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.

29 Mar2021
Birmingham and Solihull
Concerns raised1
1. Failure to record preceding resident falls in resident files
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.
  Stated by Cole Valley Nursing HomeStated planned
2. Action
  Implement and maintain a centralized post-fall protocol folder containing guidance, a NEWS chart, and a timed observation log.
  Stated by Cole Valley Nursing HomeStated completed
3. Action
  Implement daily and nightly nursing handover reports, with daily managerial review and a Daily Walkabout Form recording recent incidents and resulting actions.
  Stated by Cole Valley Nursing HomeStated completed
AI-generated summary

Raymond Alfred POWELL · 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

Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.

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 preceding resident falls in resident files
Wider context from the report
“(1) The nursing home manager confirmed that a preceding fall (most likely on 15 October) had not been recorded anywhere within Raymond's file and this was the first time she was aware of a preceding fall (Raymond's family's evidence was they were told during a visit on 15 October, and nursing home carer ████████ confirmed there was a preceding fall a few weeks earlier). The nursing home manager was unable to explain why this preceding fall had not been recorded anywhere. ”
Source location
Raymond Alfred POWELL · 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
Conduct internal investigations of all falls, attach action plans, and report falls and incidents weekly to the Nominated Individual.

Verbatim wording from the response
“1. Manager to conduct internal investigations to all falls and attach action plans. All falls and incidents to be reported on the weekly manager’s report and submitted to Nominated Individual.”

Source location
2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
Page 1 · response
Published 30 March 2021
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 and maintain a centralized post-fall protocol folder containing guidance, a NEWS chart, and a timed observation log.

Verbatim wording from the response
“2. The Manager has reviewed current documentation regarding post falls reporting and observing. The manager agrees that post documentation protocols was not substantial and did not accurately reflect the observations that took place on the day, so has implemented a new robust post falls protocol folder for the nursing team. This is allocated in one place and therefore nurses can easily access documents. This protocol now gives guidance and clear direction to follow. This protocol also has a NEWS chart that is included within this pack and a timed observation log post fall. Regarding the previous fall, the manager has reviewed archived documentation but is unable to locate any documentation to support the reported preceding fall on or around the 15th October 2021. The manager has spoken to ████████ about this concern.”

Source location
2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
Page 1 · response
Published 30 March 2021
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 daily and nightly nursing handover reports, with daily managerial review and a Daily Walkabout Form recording recent incidents and resulting actions.

Verbatim wording from the response
“████████ said he was extremely nervous about this situation and had many anxiety attacks before attending Coroner’s Court. ████████ stated he that he panicked throughout the questioning and was not completely sure about the fall around this time. The manager has, however, implemented a new manager’s report/handover for nurses to complete daily and every night. The manager to review handover daily. A Daily Walkabout Form is also in place. This identifies if there has been any accidents or incidents in the last 24 hours and what actions have been done, such as evaluating care needs of the individual involved. Cole Valley Nursing home has promoted an RGN to Deputy Manager with supernumerary time to assist the manager with audits and action plans, supervisions and implementing and monitoring documentation to aid continuous improvement of the Home.”

Source location
2021-0089-Response-from-Cole-Valley-Nursing-Home-Redacted
Page 1 · response
Published 30 March 2021
Open published response
25 Mar2021
Birmingham and Solihull
Concerns raised1
1. Failure to record significant family concerns and patient accounts
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.

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

Azra Parveen HUSSAIN · 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

Azra Parveen HUSSAIN was found hanging from her en-suite bathroom door at Mary Seacole House on 6 May 2020 and could not be resuscitated. Concerns included that information from her family about a reported ligature attempt was not recorded, shared or used to reassess her risk, and that high-risk bathroom doors and other bedroom-area doors lacked adequate ligature mitigation. The inquest jury also identified missed opportunities concerning ECT treatment and suicide-risk management.

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 significant family concerns and patient accounts
Wider context from the report
“1. On the 4th May 2020 Azra's mother and daughter had been in telephone contact with the nurse in charge on the ward expressing concerns that Azra had messaged them to say she had attempted suicide using shoelaces as a ligature. The nurse spoke to Azra who denied making a ligature, Azra's neck was examined and she had no marks from ligature use. The shoelaces from one pair of shoes were removed but other shoelaces, clothing and bedding were left in her possession as it was felt that Azra was not at an immediate risk. She was not believed to be at immediate risk because, whilst it was a feature of her mental state common to many patients that she would regularly talk about not wanting to live and requesting an overdose, there was no evidence that she had made an active suicide attempt and she had no history of suicide or self-harm attempts. The fact that she was now saying that she had attempted to make a ligature was a change in her presentation (her previous suicidal ideation had centred around requesting assistance to overdose), it was also of significance that she was saying one thing to her family and something different to a clinician. BSMHT accepted that the information was significant and therefore there ought to have been consideration of it by her treating team with a review of her risk and observation levels. However, no record at all was made of the family's concerns and the account given by Azra. Her risk screen was not updated, an incident report was not raised, and the information was not included in handover to the next shift or at the next MDT on the 6th May 2020. Due to the COVID19 pandemic Azra's family could not attend that meeting and raise their concerns directly. Microsoft Teams was used by some clinicians to attend the MDT on the 6th May but was not made available to Azra's family nor was a telephone number to dial into the meeting. BSMHT has put in a system for a form to be completed in advance of an MDT which requires the family's input to be sought, placed on the form and considered in the MDT. It is my concern that this is equivalent to the family being included in the meeting (prior to COVID families were invited to attend MDTs): there is the potential that information will not be recorded accurately or will not be understood in written form, it also doesn't afford family the opportunity to hear the plan arising from the meeting and provide their views. There is no reason why attendance by a remote platform or telephone line at the meeting itself cannot be offered to family for all MDTs. ”
Source location
Azra Parveen HUSSAIN · Prevention of Future Deaths report
Page 2 · concerns
Open source report
8 Mar2021
Blackpool and the Fylde
Concerns raised1
1. Poor overnight record keeping
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.

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

Joan Elizabeth Rutter · 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

Joan Elizabeth Rutter, aged 94, was found unresponsive after an unwitnessed fall beside her bed at the rest home on 23 October 2020; the fall resulted in a fatal spinal fracture. The report identified concerns about poor overnight record keeping, staffing and the delivery of night care, and an unplugged falls mat that did not alert staff to her movement.

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 overnight record keeping
Wider context from the report
“Record keeping. The standard of the records provided by the rest home were poor. There was a paucity of entries made during the night shift. For example, entries to reflect Joan had been found wandering in the rest home having left her own room were unrecorded. A member of the staff taking over the care of residents would have found it very difficult to review the records and have an accurate understanding of how the residents had presented overnight, thereby placing such day staff in a difficult position taking over the care of often elderly, vulnerable residents but potentially unaware of recent important events. Although the court received some evidence that changes have been made since Joan’s death, the court remains of the view that the standard of record keeping continues to pose a risk to residents and future deaths may occur. ”
Source location
Joan Elizabeth Rutter · Prevention of Future Deaths report
Page 2 · concerns
Open source report
3 Mar2021
East London
Concerns raised1
1. Failure to accurately record and file important medical records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Provide record-keeping training to Turner Ward staff on Trust expectations.
  Stated by TrustStated planned
AI-generated summary

Steven Paul David Gary Stout · 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

Steven Paul David Gary Stout was detained under section 136 of the Mental Health Act after cutting both wrists while intoxicated by alcohol, and was later admitted to a mental health ward. He was discharged on 18 October 2019 without a referral to the home treatment team and was found unresponsive, suspended by his neck from a ligature, on 4 November 2019; he could not be resuscitated. The concerns included failures to accurately record and file important medical records and to ensure an effective referral to the home treatment team.

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 accurately record and file important medical records
Wider context from the report
“1. The failure of Turner Ward, Goodmayes hospital to accurately record and file important medical records including; decisions on discharge, risk assessments, and a crisis, relapse and contingency plan. ”
Source location
Steven Paul David Gary Stout · 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
Provide record-keeping training to Turner Ward staff on Trust expectations.

Verbatim wording from the response
“The Trust has taken into consideration concerns highlighted in the Regulation 28 report and agreed to take a number of actions to address your concerns. This includes:”

Source location
2021-0059 Response from North East London NHS Foundation Trust
Page 1 · response
Published 8 March 2021
Open published response
2 Mar2021
Lancashire and Blackburn with Darwen
Concerns raised1
1. Failure to identify the responsible specialty and document its management in medical records
This report raised 16 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

Mr Frank Charles Medley · 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

Mr Frank Charles Medley presented with acute weakness in all four limbs, but an MRI scan that was considered urgent was delayed for four working days. He underwent surgery for multiple paraspinal abscesses and died on 14 July 2019. The principal concerns included delays and inadequate prioritisation of imaging, deficiencies in the Trust’s adverse incident review, and shortcomings in systems for detecting adverse outcomes and coordinating relevant departments.

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 identify the responsible specialty and document its management in medical records
Wider context from the report
“(2) The Trust's review of this case was seriously deficient in the following instances: a. At no point were members of the family spoken to for their views or concerns regarding the death up to and including the inquest. b. The date of death was 14 July 2019. The Report was incomplete eight months later in March 2020 when it was suspended during the first Covid wave. The report was not completed before the inquest on 23 February 2021. This is not in accordance with NHS guidance; c. The case was inappropriately allocated to a structured judgement review; d. The "Summary of the Incident" contains substantial factual inaccuracies to such an extent that it is deeply misleading; e. Mr Medley's death was due to complications of sepsis. The report failed to note that due to admission for query sepsis at the same hospital 11 days before, that: i. the EWS score was sufficient to trigger the septic shock pathway; ii. the nurse correctly identified that the septic shock pathway should be followed and drew this to the attention of "a doctor"; iii. that due to the referrals taking place between specialties at this time the relevant specialty responsible for dealing with this issue cannot be identified and made no entry in the medical records (this raises similar issues to those concerns raised in the Regulation 28 report concerning Mrs Gillian McKinley at the same Trust); iv. that, despite the patient observations being readily available to the treating consultant orthopaedic surgeon the following morning and the nurse having documented the septic shock pathway should be activated in the notes, the consultant orthopaedic surgeon failed to note this both at the time and during the preparation of his witness statement for the inquest; v. the error was only detected by the Trust's Legal Services Department when preparing for the inquest 19 months after the event. f. That the consultant physician responsible for Mr Medley's care appreciated that his symptoms constituted a medical emergency, that the MRI scan should be completed on 2 July 2019 but took no action himself to expedite the scan. There is no documented evidence in the medical records regarding junior doctors attempts to expedite the scan; g. The consultant physician responsible for Mr Medley's care after input from the neurologists on 3 July 2019 made no attempts to expedite the scan or to contact tertiary neurosurgical services; h. On 2 July 2019 the treating clinicians suspected infective complications high in the cervical spine but only undertook a chest x-ray and blood cultures without considering sending a urine sample for analysis, considering an echocardiogram or OPG; i. Mr Medley's scan should have been completed within 24 hours of request in accordance with NICE guidance, which was not cited anywhere in the report, and that the priority attached to the scan on 2 July 2019 placed Mr Medley in the lowest priority category when he should have been in the highest priority category. This mistake was repeated on 3 July 2019 when Mr Medley was placed in the middle priority category. There is no documentation as to any rationale for the priority allocation; j. The scan when it was performed on 5 July 2019 was not a contrast scan necessary to accurately delineate foci of infection resulting in a further scan using contrast to be performed later that day. k. That prioritisation of scans within the radiology department depended to a considerable extent on a personal attendance by clinicians at the department or speaking to radiologists rather than solely on clinical need; l. There was insufficient senior clinical oversight of the conclusions drawn. ”
Source location
Mr Frank Charles Medley · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Feb2021
North Northumberland and South Northumberland
Concerns raised1
1. Failure to maintain accurate and up-to-date resident care records and care plans
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 1
1. Action
  Review and implement new care-planning processes.
  Stated by Alcyone Healthcare North East LtdStated in progress
AI-generated summary

Margaret Elizabeth Greenacre · 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

Margaret Elizabeth Greenacre, known as Betty, was a care home resident who suffered an unwitnessed fall on 30 August 2020, sustaining significant soft tissue damage to her lower right leg. She deteriorated after the injury and died in hospital on 18 September 2020. Concerns included late or missing statutory notifications of incidents and poor care-home record keeping, including care plans that were not updated and did not accurately reflect residents’ needs.

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 accurate and up-to-date resident care records and care plans
Wider context from the report
“2. I have concerns with regard to the standard of record keeping at Baedling Manor Care Home, I am concerned that the care notes did not present an accurate picture of a resident and did not reflect what a resident was like and therefore what their needs were. It was accepted in evidence that the record keeping was very poor, the care plans were not changed or updated. In fact, upon the appointment of a new home manager, every resident’s care plan has been reviewed and updated. The information provided in the care plan contradicted the information provided in evidence and it appears staff may have had difficulty understanding Betty’s care needs for lifting. ”
Source location
Margaret Elizabeth Greenacre · 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
Review and implement new care-planning processes.

Verbatim wording from the response
“• Full review and implementation of new care planning processes”

Source location
2022-0119-Response-from-Alcyone-Healthcare_Published
Page 2 · response
Published 27 April 2022
Open published response
3 Feb2021
Mid Kent and Medway
Concerns raised1
1. Incomplete and inaccurate discharge nursing documentation
This report raised 12 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

CHRISTOPHER SMITH · 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

Christopher Smith was admitted to hospital with peripheral vascular disease, extensive leg ulcers, epilepsy and infections, and died on 4 March 2019 after deterioration following discharge home. Principal concerns included inadequate discharge planning and capacity reassessment, failure to arrange home and district nursing support, unsafe home conditions and an unacted-on safeguarding alert, and inadequate nutritional care.

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
Incomplete and inaccurate discharge nursing documentation
Wider context from the report
“(4) Nursing notes in respect of Mr Smith’s discharge were incomplete, incorrect, and led to assumptions being made that Mr Smith a. had capacity to make decisions about his care and treatment b. was being cared for in the community. ”
Source location
CHRISTOPHER SMITH · Prevention of Future Deaths report
Page 2 · concerns
Open source report
5 Jan2021
Inner North London
Concerns raised1
1. Failure to record severe adverse reactions to Naso-Gastric tube insertion
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.

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

Hariharan Harichandra · 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

Hariharan Harichandra, a 65-year-old man, fell from an electric wheelchair in hospital on 5 December 2019, sustaining a neck fracture, and died at The Royal Free Hospital on 19 December 2019. The concerns included errors in reporting and reviewing the CT scan, incomplete falls assessment, insufficient consideration of wheelchair safety equipment and spinal condition, and failure to record a severe adverse reaction to a naso-gastric tube.

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 severe adverse reactions to Naso-Gastric tube insertion
Wider context from the report
“I am concerned that: (a) The error by the original clinician who interpreted the CT scan images of 5th December 2019 has not been properly explained. (b) The Consultant Radiologist who reviewed the CT scan images of the 5th December 2019 should have noticed the clear and obvious neck fracture. Although there were 2 scans of the 5th December 2019 to review, it appeared that the clinician most probably reviewed only one of them. There ought to be a system in place when ensuring that a scan review can only be completed if all the scans taken are reviewed by a second clinician. (c) The Falls Assessment Tool was not properly completed or reviewed by staff; (d) Hospital staff have no training in how to assess and deal with private equipment brought from outside such as an electric wheelchair and the safety features of such devices; (e) By hospital staff not recording Mr Harichandra’s adverse reaction to the Naso-Gastric tube insertion, future clinicians would have been unaware of this severe reaction when treating him and considering how his important nutritional needs should be met had he survived. ”
Source location
Hariharan Harichandra · Prevention of Future Deaths report
Page 3 · concerns
Open source report
14 Dec2020
West Sussex
Concerns raised1
1. Failure to maintain nursing and clinical records in accordance with policy
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 3
1. Action
  Review inpatient care plans, risk assessments and clinical documentation, and maintain compliance through audits and competency plans.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
2. Action
  Require inpatient staff to complete note-writing competency checks and monitor adherence through weekly audits and daily spot checks by Ward Managers.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
3. Action
  Conduct daily risk-assessment, huddle and clinical-notes audits with Ward Manager oversight from senior leadership.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
AI-generated summary

Christopher Swain · 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

Christopher Swain, who was detained under Section 3 of the Mental Health Act 1983, was found unresponsive in his room at Langley Green Hospital on 22 September 2019 with a ligature around his neck and was confirmed deceased by paramedics. Concerns included inconsistent staff practices when conducting observations, uncertainty about when he was last seen alive, the absence of a formal mental health review, care plan and adequate risk assessment, inadequate record-keeping, no recorded therapeutic engagement, and failure to provide staff to accompany a sectioned patient to another hospital.

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 nursing and clinical records in accordance with policy
Wider context from the report
“a) During the evidence there was some confusion amongst staff as to what was required of them when carrying out observations patients in their rooms. There were different practices adopted by different staff and there appeared to be a custom of not entering a patient's room on the hourly observations so as not to disturb the patients. Sadly because of this practice it was unclear when Christopher had last been seen alive. Whilst the Trust has indicated that all staff have received further training in respect of this I am still not convinced that it is clear as to what is required by staff. b) Following the evidence the Jury concluded:- (a) that during Christopher’s time at Langley Green Hospital no formal review, care plan or adequate risk assessment was carried out in respect of his mental health. (b) that the nursing and clinical records were not kept in accordance with the trust health and record policy. (c) that here was no recorded evidence that any therapeutic engagement has taken place during the period of Christopher's short stay. Whilst the Trust have indicated that there has been a review of the professional conduct of all staff involved in this case this does not allay my concerns that these practices are limited to just those staff involved in this case. c) Failure to provide staff to accompany a sectioned patient to the emergency department of another Hospital for treatment for a physical condition. Requesting family member to undertake this role puts the patient and/or the family at risk ”
Source location
Christopher Swain · 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
Review inpatient care plans, risk assessments and clinical documentation, and maintain compliance through audits and competency plans.

Verbatim wording from the response
“The absence of clinical documentation for Christopher during his admission to Langley Green Hospital was not completed to an expected standard in accordance with Trust Policy. The Trust therefore completed a review of professional conduct of all the staff involved in Christopher’s care through HR processes and made referrals to relevant Regulatory bodies. The Langley Green Hospital Leadership team and Trust took immediate action to prevent reoccurrence of any non-compliance with Trust Policy including an immediate review of all care plans, risk assessments and clinical documentation. This has been maintained through audit and competency plans. Feedback was given to the whole team by the Trust Deputy Chief Nurse due to the seriousness and the immediate requirement to reflect and improve.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 6 January 2021
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 inpatient staff to complete note-writing competency checks and monitor adherence through weekly audits and daily spot checks by Ward Managers.

Verbatim wording from the response
“Therefore, a review of all the professional conduct of the staff involved was completed at the time and managed through appropriate internal processes including HR and referrals to relevant Regulatory bodies. From a systems perspective, all Trust inpatient staff have completed competency checks in note writing and ongoing adherence is monitored by Ward Managers who check the content of patient notes weekly in audit form and complete spot checks on a daily basis.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 4 · response
Published 6 January 2021
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 daily risk-assessment, huddle and clinical-notes audits with Ward Manager oversight from senior leadership.

Verbatim wording from the response
“There have, since Christopher's death, been daily risk assessment audit, daily huddles as well as notes audits by Ward Managers with oversight by the senior leadership team. These audits demonstrate as of December 2020 there is 100% adherence to the training in quality record keeping.”

Source location
2020-0284-Response-from-Sussex-Partnership-NHS-Foundation-Trust-Redacted
Page 3 · response
Published 6 January 2021
Open published response
9 Dec2020
South Yorkshire (Western)
Concerns raised1
1. Failure of EPR records to accurately reflect information given to patients
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.
  Stated by Yorkshire Ambulance Service NHS TrustStated planned
2. Action
  Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.
  Stated by Yorkshire Ambulance Service NHS TrustStated planned
3. Action
  Re-audit care-plan documentation after the intervention.
  Stated by Yorkshire Ambulance Service NHS TrustStated planned
1. Action
  Develop EPR tick-box indicators to record information left with patients.
  Stated by Yorkshire Ambulance Service NHS TrustStated planned
AI-generated summary

Thomas Rawnsley · 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

Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.

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 EPR records to accurately reflect information given to patients
Wider context from the report
“(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient. ”
Source location
Thomas Rawnsley · 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
Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.

Verbatim wording from the response
“The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. I am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an ‘on notice’ audit and results may therefore be skewed against the true position.”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
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
Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.

Verbatim wording from the response
“Additionally, and as an interim phase, the Trust will undertake the following:”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
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
Re-audit care-plan documentation after the intervention.

Verbatim wording from the response
“Additionally, and as an interim phase, the Trust will undertake the following:”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
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 EPR tick-box indicators to record information left with patients.

Verbatim wording from the response
“Additionally, and as an interim phase, the Trust will undertake the following:”

Source location
2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
Page 2 · response
Published 6 January 2021
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to record preceding resident falls in resident files

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

Concerns raised1

Failure to record significant family concerns and patient accounts

Concerns raised1

Poor overnight record keeping

Concerns raised1

Failure to accurately record and file important 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.1

Concerns raised1

Failure to identify the responsible specialty and document its management in medical records

Concerns raised1

Failure to maintain accurate and up-to-date resident care records and care plans

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

Concerns raised1

Incomplete and inaccurate discharge nursing documentation

Concerns raised1

Failure to record severe adverse reactions to Naso-Gastric tube insertion

Concerns raised1

Failure to maintain nursing and clinical records in accordance with policy

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

Concerns raised1

Failure of EPR records to accurately reflect information given to patients

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

Actions described in response 3

Actions described in response 1

Actions described in response 1

Actions described in response 3

Actions described in response 4