Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

First to latest report 13 Dec 2008 — 26 Jun 2026

Reports that mention this concern
474
Times this concern has been raised
568
Stated actions linked to this concern
780

What this concern includes

Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.

What is 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 and published responses 474 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Black Country

    AI-generated summary

    Mr Richard Parkes · 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 Richard Parkes collapsed and died on 28 December 2015 after developing deep vein thrombosis with associated pulmonary thromboembolism. Concerns included poor record keeping, unavailable records from an August appointment, and the practice policy of not seeing patients more than ten minutes late, including on an occasion when Mr Parkes was not seen because he was late.

    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 record keeping and unavailability of patient appointment records

    Wider context from the report

    “1. There was evidence of poor record keeping at The Black Country Family Practice. Specifically records of the August appointment were not available and there was a policy of not seeing patients who were more than ten minutes outside their appointment time. Evidence emerged during the inquest that the GP who had seen Mr Parkes initially on the 12 October 2015 and arranged a further appointment on the 23 October 2015 and crucially, was aware of his medical history had decided not to see him on the latter date when he was late for his appointment. 2. Continuity of care and knowledge of medical history is extremely important in the management of patient care and this GP Practice may wish to consider reviewing their policy and management of record keeping. 3. In addition they may wish to consider reviewing the systems in place for excluding patients who are more than ten minutes or more late for appointments. There are inherent risks in adopting this policy and each case should be considered on a case by basis based on risk assessment. ”

    Source location

    Mr Richard Parkes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Wilfrid Pearson · 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

    Wilfrid Pearson was admitted to Tameside Hospital on 22 April 2015 with epilepsy, developed status epilepticus, and died at a local hospice about a month later. Concerns included possible failures in updating and communicating the status epilepticus protocol, unclear and incomplete records, inadequate escalation of care, staffing pressures, and the legal basis for detaining him after he left the ward.

    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

    Inadequate clarity, accuracy and completeness of medical and nursing notes

    Wider context from the report

    “2. The medical and nursing notes for Mr Pearson left much to be desired in terms of their clarity, accuracy and completeness. ”

    Source location

    Wilfrid Pearson · Prevention of Future Deaths report
    Page 1 · 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

    Revise nursing documentation and reinforce Ward Manager and Matron monitoring of documentation quality.

    Verbatim wording from the response

    “I am disappointed that HM Coroner found the medical and nursing records left much to be desired and I am sorry that you found this to be the case. HM Coroner will be aware that individual nursing and medical clinicians are responsible for their own professional standards. The Trust has a standard for medical record keeping and expects records to be timed and reflect an actual chronology. The Clinicians carrying out the assessment should document the time the assessment was carried out as well as the time of the medical entry. This is our Trust standard and the Trust encourage and promote this. The Trust has, since Mr Pearson’s admission, revised some of the nursing documentation and reinforced the role of Ward Managers and Matrons in monitoring the quality of documentation completed by staff.”

    Source location

    W-Pearson-Response
    Page 2 · response
    Published 24 February 2016

    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

    Audit key aspects of medical clinical documentation through the Trust’s Clinical Audit programme.

    Verbatim wording from the response

    “The Trust’s Clinical Audit programme, the Trust’s Clinical Lead for Clinical Audit has been working with doctors in training and audits have been undertaken which include key aspects of medical clinical documentation.”

    Source location

    W-Pearson-Response
    Page 2 · response
    Published 24 February 2016

    Open published response

  3. Manchester South

    AI-generated summary

    Edith Kirkham · 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

    Edith Kirkham fell at home on 13 August 2015, broke her hip, underwent surgery and was later moved to intermediate care, where she was not mobilised despite medical advice; she died some days later in North Manchester General Hospital. Concerns included unclear management arrangements, inadequate staffing and handover, failures to read or understand clinical instructions, lack of physiotherapy, and missing records relating to her stay.

    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

    Unavailability of records for patients’ ward stays

    Wider context from the report

    “6. Despite the request from me as HM Senior Coroner, it appears that no records were available relating to the whole of her stay in this ward. ”

    Source location

    Edith Kirkham · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner North London

    AI-generated summary

    Brenda Elizabeth MORRIS · 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

    Brenda Elizabeth Morris, aged 66, died by drowning herself in the bath at home after being admitted to Larch Lodge as an informal patient and granted weekend leave. Concerns included inadequate communication with her partner about the basis for leave, limited routine feedback from family after leave, confusion about authorisation of unplanned leave, and substandard nursing documentation affecting the recording of risk assessments.

    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

    Substandard nursing-record documentation of risk assessments before weekend leave

    Wider context from the report

    “4. Substandard documentation in the nursing records had already been identified before the inquest by your serious incident review. Without improvement in the records, it is not possible to determine whether and if so by whom a necessary risk assessment is undertaken, e.g. immediately before weekend leave is taken. ”

    Source location

    Brenda Elizabeth MORRIS · 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

    Implement and roll out the Informal patient leave agreement documenting doctor-approved leave, conditions, contingency plans, and signatures.

    Verbatim wording from the response

    “However, in light of the importance of this issue the Trust has taken the decision to implement the use of template documentation to ensure that any leave has been appropriately agreed by a doctor. A new ‘Informal patient leave agreement’ has been developed. This document details the agreement of leave following assessment by a doctor. The template includes a box detailing any leave conditions along with any expectations from staff, patients, relatives and carers. A separate box deals with contingency plans. The agreement is then signed by the doctor, the patient and the relative. This document is expected to be in place before a patient goes on leave.”

    Source location

    2016-0065-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 19 February 2016

    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 roll out the inpatient leave checklist requiring risk assessment, family discussions, contingency plans, return feedback, and RIO documentation.

    Verbatim wording from the response

    “In addition to the above an ‘In-patient leave checklist for informal and detained patients’ has been developed. It is also a requirement for this checklist to be completed for all leave. The checklist requires staff to assess risk prior to any period of leave, discuss with family or friends issues of risk and provide relatives/carers with a copy of an individualised contingency care plan. On return from leave staff will need to confirm that they have obtained feedback from family on the patient’s return from leave. The detail of all assessments and discussions will be fully documented on RIO.”

    Source location

    2016-0065-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 19 February 2016

    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 quarterly audits of leave forms and corresponding RIO entries from July 2016 through January 2017.

    Verbatim wording from the response

    “Both forms are currently being piloted on one of our Mental Health Care for Older Persons wards with the aim of full introduction across all of our Older Persons wards by the end of this month. Use of the forms and the corresponding RIO entries will be the subject to quarterly audits starting from the end of July 2016 until January 2017 and will be subject to further review thereafter if necessary.”

    Source location

    2016-0065-Response-by-East-London-NHS-Trust
    Page 2 · response
    Published 19 February 2016

    Open published response

  5. Surrey

    AI-generated summary

    Adam James Withers · 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

    Adam James Withers, who was suffering from an acute psychotic illness and detained in hospital, climbed a 130-foot chimney and fell from it, suffering fatal injuries. The report identified concerns about failures to manage his known risk of absconding, reassess his risk after he spoke about climbing the chimney ladder, prevent access to the ladder, communicate environmental risks, and ensure adequate supervision and reliable record-keeping.

    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

    Insufficient recording of psychiatric patient observations and interactions

    Wider context from the report

    “It was apparent from the evidence that periodic observations of psychiatric patients are conducted not only to check that each is present, but also in order to observe and assess their current state of mind and presentation, by means of a meaningful interaction, if possible. The importance of nursing staff (Registered Nurses and Health Care Assistants) making a sufficient written record of these observations was acknowledged. Regular notes of a patient’s condition are important for the purposes of diagnosis and they provide the information which is needed for a reliable assessment of the patient’s progress and current level of risk of harm or death. It was accepted in evidence that this is especially so in relation to any patient whose condition fluctuates. It was clear from the evidence that the nursing staff involved in Adam Withers’ care failed to record sufficiently his presentation and their interactions with him. For example, on the day of his death Adam Withers was subject to four observations per hour but no entries were made on his RIO notes or elsewhere about his state of mind or presentation at these observation points and no record was made about the conversation a nurse conducted with him that afternoon. Some of the nursing staff who gave evidence appeared to have little understanding of the need to make such written records and/or their importance. If permitted to continue, the insufficient recording of observations and events could have an adverse impact on the assessment, treatment and care of current and future patients and upon the protection of their lives. ”

    Source location

    Adam James Withers · 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

    Implement purposeful engagement in adult inpatient services and require timely recording of staff interactions in clinical records.

    Verbatim wording from the response

    “We acknowledge that our record keeping practice did not meet our desired and expected quality levels in this instance and we have learnt from these identified deficiencies. We have already instigated work to further improve the quality of our engagement with people using our adult inpatient services, by ensuring that all interactions are meaningful, using a process of purposeful engagement (a modified form of intentional rounding). The purposeful engagement process assists our staff in ensuring continuous assessment of individuals so timely interventions can be undertaken when necessary. As part of this process we expect all staff in these services to record interactions in the person’s clinical records in a timely way.”

    Source location

    Adam-WITHERS-Response
    Page 1 · response
    Published 15 February 2016

    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

    Revise the Observation Policy to require comprehensive risk assessments and documented observation decisions, risks and triggers.

    Verbatim wording from the response

    “We have also revised our Observation Policy to include much clearer guidance on how, when and where people should record all clinical interventions. This includes a review of the assessment section of this policy, which clearly states that all people that use our inpatient services will have a comprehensive Risk Assessment. This will include”

    Source location

    Adam-WITHERS-Response
    Page 1 · response
    Published 15 February 2016

    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

    Review the Records Management Policy and establish standards for factual, accurate, evidence-based and timely record keeping.

    Verbatim wording from the response

    “We have since reviewed our Records Management Policy which has a section outlining the ‘Standards for Record Keeping’. Under these standards there is clear expectation that:”

    Source location

    Adam-WITHERS-Response
    Page 2 · response
    Published 15 February 2016

    Open published response

  6. Portsmouth and South East Hampshire

    AI-generated summary

    James Robertson · 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

    James Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction unit.

    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 the timing of resident checks

    Wider context from the report

    “1) At Mr Robertson's Inquest, his care notes were referred to and I was told that carers were not required to accurately report the time of carrying out checks on him. This meant the Inquest could not accurately ascertain when he had been checked by care staff on the day of his death. ”

    Source location

    James Robertson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. South Yorkshire (Eastern)

    AI-generated summary

    Marc Jason Stephen Poole · 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

    Marc Jason Stephen Poole, aged 6, was admitted to hospital on 16 May 2015 with suspected infection and died in Sheffield Children’s Hospital on 18 May 2015 from the effects of pneumococcal septicaemia. The report identified concerns about delayed antibiotic treatment, poor communication, inaccurate observation and warning-score recording, inadequate paediatric sepsis guidance, dissemination of medical information, and poor record keeping.

    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 events and developments

    Wider context from the report

    “(5) Poor record keeping Even when a ward is busy, it is imperative that clear records are made of significant events or developments. There were a number of occasions where no record was made at all ”

    Source location

    Marc Jason Stephen Poole · 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

    Remind medical and nursing staff that record keeping must meet Nursing and Midwifery Council and General Medical Council standards.

    Verbatim wording from the response

    “It is acknowledged that record keeping was poor both from medical and nursing staff and I confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients. Staff have been reminded that good record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping. In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal.”

    Source location

    Marc-Poole-Response
    Page 3 · response
    Published 2 February 2016

    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 all Trust consultants to audit clinical records as part of annual appraisal.

    Verbatim wording from the response

    “It is acknowledged that record keeping was poor both from medical and nursing staff and I confirm the individuals who were involved in this case have reflected on this and the importance of recording care that is given to patients. Staff have been reminded that good record keeping is in line with what is expected by the Nursing and Midwifery Council and the General Medical Council Guidelines on record keeping. In respect of this all Consultants within the Trust are required to undertake an audit of clinical records as part of their yearly appraisal.”

    Source location

    Marc-Poole-Response
    Page 3 · response
    Published 2 February 2016

    Open published response

  8. Manchester South

    AI-generated summary

    Derek Edward Hare · 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

    Derek Edward Hare underwent a colectomy and later embolization after experiencing severe abdominal pain and rectal bleeding. A subsequent colonoscopy led to failure of the bowel anastomosis, causing loss of bowel content and sepsis; he died after later surgery. The substantive concerns included separate hospital records, repeated refusal of requests for review, and discharge on 6 May 2015 despite abdominal pain when keeping him in hospital might have benefited his 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

    Failure to maintain a single coherent set of clinical notes

    Wider context from the report

    “1. It would appear that throughout his various admissions to the hospital, two completely separate sets of “notes” were open and being used. Thus when the doctor tried to refer to the notes in court he could not do so and had to seek a short adjournment to find the relevant entry. If this were the case when the patient was in the hospital, it is hardly surprising that errors were made and staff members were not clear as to what would comprise the optimum care for this patient. ”

    Source location

    Derek Edward Hare · Prevention of Future Deaths report
    Page 1 · 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

    Reiterate and reinforce the record-keeping policy requiring staff to use one current set of records during each admission, through clinical leads and governance meetings.

    Verbatim wording from the response

    “In respect of your concerns regarding the case notes I recognise that staff entries into the records should be in one set of records which should be the current ones in use during the patient’s admission. This is the Trust’s standard and expectation and has been reiterated to the Consultant Clinical Leads, Lead Clinicians and Senior Nurses in the Clinical Divisions for discussion to all staff and for discussion at their Clinical Governance and team meetings. As you have highlighted where it is necessary to provide two sets of notes for reference to the previous history and continuity of care there is a risk that medical staff may enter their notes in the older set of notes. This reiteration and reinforcement of the record keeping policy will minimise this.”

    Source location

    D-hare-Response
    Page 2 · response
    Published 20 January 2016

    Open published response

  9. Manchester South

    AI-generated summary

    Irene Anne Pearson · 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

    Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.

    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 clear and sufficiently detailed electronic clinical notes

    Wider context from the report

    “5. The GP Practice’s electronic notes of the attendances upon the patient were unclear and there appeared to be discrepancies between what was noted as prescribed by way of opiate patches, and what the patient actually had in her possession. The notes were on occasions ‘scanty’ in detail and the doctor giving evidence accepted this and told me that this was because they, as doctors, are limited to ten-minute appointments and they do not always have time properly to record their notes. (Churchgate Surgery) ”

    Source location

    Irene Anne Pearson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. West Sussex

    AI-generated summary

    Joanne Michelle French (otherwise known as Joanne Michelle Hay) · 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

    Joanne Michelle French, also known as Joanne Michelle Hay, was discharged from Meadowfield Hospital on 11 December 2014 after a serious suicide attempt. She was found hanging on 14 December 2014 and could not be revived. Concerns included unclear communication about the discharge assessment, inaccurate assessment notes, and the absence of a process for family members to provide relevant views or information about the early discharge.

    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 assessment notes to clearly and accurately record information for the discharge decision-maker

    Wider context from the report

    “(3) The assessment notes were not completely clear and accurate in recording the information to be provided to the person making the decision to discharge. ”

    Source location

    Joanne Michelle French (otherwise known as Joanne Michelle Hay) · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026