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 raised2
Inability of the GP team to access the electronic record
Delays in scanning clinical notes onto the electronic system
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
Provide ED GPs with access to Evolve and Lorenzo electronic records and require completion of related e-learning.
Stated by South Warwickshire University NHS Foundation Trust -
Action
Improve ED staff access to AEC notes and inform them where notes are located for patients who re-present.
Stated by South Warwickshire University NHS Foundation Trust
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Concerns raised1
Lack of completion of required 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 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
Audit medical-record completion and route findings through governance forums for oversight and improvement.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Facilitate transfer to electronic patient records through the Multidisciplinary Documentation Forum.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust -
Action
Improve multidisciplinary documentation of medicines, fluids, feeds, vital-sign monitoring and deterioration.
Stated by the Queen Elizabeth Hospital, King'S Lynn, NHS Foundation Trust
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Concerns raised1
Failure to maintain accurate, detailed and reliable nursing home 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 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
Implement electronic care documentation with handset updates, cloud storage, daily review, care-plan access and recorded night checks.
Stated by Blackpool & Fylde Coroners -
Action
Provide walk-around, written and verbal handovers at each shift change to share, organise and delegate care.
Stated by Blackpool & Fylde Coroners -
Action
Follow the post-fall protocol and complete post-fall observations and investigations after falls.
Stated by Blackpool & Fylde Coroners
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Concerns raised1
Failure to record vital signs observations in the observation chart
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.3
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Action
Monitor NEWS2 chart completion through ward-level spot audits, immediate gap management and shared-learning governance discussions.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust -
Action
Conduct regular Emergency Department spot audits and huddles to verify NEWS2 recording, prompt escalation and completion of fluid charts.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust -
Action
Complete daily real-time Consistency in Care Audits reviewing NEWS2 and fluid-balance compliance and manage identified inconsistencies.
Stated by Blackpool Teaching Hospitals NHS Foundation Trust
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Concerns raised2
Failure to record district nurse visits
Failure of nursing notes to clearly record positioning and changes to ulcers
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.2
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Action
Provide additional wound-care documentation training and verify staff completion through training-register checks.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Audit nursing documentation and pressure-ulcer management, using a developed audit tool and reporting findings to senior management.
Stated by Midlands 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
Residential home carers are expected to conduct regular skin checks and contact district nurses when concerns arise.
Stated by Midlands Partnership University NHS Foundation Trust
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Concerns raised1
Inaccuracy of record keeping
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.1
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Action
Update assisted-vaginal-birth guidelines with risk assessment, improved documentation, and immediate newborn head-trauma checks.
Stated by Mid and South Essex NHS Foundation Trust
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Concerns raised1
Partial, incomplete and unverifiable record keeping by Discipline and healthcare staff
This report raised 17 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 maintain meaningful records of prescribing consultations and their rationale
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.
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 maintain accurate medication administration records
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.2
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Action
Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.
Stated by Pelham house -
Action
Conduct monthly medication audits with internal management oversight, visible summaries, and external review of medication administration.
Stated by Pelham house
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Concerns raised1
Poor-quality care documentation
This report raised 9 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
Introduce a single electronic patient record for recording and sharing patient details, notes and actions.
Stated by Bolton NHS Foundation Trust -
Action
Communicate expectations to staff that significant changes require consideration and recording of capacity assessments and Best Interest meetings, with care-plan liaison monitored through supervision.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Record Integrated Discharge Team input in patients’ electronic patient records and social services case-recording systems.
Stated by Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental 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
Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Stated by Department of Health and Social Care
Data last updated 7 September 2026