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.
Central Lincolnshire
Concerns raised2
Failure to identify and rectify missing full notes after a death
Failure to maintain full contemporaneous records of term neonatal deaths
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.
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
Deliver case-study learning and disseminate reminders to medical staff about complete contemporaneous clinical documentation.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 6 March 2015.
Action
Conduct annual operative-note spot audits for three years following the annual changeover of middle-grade doctors.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 March 2015.
Action
Audit the accuracy of medical-record information and remind medical and midwifery staff of their candour duties.
Stated by United Lincolnshire Teaching Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 6 March 2015.
Manchester West
Concerns raised1
Omissions in documentation and record keeping of falls and changes in residents’ condition
This report raised 6 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.
Inner South London
Concerns raised1
Failure to retain recorded observations in the medical 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
Require staff to secure all loose clinical documentation in the main clinical notes.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 5 March 2015.
Powys, Bridgend & Glamorgan Valleys
Concerns raised1
Failure of paper records to accurately document Consultant patient review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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
Replace tick-box tracking with standardized ED and AMU registers requiring consultant signatures to provide auditable confirmation of patient review.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
Action
Implement ward documentation requiring the senior reviewing clinician to record completion and timing of review for ward staff.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
Action
Reinforce with consultants and nursing staff their responsibilities for authenticating and checking documentation of senior patient review.
Stated by Swansea Bay University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 4 March 2015.
Action
Continue monitoring the review-tracking system and have the Clinical Director review consultant working practices while supporting development of an electronic system.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2015.
Action
Pilot a live electronic work list to notify teams about patients requiring review and treatment decisions, with auditable, time-stamped entries.
Stated by Swansea Bay University Local Health BoardStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2015.
Action
Implement the national Symphony emergency department system across Health Board emergency and assessment units, beginning at specified hospitals in September 2015 and continuing in November 2015.
Stated by Swansea Bay University Local Health BoardStated plannedThe respondent said that this action was planned when they made their response on 4 March 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing clinical assessment documentation and nursing escalation arrangements sufficiently notify ward staff whether senior review has occurred.
Stated by Swansea Bay University Local Health BoardExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sunderland
Concerns raised1
Failure to ensure medical personnel have immediate electronic access to complete patient notes
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.2
Position
Choice and implementation of electronic patient-record systems are matters for individual NHS Trusts.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Electronic RiO records and information-sharing through team meetings and handovers provide a more appropriate account than printed records alone.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Powys, Bridgend and Glamorgan Valleys
Concerns raised1
Failure to make clinical records of crisis team contact
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.1
Action
Improve monitoring of recording systems and processes.
Stated by Cwm Taf Morgannwg University Local Health BoardStated completedThe respondent said that this action was complete when they made their response on 19 February 2015.
London Inner (North)
Concerns raised1
Failure to maintain accurate patient addresses in medical notes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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
Emphasize to relevant staff the importance of accurately recording and changing patient details.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 February 2015.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The clerical address error did not cause Mr Dack to be lost to follow-up because he knew about and rearranged his appointment.
Stated by Barts Health NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Mid Kent and Medway
Concerns raised2
Failure of agency staff to make adequate records in patients' nursing notes
Failure of agency staff to understand the need to record information in patients' nursing notes
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.3
Action
Send monthly SMS reminders to all staff about documentation, escalation, medication administration and compassion.
Stated by Mayday Healthcare plcStated completedThe respondent said that this action was complete when they made their response on 17 February 2015.
Action
Send quarterly formal letters to staff reinforcing documentation, escalation, medication administration and compassion.
Stated by Mayday Healthcare plcStated completedThe respondent said that this action was complete when they made their response on 17 February 2015.
Action
Update the yearly training programme on documentation, escalation, medication administration and compassion beyond mandatory training requirements.
Stated by Mayday Healthcare plcStated completedThe respondent said that this action was complete when they made their response on 17 February 2015.
Northamptonshire
Concerns raised1
Poor and perfunctory risk assessment documentation
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.
Manchester South
Concerns raised1
Failure to record oxygen saturations during hospital care
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Oxygen saturations were monitored and recorded during the hospital attendance, contrary to the concern that they were not.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
