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.
South London
Concerns raised1
Failure to complete required duplicate A&E clinical record entries by mental health staff
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Investigating or acting against individual healthcare professionals falls outside the regulator’s authority.
Stated by Care Quality CommissionOutside remitThe respondent said that this matter was outside its role or authority.
Birmingham and Solihull
Concerns raised1
Failure to maintain accurate contemporaneous records of behaviour and mood
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.2
Action
Provide supervision that develops staff understanding, reflection, performance, policy compliance and responses to deteriorating mental health.
Stated by All Care in OneStated in progressThe respondent said that this action was in progress when they made their response on 4 March 2025.
Action
Revise internal safeguarding policies to clarify recognition, escalation and record-keeping for acute mental health issues.
Stated by All Care in OneStated completedThe respondent said that this action was complete when they made their response on 4 March 2025.
Inner North London
Concerns raised1
Lack of a minimum standard for psychotherapy consultation note keeping
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
Require members to keep accurate, necessary and data-protection-compliant records.
Stated by British Association For Counselling And PsychotherapyStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Action
Provide members with evidence-based guidance resources on confidentiality and record keeping.
Stated by British Association For Counselling And PsychotherapyStated completedThe respondent said that this action was complete when they made their response on 25 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ethical and contractual requirements, alongside client choice and practitioner judgment, are considered sufficient to govern psychotherapy record keeping.
Stated by British Association For Counselling And PsychotherapyExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Inner North London
Concerns raised1
Deficiencies in basic clinical record keeping
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.5
Action
Deliver regular falls-prevention simulation training, including protocol, post-fall management, documentation, escalation and prevention, to nursing and medical staff.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
Action
Update electronic patient records to capture falls assessments, interventions, care planning and post-fall management at admission, after falls and when condition changes.
Stated by Royal Free London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
Action
Reinforce accurate falls documentation requirements with ward staff through divisional governance education.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
Action
Monitor compliance with falls documentation through audits, the Falls Steering Group and clinical safety governance committees.
Stated by Royal Free London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 20 February 2025.
Action
Send a Trust-wide safety bulletin reminding staff to document falls assessments, interventions and post-fall management.
Stated by Royal Free London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 20 February 2025.
Worcestershire
Concerns raised3
Failure to complete documentation of Enoxaparin administration
Failure to complete documentation of compression stocking fitting and use
Insufficient nurse awareness of the duty to complete important documentation
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.4
Action
Reinforce requirements to sign prescription charts through daily safety huddles and team meetings.
Stated by Worcestershire Acute Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2025.
Action
Update and recirculate Trust-wide learning on mechanical thromboprophylaxis and signing prescriptions.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 January 2025.
Action
Request that the digital team ensure new electronic prescribing charts meet all requirements before launch.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 January 2025.
Action
Increase VTE compliance monitoring through regular divisional audits of prescription-chart signing and monthly reports to the Improving Safety Action Group.
Stated by Worcestershire Acute Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 20 January 2025.
County Durham and Darlington
Concerns raised2
Failure to clearly document medical advice obtained after resident falls
Failure to maintain accessible and retained resident records
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.6
Action
Prompt visiting healthcare professionals to sign in, accompany visits with senior staff, document advice and recommendations, and record information for handovers and audit.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Deliver record-keeping, care-plan and documentation training covering contemporaneous entries, professional visits, emerging risks, RADAR records and archiving.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Publish and distribute an archiving guide setting standards for record storage, safekeeping and retention across the Group.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Develop and roll out additional learning-management guidance on GDPR and the safekeeping and storage of records.
Stated by Four Seasons Health Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
Action
Conduct daily documentation checks, monthly file checks and regular care-plan sampling to identify omissions, errors and compliance issues.
Stated by Four Seasons Health Care GroupStated completedThe respondent said that this action was complete when they made their response on 13 January 2025.
Action
Pilot electronic care records at several homes to support digitisation of intensive manual record-keeping processes.
Stated by Four Seasons Health Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 13 January 2025.
Essex
Concerns raised2
Failure to maintain contemporaneous and accurate Labour Ward medication records
Failure to record Labour Ward vital signs on required MEOWS charts
This report raised 14 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
Use electronic prescribing and medication administration records for medications across all Trust sites, except unsupported variable-rate infusions.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Upload patient notes digitally before multidisciplinary meetings so attendees can scrutinise records across meeting formats.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Provide guidance on preventing and managing postpartum haemorrhage, including clinical assessment, monitoring, escalation and multidisciplinary response.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Provide guidance on maternal collapse, including early-warning observation, systematic cause identification, ongoing assessment and concealed-haemorrhage diagnosis.
Stated by Royal College of Obstetricians and GynaecologistsStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Train staff on MEWS charts and eliminate photocopied versions to support accurate scoring and escalation.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
Action
Implement the national MEWS observation package and escalation policy, including trigger-team referral and mandatory maternity-inpatient use.
Stated by Mid and South Essex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 18 December 2024.
South Yorkshire (Eastern)
Concerns raised1
Care and support placement records omitting identified stair-related fall risks
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
Continue staff training and reinforce accurate recording of falls and other health-related events.
Stated by City of Doncaster CouncilStated in progressThe respondent said that this action was in progress when they made their response on 20 February 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Council had no record that concerns about deteriorating ability on stairs were reported by family, carers or the individual.
Stated by City of Doncaster CouncilDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Yorkshire (Western)
Concerns raised1
Failure to record mental health or medication reviews
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.4
Action
Create and implement a mental health template that standardises coding of mental health and medication reviews in clinical records.
Stated by Dearne Valley Group PracticeStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Review all current SSRI patients, prioritising those discharged from mental health services, using the new template and completing mental health and medication reviews.
Stated by Dearne Valley Group PracticeStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Inform the clinical team that reviews must include clear coding and wording in patient records for all patients.
Stated by Dearne Valley Group PracticeStated completedThe respondent said that this action was complete when they made their response on 9 December 2024.
Action
Use scheduled reminders to prompt clinicians to complete patients’ mental health and medication reviews.
Stated by Dearne Valley Group PracticeStated in progressThe respondent said that this action was in progress when they made their response on 9 December 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Mental health and medication reviews had occurred; the material problem was missing clinical-record coding.
Stated by Dearne Valley Group PracticeDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to record key aspects of surgery
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.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
