Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
- 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.
Reports and published responses 474 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
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.
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.
Linked response
- Royal Devon University Healthcare NHS Foundation 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.2
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Royal Devon University Healthcare NHS Foundation Trust
Review reported tissue-damage incidents, take immediate local learning actions, and assess implications for the Trust-wide improvement plan.
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Royal Devon University Healthcare NHS Foundation Trust
Establish a Northern-site leadership workstream to strengthen front-line nursing practice in pressure-ulcer prevention and management, with senior oversight of delivery.
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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Royal Devon University Healthcare NHS Foundation Trust
Existing Trust-wide pressure damage prevention arrangements provide sufficient assurance that further work and dissemination are not required.
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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.
Linked responses
- NHS Dorset Integrated Care Board
- NHS England
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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NHS England
The Summary Care Record cannot include the full detail of a patient’s care plan because its design and format do not support it.
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NHS England
Registered GP practices must enter care-plan information into the Summary Care Record using an appropriate clinical code.
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NHS Dorset Integrated Care Board
Uploading patient records into the national summary care record is outside NHS Dorset’s control, preventing it from addressing that issue.
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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.
Linked response
- Essex Partnership University NHS Foundation 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
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Essex Partnership University NHS Foundation Trust
Implement the MaST caseload-management tool with electronic risk, disengagement and RAG indicators supporting MDT prioritisation, and monitor its use through regular audits.
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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.
Linked response
- East London NHS Foundation 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.5
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East London NHS Foundation Trust
Introduce an e-observations system linking observation care plans to records, time-stamping entries, and requiring documentation of observation-level changes and escalation decisions.
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East London NHS Foundation Trust
Amend daily ward spot-check audits to review observation records, documentation timeliness, completeness, accuracy, and actions taken in response to patient deterioration.
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East London NHS Foundation Trust
Introduce the updated Observations and Therapeutic Engagement Policy, including documentation standards, missed-observation procedures, improvement ideas, and Honesty in Documentation training.
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East London NHS Foundation Trust
Continue reinforcing record-keeping standards through regular audits, continuous training, and checks of timely, accurate, and complete documentation.
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East London NHS Foundation Trust
Continue reviewing and enhancing record-keeping and auditing processes.
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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.
Linked responses
- Barking, Havering and Redbridge University Hospitals NHS Trust
- Department of Health and Social Care
Stated actions 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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Barking, Havering and Redbridge University Hospitals NHS Trust
Implement a full Electronic Patient Care Record to integrate clinical records.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Deliver Good Medical Record Keeping training through Legal Services and junior doctors’ emergency department induction.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Establish and operate a Quarterly Health Records Group to review best practice, learning opportunities and resulting action plans.
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Barking, Havering and Redbridge University Hospitals NHS Trust
Undertake paper-based CRABEL medical-record audits across specialties and share results Trust-wide.
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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Department of Health and Social Care
BHRUT is responsible for responding fully to the concerns, so the Department will not duplicate its response.
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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.
Linked responses
- Care Quality Commission
- Department of Health and Social Care
- The Children's 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.2
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The Children's Trust
Audit medical records regularly against NHS standards and address ongoing health-record integration issues with system partners.
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Care Quality Commission
Undertake a comprehensive inspection of the service, including assessment of overnight observations, care planning, clinical monitoring and governance.
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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Department of Health and Social Care
The Local Authority, not NHS England, is responsible for overseeing the quality of the residential care service because it commissioned the bed.
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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.
Linked response
- North East London NHS Foundation 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.4
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North East London NHS Foundation Trust
Complete a thematic review of patient-safety incidents and establish Trust-wide workstreams to address identified record-keeping gaps and embed learning.
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North East London NHS Foundation Trust
Provide all staff with an intranet resource containing record-keeping guidance, escalation information, and quick access to related documentation standards.
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North East London NHS Foundation Trust
Put revised good-record-keeping training packages into induction for all staff.
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North East London NHS Foundation Trust
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.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026