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.

18 Nov2019
Manchester North
Concerns raised1
1. Failure to make complete lists of current and recent prescriptions readily accessible
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.

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

Alex Grady · 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

Alex Grady was found deceased in his bed on 26 February 2019 and died from combined toxicity involving prescribed and non-prescribed medication and illicit drugs. Concerns included the adequacy of support and follow-up when alcohol detoxification is managed solely by a GP, and the accessibility of complete prescription information to healthcare practitioners.

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 make complete lists of current and recent prescriptions readily accessible
Wider context from the report
“I heard evidence that the reason that the prescriptions for Chlordiazepoxide were not referred to in the two reports prepared by the GP for the purpose of this inquest was because of a ‘glitch’ in the computer system which meant that it was not included in the list of medications listed on the first screen of the patient’s records. My concern is that a complete list of all current and recent prescriptions should be readily accessible to GPs and other healthcare practitioners working within the practice. ”
Source location
Alex Grady · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Nov2019
Mid Kent and Medway
Concerns raised1
1. Incomplete recording in district nurse electronic care and treatment records
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 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

Dorothy June MACEY · 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

Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

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 recording in district nurse electronic care and treatment records
Wider context from the report
“(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”
Source location
Dorothy June MACEY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Nov2019
Swansea and Neath Port Talbot
Concerns raised1
1. Lack of documentation of discrepancies between clinicians’ accounts
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.

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

Pamela Moran · 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

Pamela Moran died at Morriston Hospital on 17 March 2017 after falling at Tonna Hospital and suffering fractures and a head injury. She developed an acute on chronic intracranial bleed, and the report identified three missed opportunities for a CT head scan, along with inadequate documentation and a system that relied on junior doctors to hand over requests for scans.

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 of discrepancies between clinicians’ accounts
Wider context from the report
“During the course of the inquest a report from Dr ████████ instructed as an independent expert in this case, found 3 missed opportunities for the CT head scan to be performed. Dr ████████ conclusion noted at paragraph 6.5.6 that: “Regional neurosurgical services keep a record of the cases referred to them and discuss all cases at a handover meeting so that if the advice given is to carry out certain investigations or initiate a line of management and then ring back the second doctor giving advice has access to the earlier information. The discrepancy between D████████ account and Dr ████████ account of the conversation on the evening of 14 March 2017 about Mrs Moran unfortunately cannot be clarified by the use of structured documentation generated by either or both parties. Dr ████████ states that he was not given Mrs Moran’s name and has relied on his memory about anticoagulation and a previous CSH not being mentioned. The local system does not seem to facilitate an overnight consultant authorising a next day CT scan but relies on the junior doctors to hand over the task of requesting the scan again, possibly twice - firstly from the evening to the night shift doctors and then the night shift doctor to a third, different morning shift doctor. There may be other radiology services that have developed formal systems which the Health Board could adopt.” 1. There were 3 missed opportunities for a CT scan to be undertaken in this case, which may have prevented the deceased’s death, or at the very least improved her prospects of survival. 2. There appeared to be no documentation relating to the discrepancy between the accounts of Drs ████████████████ in respect of their conversation on the 14th of March 2017. 3. There does not appear to be a facility for an overnight consultant to authorise a next day CT scan, and relies on a junior doctor to hand over the task at the end of their shift. ”
Source location
Pamela Moran · Prevention of Future Deaths report
Page 2 · concerns
Open source report
11 Nov2019
Avon
Concerns raised1
1. Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance
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 4
1. Action
  Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.
  Stated by Spire Bristol HospitalStated completed
2. Action
  Update the Admission and Discharge policy and RMO Handbook to reinforce comprehensive documentation requirements, including temporary records when original notes are unavailable.
  Stated by Spire Bristol HospitalStated completed
3. Action
  Add a 2020 local audit of documentation for patients who re-attend after discharge.
  Stated by Spire Bristol HospitalStated planned
1. Action
  Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.
  Stated by Spire Bristol HospitalStated completed
Respondent positions 1
1. Position
  Existing patient-records policies, professional obligations, training and routine audits provided a formal system for comprehensive record keeping.
  Stated by Spire Bristol HospitalExisting arrangements considered sufficient
AI-generated summary

Antonis Tofali Hannides · 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

Antonis Tofali Hannides died on 29 March 2019 from liver and heart disease after undergoing hernia repair and subsequently reattending hospital with confusion. Concerns included the lack of a formal system for managing unexpected reattendance after discharge, inadequate documentation, and failure to inform his consultant immediately.

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 full and comprehensive record keeping in accordance with GMC and NMC guidance
Wider context from the report
“No formal system at Spire Bristol for 1) Seeing patients who reattend unexpectedly after discharge; 2) Ensuring full and comprehensive record keeping in accordance with GMC and NMC guidance; 3) Ensuring that consultants are informed immediately of any patient who reattends unexpectedly after discharge. ”
Source location
Antonis Tofali Hannides · 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
Update the Admission and Discharge policy to require assessment, consultant notification, documented follow-up and incident tracking for unexpected post-discharge re-attendances.

Verbatim wording from the response
“In light of the concerns raised at the Inquest, Spire Healthcare has updated its National Clinical Admission and Discharge policy (copy enclosed at Appendix A) to ensure that the existing triage process applies equally to patients who unexpectedly re-attend the hospital (as happened in Mr Hannides’ case). In such circumstances, the policy provides that the patient must be reviewed by an RMO. The patients’ consultant must be informed of their attendance post-discharge and the RMO or nurse reviewing the patient must document that the consultant has been notified (and when), and whether advice has been sought from the consultant. Where advice was not specifically sought before providing care, for example as a result of minor concerns, the reasons for not doing so should also be documented.”

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 2 · response
Published 27 December 2019
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
Update the Admission and Discharge policy and RMO Handbook to reinforce comprehensive documentation requirements, including temporary records when original notes are unavailable.

Verbatim wording from the response
“As identified above, in light of the concerns raised at the inquest, Spire’s Admission and Discharge policy and RMO Handbook have been updated to remind staff of the requirements and standards of good medical record keeping practices and explicitly how post-discharge enquiries should be recorded. This policy requires that any clinical encounter with the patient must be comprehensively documented in the patient’s records by the clinical staff involved in the patients’ care. In situations where the patient’s notes are not immediately available, for example as a result of any out of hours query (or in Mr Hannides’ case as a result of an un-expected presentation to outpatients), then a temporary set of records will be created by the team involved in the care of the patient, and merged as soon as possible with the original patient records.”

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 4 · response
Published 27 December 2019
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
Add a 2020 local audit of documentation for patients who re-attend after discharge.

Verbatim wording from the response
“All RMOs practising at Spire are provided with a copy of Spire’s RMO Handbook, and an induction pack (copy enclosed at Appendix F) which outline further the obligations with regard to good medical record keeping and adherence to Spire’s Patient Records policy. Spire Bristol undertake routine audits of record keeping standards at the hospital in keeping with the Spire Patient Records policy. An additional audit has been added to the local 2020 schedule that will focus specifically on the standard of documentation in the medical records where patients have re-attended the hospital following their discharge.”

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 3 · response
Published 27 December 2019
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
Deliver shared learning sessions to clinical staff on post-discharge re-attendance documentation and NMC documentation standards.

Verbatim wording from the response
“Spire Bristol has undertaken a number of local actions to share learning from this case with respect to record keeping practices including:-”

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 4 · response
Published 27 December 2019
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 patient-records policies, professional obligations, training and routine audits provided a formal system for comprehensive record keeping.

Verbatim wording from the response
“All nursing and medical staff at Spire Bristol are subject to professional and contractual obligations to maintain good record keeping standards. Those obligations are detailed in Spire’s Patient Records policy (which was in place at the time of Mr Hannides’ care, a copy of which is enclosed at Appendix E) and provides that “an entry should be made in the healthcare record whenever a patient is seen by a clinician or member of staff. All clinicians and healthcare professionals must make clear, accurate and contemporaneous records relating to their patients. The record must contain regular and timely progress notes, observations and consultation reports made by such professionals. In addition to Spire Healthcare’s requirements, clinicians and healthcare professionals may formally be required to do so by their professional regulatory body.””

Source location
2019-0382-Response-from-Spire-Bristol-Hospital_Redacted
Page 3 · response
Published 27 December 2019
Open published response
5 Nov2019
Manchester North
Concerns raised1
1. Failure to record pharmacist-clinician discussions and advice
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 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 Byron · 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 Byron, who had multiple sclerosis and had become bedbound, developed infected pressure sores and was admitted to hospital. He received a second intravenous iron infusion on 9 January 2017 without adequate consideration of the risks and was not observed for 30 minutes afterwards; he suffered cardiac arrest within minutes and died. Concerns included inadequate continuity and documentation of nursing and pharmacy care, shortages of staff and dressings, unclear observation guidance for iron infusions, and inaccurate post-mortem reporting that failed initially to identify anaphylaxis.

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 pharmacist-clinician discussions and advice
Wider context from the report
“3. The Court heard of discussions which take place between the Pharmacists and clinicians. These can take place at times when the pharmacist is off the ward. In these circumstances there is no ability for the pharmacist to record such discussions. There was no record anywhere of any discussions on the 30th December 2016 or the 9th January 2017 and any such advice provided, so there was no way of confirming if such conversations had taken place. ”
Source location
Christopher Byron · Prevention of Future Deaths report
Page 2 · concerns
Open source report
21 Oct2019
Manchester West
Concerns raised1
1. Delays of up to 24 hours in recording clinical information
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 2
1. Action
  Deliver face-to-face refresher training on observation and engagement policy, including delayed record-keeping requirements, to nursing staff and healthcare assistants.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated planned
2. Action
  Conduct monthly audits of electronic clinical records to identify delayed record keeping and prompt action to improve compliance with record-keeping policy.
  Stated by North West Boroughs Healthcare NHS Foundation TrustStated planned
AI-generated summary

Lauren Victoria Finch · 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

Lauren Victoria Finch, aged 23, died on 24 September 2018 after suspending herself from a bedroom door while detained as a patient at Atherleigh Park Hospital; she suffered a significant brain injury and later died in hospital. The principal concerns included inadequate suicide-risk assessment and review, inappropriate observation levels and practices, failures in the anti-barricade system, and delayed clinical record entries.

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
Delays of up to 24 hours in recording clinical information
Wider context from the report
“4. There were examples in the records of nursing staff putting in entries 24 hours after the event had occurred. Whilst it is accepted that nursing staff may, on occasion, need to wait some time before marking an entry into the clinical record, a period of 24 hours when dealing with patients at risk of self-harm and suicide means that relevant information is potentially not available to staff on the next shift. ”
Source location
Lauren Victoria Finch · 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
Deliver face-to-face refresher training on observation and engagement policy, including delayed record-keeping requirements, to nursing staff and healthcare assistants.

Verbatim wording from the response
“• A training package has been developed to support face to face refresher training for all Nursing staff and Health Care Assistants. This training not only reminds clinicians of the correct procedure when completing therapeutic observations, but will use case studies to discuss various scenarios in how this policy should be applied in clinical practice. This training is to be delivered to all Nursing staff (including health care assistants) working at Atherleigh Park during December 2019.”

Source location
2019-0506-Response-from-North-West-Boroughs-Healthcare-NHS-Foundation-Redacted
Page 1 · response
Published 14 May 2020
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 monthly audits of electronic clinical records to identify delayed record keeping and prompt action to improve compliance with record-keeping policy.

Verbatim wording from the response
“• The operational manager will conduct a monthly audit of our electronic clinical record (RIO) to identify patterns of delayed record keeping, in order for appropriate actions to be taken to improve standards that fall short of the Trusts record keeping policy.”

Source location
2019-0506-Response-from-North-West-Boroughs-Healthcare-NHS-Foundation-Redacted
Page 3 · response
Published 14 May 2020
Open published response
30 Sep2019
Manchester South
Concerns raised1
1. Poor-quality nursing documentation of fluid charts
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.

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

Mary Jones · 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

Mary Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.

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-quality nursing documentation of fluid charts
Wider context from the report
“3. The documentation within the nursing notes, particularly the fluid charts was poor quality, making it difficult to understand what had happened in relation to the hydration of Mrs Jones; ”
Source location
Mary Jones · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Sep2019
South Wales Central
Concerns raised2
1. Inconsistent timing of FACE record entries following patient interaction
2. Ad hoc requesting and documentation of ECGs
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.

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

Annette Susan HEWINS · 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

Annette Susan Hewins was detained under the Mental Health Act on 7 February 2017 for assessment and treatment of psychotic symptoms and opiate withdrawal. She was found unconscious in hospital on 8 February 2017 and died despite resuscitation; the post-mortem identified extensive coronary artery atherosclerosis as the likely cause of death. Concerns included inconsistent clinical record-keeping, incorrectly completed NEWS charts, missed observations, inadequate documentation and requesting of an ECG, insufficient detail in observation records, and the absence of a Trust policy for managing opiate-dependent patients in acute admissions.

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
Inconsistent timing of FACE record entries following patient interaction
Wider context from the report
“(1) There appeared to be some inconsistency as to approach to be taken amongst the Nursing staff/Health Care Assistant as to when entries should be made in the FACE records following interaction with a patient. It is considered that some guidance/training on this issue would be of benefit to promote greater consistency ”
Source location
Annette Susan HEWINS · 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
Ad hoc requesting and documentation of ECGs
Wider context from the report
“(4) ECG Requests – ████████ plan on 8.2.17 was for an ECG to be undertaken. There was no evidence that it had, or had been requested – not documented. The system in place for requesting ECG’s – routine or otherwise appeared somewhat ad hoc and it is suggested that a more robust system for documenting & requesting ECG’s should be considered & implemented. ”
Source location
Annette Susan HEWINS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
19 Sep2019
Manchester South
Concerns raised1
1. Failure to clearly document clinical decision-making in the notes
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 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

Caspian Thorn · 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

Caspian Thorn was born with significant brain damage after chronic placental insufficiency and died in hospital on 29 September 2018 after developing a gram-negative hospital-acquired infection and sepsis. The concerns included failure to offer induction or follow up a missed growth scan, poor communication and support for a vulnerable family, undocumented triage calls, inadequate documentation of decision-making, delayed recognition of a pathological CTG, and delayed recognition of signs of sepsis.

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 clearly document clinical decision-making in the notes
Wider context from the report
“4. Decision making that was not in accordance with trust guidance on 10th September was not clearly documented in the notes; ”
Source location
Caspian Thorn · Prevention of Future Deaths report
Page 2 · concerns
Open source report
29 Aug2019
Nottinghamshire
Concerns raised2
1. Failure to record contemporaneous home-visit notes on patient records
2. Failure to document all patient calls
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 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

Evelyn Ann Swift · 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

Evelyn Ann Swift became increasingly unwell over several days and contacted her GP surgery repeatedly on 3 January 2019, but a home visit was not arranged until that evening. The assessment was incomplete, her condition was not recognised as severe, and she was not admitted to hospital; she was found deceased at home the following morning. The principal concerns related to unsafe procedures for triage, home-visit allocation, urgent clinical advice, documentation, clinical cover, and review of significant events.

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 contemporaneous home-visit notes on patient records
Wider context from the report
“4. The Beechdale Medical Group did not have safe processes in place to ensure that all calls from patients were documented, nor safe processes to ensure that contemporaneous notes made during a home visit were recorded on the patient record. ”
Source location
Evelyn Ann Swift · 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 document all patient calls
Wider context from the report
“4. The Beechdale Medical Group did not have safe processes in place to ensure that all calls from patients were documented, nor safe processes to ensure that contemporaneous notes made during a home visit were recorded on the patient record. ”
Source location
Evelyn Ann Swift · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to make complete lists of current and recent prescriptions readily accessible

Concerns raised1

Incomplete recording in district nurse electronic care and treatment records

Concerns raised1

Lack of documentation of discrepancies between clinicians’ accounts

Concerns raised1

Lack of full and comprehensive record keeping in accordance with GMC and NMC guidance

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to record pharmacist-clinician discussions and advice

Concerns raised1

Delays of up to 24 hours in recording clinical information

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

Concerns raised1

Poor-quality nursing documentation of fluid charts

Concerns raised2

Inconsistent timing of FACE record entries following patient interaction

Ad hoc requesting and documentation of ECGs

Concerns raised1

Failure to clearly document clinical decision-making in the notes

Concerns raised2

Failure to record contemporaneous home-visit notes on patient records

Failure to document all patient calls

Actions described in response 4

Respondent positions 1

Actions described in response 2