeping
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.
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 properly record, store or audit paper observations and records
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.4
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Action
Attend inpatient handovers, audit clinical records, and escalate audit outcomes through governance meetings to assure handover quality and accuracy.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Replace paper-based clinical observation forms with electronic forms feeding directly into SystmOne, including tablet procurement and ward testing.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation Trust -
Action
Provide temporary staff and partner mental health teams with electronic access to document assessments and care plans in Oceano.
Stated by Portsmouth Hospitals University NHS Trust
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Action
Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Stated by Portsmouth Hospitals University NHS Trust
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Concerns raised1
Inconsistencies in record keeping between specialities
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.2
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Action
Progress the contracted integrated electronic patient record programme toward operational use from Spring 2025.
Stated by Royal Cornwall Hospitals NHS Trust -
Action
Require inpatient clinical entries to be recorded in written paper notes, except in specified intensive-care areas, with the change communicated and effective from 13 September 2023.
Stated by Royal Cornwall Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Because specialties must record inpatient entries in paper notes, no electronic alert is considered necessary for handwritten clinical entries.
Stated by Royal Cornwall Hospitals NHS Trust
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Concerns raised1
Failure of the community team to consistently record key clinical assessment information
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Make changes to electronic clinical-record proformas to strengthen record keeping and capture accurate, relevant clinical information.
Stated by Gateshead Health 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
The Trust disputes that key clinical information was inconsistently recorded, stating that information was recorded and concerns were appropriately escalated.
Stated by Gateshead Health NHS Foundation Trust
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Concerns raised1
Failure to include bed rail assessment in the Welsh Nursing Care Record
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
Raise the bed-rail assessment issue nationally to expedite standardisation and inclusion in the WNCR.
Stated by Betsi Cadwaladr University LHB -
Action
Remind ward managers, matrons and heads of nursing about paper-based bed-rail assessments and provide materials for staff safety briefings and ward display.
Stated by Betsi Cadwaladr University LHB -
Action
Finalise and introduce the updated Bed Rails Procedure.
Stated by Betsi Cadwaladr University LHB
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
Creation of a standardised bed-rails assessment tool is being led nationally by Cwm Taf Morgannwg University Health Board.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Failure to complete and retain sufficiently detailed MDT discussion documentation
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Review Crisis Team MDT processes and improve the functionality of recording and documenting MDT meeting notes through a quality improvement programme.
Stated by Leicestershire Partnership NHS Trust
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Concerns raised2
Failure to record clinical observations during hospital attendance
Failure to record inter-hospital clinical communications
This report raised 8 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
Update and disseminate clinical record-keeping guidance to clinical staff.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Draft and send a patient safety briefing to all staff on documenting clinician communications.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust -
Action
Present the case to surgical colleagues at a Surgical Clinical Governance meeting.
Stated by York and Scarborough Teaching Hospitals NHS Foundation Trust
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Action
Use Patient Pass to coordinate and record referrals, information requests and advice between hospitals and specialist departments.
Stated by Leeds Teaching Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Trust has no record or recollection of any communication from York Hospital about the deceased’s admission.
Stated by Leeds Teaching Hospitals NHS Trust
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Concerns raised1
Lack of written nursing documentation of patient care
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.
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 record injuries from body maps in daily communication records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Prepare, distribute and display record-keeping guidance, and require all staff to review it and the record-keeping policy.
Stated by Sequoia CH Group Ltd -
Action
Provide record-keeping training during induction and staff supervisions throughout the year.
Stated by Sequoia CH Group Ltd -
Action
Review record-keeping quality through weekly and monthly management audits and documentation spot checks.
Stated by Sequoia CH Group Ltd
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Action
Strengthen staff communication by requiring documented concerns, daily records, written handovers, shift briefings and review of relevant resident records.
Stated by Sequoia CH Group Ltd -
Action
Implement a Referral for Medical Attention policy requiring prompt clinical referral, documented professional guidance, care-plan updates and recorded follow-up.
Stated by Sequoia CH Group Ltd
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Concerns raised2
Inaccurate clinical record keeping
Failure to reconcile clinical documentation with the patient’s observed condition
This report raised 13 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.
Data last updated 7 September 2026