Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
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
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure of clinical records to provide sufficiently detailed and accurate information
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Destruction of contemporaneous handwritten notes following neonatal deaths
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to routinely document skin checks
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 concernsEach 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
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Action
Review reported tissue-damage incidents, take immediate local learning actions, and assess implications for the Trust-wide improvement plan.
Stated by Royal Devon University Healthcare NHS Foundation Trust -
Action
Establish a Northern-site leadership workstream to strengthen front-line nursing practice in pressure-ulcer prevention and management, with senior oversight of delivery.
Stated by Royal Devon University Healthcare NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing Trust-wide pressure damage prevention arrangements provide sufficient assurance that further work and dissemination are not required.
Stated by Royal Devon University Healthcare NHS Foundation Trust
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Concerns raised1
Lack of care plans in Summary Care Records
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 concernsEach 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.3
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Position
The Summary Care Record cannot include the full detail of a patient’s care plan because its design and format do not support it.
Stated by NHS England
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Position
Registered GP practices must enter care-plan information into the Summary Care Record using an appropriate clinical code.
Stated by NHS England -
Position
Uploading patient records into the national summary care record is outside NHS Dorset’s control, preventing it from addressing that issue.
Stated by NHS Dorset Integrated Care Board
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Concerns raised1
Weak record keeping
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 concernsEach 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
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Action
Implement the MaST caseload-management tool with electronic risk, disengagement and RAG indicators supporting MDT prioritisation, and monitor its use through regular audits.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Inaccurate record-keeping of patient observations
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 concernsEach 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
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Action
Introduce an e-observations system linking observation care plans to records, time-stamping entries, and requiring documentation of observation-level changes and escalation decisions.
Stated by East London NHS Foundation Trust -
Action
Amend daily ward spot-check audits to review observation records, documentation timeliness, completeness, accuracy, and actions taken in response to patient deterioration.
Stated by East London NHS Foundation Trust -
Action
Introduce the updated Observations and Therapeutic Engagement Policy, including documentation standards, missed-observation procedures, improvement ideas, and Honesty in Documentation training.
Stated by East London NHS Foundation Trust
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Action
Continue reinforcing record-keeping standards through regular audits, continuous training, and checks of timely, accurate, and complete documentation.
Stated by East London NHS Foundation Trust -
Action
Continue reviewing and enhancing record-keeping and auditing processes.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to maintain contemporary nursing and medical records of treatment and treatment decisions
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 concernsEach 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
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Action
Implement a full Electronic Patient Care Record to integrate clinical records.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Deliver Good Medical Record Keeping training through Legal Services and junior doctors’ emergency department induction.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust -
Action
Establish and operate a Quarterly Health Records Group to review best practice, learning opportunities and resulting action plans.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
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Action
Undertake paper-based CRABEL medical-record audits across specialties and share results Trust-wide.
Stated by Barking, Havering and Redbridge University Hospitals NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to maintain comprehensive, understandable, accurate and contemporaneous medical records
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 concernsEach 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
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Action
Audit medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
Stated by The Children's Trust -
Action
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
Stated by Care Quality Commission
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
Stated by Department of Health and Social Care
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Concerns raised1
Significant omissions in medical record 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 concernsEach 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
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Action
Complete a thematic review of patient-safety incidents and establish Trust-wide workstreams to address identified record-keeping gaps and embed learning.
Stated by North East London NHS Foundation Trust -
Action
Provide all staff with an intranet resource containing record-keeping guidance, escalation information, and quick access to related documentation standards.
Stated by North East London NHS Foundation Trust -
Action
Put revised good-record-keeping training packages into induction for all staff.
Stated by North East London NHS Foundation Trust
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Action
Require Home Treatment Team staff to use an agreed home-visit documentation template covering mental state, physical health, safeguarding, risk assessment, and follow-up planning, with fortnightly audits.
Stated by North East London NHS Foundation Trust
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Concerns raised1
Delays in recording senior clinical findings in the electronic patient record
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026