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.
Nottinghamshire
Concerns raised1
Failure to make accurate and prompt records of consultations
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Train and instruct Crisis Team staff, and provide software and devices, to support contemporaneous recording of consultations in RiO.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Monitor compliance with timely RiO recording through monthly managerial supervision.
Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Prompt recording can be delayed when intermittent telecommunications signals prevent staff from entering notes remotely.
Stated by Nottinghamshire Healthcare NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Surrey
Concerns raised1
Failure to keep accurate care records
This report raised 11 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 raised2
Poor-quality documentation of second visits
Failure to complete evaluation or assessment sheets
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Reinforce full, legible documentation expectations during twice-daily ED Board Rounds.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Address documentation non-compliance through senior discussions and reflective learning recorded in clinicians’ Personal Development Plans.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Randomly audit ED documentation and address identified issues through the compliance process.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Disseminate documentation requirements through new-clinician induction, Grand Rounds, training sessions and clinical meetings.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Implement a fully electronic ED documentation system to replace handwritten clinical notes.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 February 2018.
Action
Apply the falls prevention and post-fall protocol, including prompt assessment, incident recording, investigation and review of care plans and risk assessments.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Increase Area Director and Quality Regulation Manager scrutiny of falls assessments and evaluations during visits and inspections.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Share sample falls risk assessments with staff to clarify assessment and post-fall evaluation requirements.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Hold daily flash meetings to discuss incidents and verify completion of follow-up actions, including referrals and risk-assessment updates.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Establish an internal falls team to review and update risk assessments, with three-monthly audits.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Action
Implement 24-hour post-incident observation records and senior clinical walk-rounds, with operational and internal inspection audits.
Stated by Hc-One LimitedStated completedThe respondent said that this action was complete when they made their response on 12 February 2018.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
There is no cultural acceptance of poor Emergency Department documentation; senior clinicians reinforce standards and address non-compliance.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Existing documentation standards, audits, corrective processes and electronic documentation address the concerns, making a Regulation 28 report unnecessary.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to enter engagement notes into the electronic system contemporaneously
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The concerns about Lifeline/CGL’s records are not a Pennine Care issue, so no further action will be taken.
Stated by Pennine Care NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Portsmouth and South East Hampshire
Concerns raised1
Failure to record requests for transfer to hospital in clinical notes
This report raised 11 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.
Avon
Concerns raised1
Failure to make clinical 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 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.1
Action
Add walk-in patients to the on-call triage list and obtain the on-call doctor’s advice, creating a prompt to document relevant information.
Stated by Wells Road SurgeryStated completedThe respondent said that this action was complete when they made their response on 27 February 2018.
Nottinghamshire
Concerns raised2
Failure to ensure clinical records reflect examinations actually performed
Failure to record that consultations were by telephone
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.
Norfolk
Concerns raised1
Workload-related delays in staff record completion
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Improve health-record completion through an organisation-wide programme with active monitoring.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
Action
Work with clinical teams to provide sufficient staffing and equipment for consistent, balanced work allocation.
Stated by Norfolk and Suffolk NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 February 2018.
Worcestershire
Concerns raised1
Inadequate case notes and medical records
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.
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
Action
Complete an audit establishing baseline clinical record-keeping performance and assessing improvement interventions.
Stated by Worcestershire Acute Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 28 November 2017.
Action
Develop a clinical record-keeping video with the communications team to improve documentation standards.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 28 November 2017.
Action
Finalize and distribute a clinical record-keeping leaflet to Trust staff who use patient notes.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 28 November 2017.
Manchester West
Concerns raised1
Failure to record prescriptions in relevant records in a timely effective manner
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.
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
Action
Roll out the Electronic Patient Record and Electronic Prescribing to enable clinicians to access current prescribed medication in outpatient clinics.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
