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
Trends
Reports over time
Reports mentioning this concern, 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
Reports and published responses 474 reports
See individual reports that have raised this concern, and the actions taken in response
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.
Linked response
United Lincolnshire Teaching Hospitals NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
United Lincolnshire Teaching Hospitals NHS Trust
Deliver case-study learning and disseminate reminders to medical staff about complete contemporaneous clinical documentation.
United Lincolnshire Teaching Hospitals NHS Trust
Conduct annual operative-note spot audits for three years following the annual changeover of middle-grade doctors.
United Lincolnshire Teaching Hospitals NHS Trust
Audit the accuracy of medical-record information and remind medical and midwifery staff of their candour duties.
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.
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.
Linked response
Lewisham and Greenwich NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Lewisham and Greenwich NHS Trust
Require staff to secure all loose clinical documentation in the main clinical notes.
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.
Linked response
Swansea Bay University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
Swansea Bay University Local Health Board
Replace tick-box tracking with standardized ED and AMU registers requiring consultant signatures to provide auditable confirmation of patient review.
Swansea Bay University Local Health Board
Implement ward documentation requiring the senior reviewing clinician to record completion and timing of review for ward staff.
Swansea Bay University Local Health Board
Reinforce with consultants and nursing staff their responsibilities for authenticating and checking documentation of senior patient review.
Swansea Bay University Local Health Board
Continue monitoring the review-tracking system and have the Clinical Director review consultant working practices while supporting development of an electronic system.
Swansea Bay University Local Health Board
Pilot a live electronic work list to notify teams about patients requiring review and treatment decisions, with auditable, time-stamped entries.
Swansea Bay University Local Health Board
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Swansea Bay University Local Health Board
Existing clinical assessment documentation and nursing escalation arrangements sufficiently notify ward staff whether senior review has occurred.
Existing 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.
Linked responses
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Department of Health and Social Care
Choice and implementation of electronic patient-record systems are matters for individual NHS Trusts.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
Electronic RiO records and information-sharing through team meetings and handovers provide a more appropriate account than printed records alone.
Existing 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.
Linked response
Cwm Taf Morgannwg University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Cwm Taf Morgannwg University Local Health Board
Improve monitoring of recording systems and processes.
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.
Linked response
Barts Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Barts Health NHS Trust
Emphasize to relevant staff the importance of accurately recording and changing patient details.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Barts Health NHS Trust
The clerical address error did not cause Mr Dack to be lost to follow-up because he knew about and rearranged his appointment.
Disputes 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.
Linked response
Mayday Healthcare plc
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Mayday Healthcare plc
Send monthly SMS reminders to all staff about documentation, escalation, medication administration and compassion.
Mayday Healthcare plc
Send quarterly formal letters to staff reinforcing documentation, escalation, medication administration and compassion.
Mayday Healthcare plc
Update the yearly training programme on documentation, escalation, medication administration and compassion beyond mandatory training requirements.
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.
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.
Linked response
Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Tameside and Glossop Integrated Care NHS Foundation Trust
Oxygen saturations were monitored and recorded during the hospital attendance, contrary to the concern that they were not.
Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.