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
Distinct published reports
Individual concerns
568
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
780
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.
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
NHS trust265
Healthcare site91
Ministerial department73
Executive non-departmental public body44
Private limited company32
Health and social care service regulator30
Integrated care board26
Type not available24
Local health board21
Residential care home17
Multi-service care provider15
Nursing home15
Health professional body14
Independent healthcare provider12
Coronial office9
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.
Essex
Concerns raised1
Inadequate electronic record documentation
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 concerns
Each 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.7
Action
Review Prisoner Warning Notice alerts daily, record risk information in patient records, and alert relevant healthcare professionals, particularly mental health staff.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Introduce targeted SystmOne training, require basic training for new staff, and provide refresher training for existing staff.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Provide structured reception-nurse supervision, coaching, documentation audits, case-based feedback, and governance reporting to improve recording and escalation of mental-health risks.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Provide bespoke documentation and incident-reporting training, induction support, and guidance materials for staff.
Stated by HCRG Care GroupStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Review the need for an interim documentation and workflow support post before NOVA implementation.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Review existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Monitor clinical-documentation timeliness and quality through supervision, monthly performance reporting, and targeted follow-up.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Kent and Medway
Concerns raised1
Inconsistent, unreliable and incomplete medical 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 concerns
Each 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
Action
Present documentation standards and accurate-recording expectations during junior doctor Trust induction.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
Action
Implement improvements to electronic documentation of neurological observations.
Stated by East Kent Hospitals University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 January 2026.
West London
Concerns raised1
Lack of record-keeping requirements for NTMC
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Responsibility for the reported issues rests with DHSC, which has provided the comprehensive government response; MHCLG has nothing further to add.
Stated by Ministry of Housing, Communities and Local GovernmentRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Sunderland
Concerns raised1
Inconsistent use of the Omnicell cabinet and electronic medication record
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 concerns
Each 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.6
Action
Configure ARMS alerts so ward pharmacy teams can deliver face-to-face Omnicell training during newly employed nursing staff’s induction.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Update and deliver face-to-face Omnicell training for ward pharmacy teams, with training offered to bed-based nursing teams.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Update Omnicell guides and training checklists, publish them on the intranet, and circulate them through the Trust bulletin.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Action
Update the Medicines Optimisation Policy and medicines-management e-learning package for Omnicell competencies and EPMA use, and circulate the policy updates.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 December 2025.
Action
Operate a Task and Finish group developing further safer-medicines-administration actions, including mandatory Omnicell assessment, competency support and possible medicines-management roles.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Integration of Omnicell and EPMA is currently not viable because evidence is limited, costs are significant, and integration may introduce patient safety risks.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure to maintain complete and comprehensible care notes
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 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.
Manchester South
Concerns raised1
Limited documentation of wound care concerns and escalation attempts
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 concerns
Each 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
Action
Require documentation of all hospital and community-team calls, unsuccessful attempts and mitigation for missing treatment plans.
Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
Action
Record hospital admission and discharge-planning calls in Nourish with contact details, timing and required follow-up.
Stated by Lentulus Properties Ltd t/a Bamford Grange and Springcare LimitedStated completedThe respondent said that this action was complete when they made their response on 11 November 2025.
North Yorkshire and York
Concerns raised1
Failure to obtain or record a clear contemporaneous account of GP consultations
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The existing Clinical Care Review process is considered robust, with independent scrutiny identifying learning and mitigating recurrence risks.
Stated by Ministry of DefenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Gateshead and South Tyneside
Concerns raised1
Failure to complete documentation to an accepted standard
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 concerns
Each 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
Action
Use Nourish automated alerts to identify and escalate overdue care records.
Stated by Malhotra Care Homes LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
Action
Use Nourish wound-management workflows requiring tailored assessments, photographs and treatment plans.
Stated by Malhotra Care Homes LtdStated completedThe respondent said that this action was complete when they made their response on 14 October 2025.
East London
Concerns raised1
Unavailability of notes for the 24th November admission
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.
South Yorkshire (Eastern)
Concerns raised1
Failure to keep adequate wound management 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 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.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
