Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

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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
Individual concerns: 568
Date range: 2008–2026
Stated actions: 780

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

30 Sep2024
Inner North London
Concerns raised2
1. Failure to ensure that consultation notes fully record discussions and assessments
2. Omissions from 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Sophie Ann Dean · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Sophie Ann Dean, who was aged 18, underwent surgery after free air was found in her abdomen and later required re-closure of her abdominal wound. She developed a chest infection and, after the second operation on 4 September 2023, suffered a cardiac arrest and died despite resuscitation efforts. The substantive concerns related to omissions and inadequacies in the medical records and whether the rationale and alternatives to surgery were sufficiently discussed with her parents before consent was given.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure that consultation notes fully record discussions and assessments
Wider context from the report
“1) Consultant’s undertaking ward rounds allowed very junior doctors to make the entry from these consultations in the patient records. While there is no concern about this per se, there were numerous key factors missing from these notes. I am concerned that the notes did not fully represent the discussions and assessments that took place, which creates risk. ”
Source location
Sophie Ann Dean · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Omissions from medical records
Wider context from the report
“2) There were other omissions from the medical records for Miss Dean’s admission. ”
Source location
Sophie Ann Dean · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Sep2024
Manchester South
Concerns raised1
1. Failure to ensure internal care documentation reflects the correct care position
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Conduct a further Single Assessment Framework assessment reviewing previously identified shortfalls and whether the provider has sufficiently improved.
  Stated by Care Quality CommissionStated in progress
AI-generated summary

George Neville Coulthard · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

George Neville Coulthard sustained skin wounds after an accidental fall, experienced gastrointestinal bleeds while in hospital, and later deteriorated and died at Bramhall Manor on 27 January 2024. The principal concerns were delays in discharge due to difficulty finding a suitable care home, ineffective communication about whether he required end-of-life care or rehabilitation, failure to clarify care arrangements, and limited community access to wound-care support.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to ensure internal care documentation reflects the correct care position
Wider context from the report
“3. The inquest also heard evidence that the staff at the care home had queried what level and type of care was to be delivered to Mr Coulthard given his overall presentation. However there was no evidence that the management team had sought to clarify the position or ensure the internal documentation reflected the correct position. ”
Source location
George Neville Coulthard · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct a further Single Assessment Framework assessment reviewing previously identified shortfalls and whether the provider has sufficiently improved.

Verbatim wording from the response
“As part of our processes, we are currently conducting a further assessment (under our new Single Assessment Framework) to review all the shortfalls identified at the last inspection and consider if there has been sufficient improvement. If we do not believe the registered provider has appropriately addressed the breaches of regulation to the extent”

Source location
Response from CQC
Page 4 · response
Published 24 September 2024
Open published response
11 Sep2024
Manchester South
Concerns raised2
1. Insufficient detail in neurology notes to communicate advice and clinical contact
2. Failure to store neurology notes in the patient record in an accessible location
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Nisren Abdul-Karim · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Nisren Abdul-Karim had underlying health conditions and developed hallucinations before being admitted to Wythenshawe Hospital, where she sustained a fractured hip in an unsupervised fall. She was transferred to Trafford General Hospital for rehabilitation, continued to deteriorate, and died there on 5 January 2024. The principal concern was that neurology notes recorded on patient pass were difficult to access and contained limited detail, resulting in disjointed neurology care and an unclear overview, particularly at sites without face-to-face neurology services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Insufficient detail in neurology notes to communicate advice and clinical contact
Wider context from the report
“The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service. ”
Source location
Nisren Abdul-Karim · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to store neurology notes in the patient record in an accessible location
Wider context from the report
“The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service. ”
Source location
Nisren Abdul-Karim · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Sep2024
Cheshire
Concerns raised1
1. Failure to record fluctuations in presentation relevant to diagnosis and pre-discharge review
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.
AI-generated summary

Charles Henry DANIELS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Charles Henry Daniels was admitted to Stepping Hill Hospital in January 2024 after a fall and was later discharged home in March despite being described as clearly unwell. He returned to hospital with an acute on chronic subdural bleed and died on 21 March 2024. Concerns included inadequate nursing record-keeping, failure to alert a doctor to his deterioration before discharge, and the distress caused by his condition and discharge arrangements at home.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record fluctuations in presentation relevant to diagnosis and pre-discharge review
Wider context from the report
“1) Record keeping by the nursing team at Stepping Hill Hospital did not record the fluctuations in presentation relevant to the diagnosis of intracranial hypotension or to enable or confirm a review of his condition prior to discharge. ”
Source location
Charles Henry DANIELS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Aug2024
Inner North London
Concerns raised1
1. Emergency department electronic patient records failing to show repeat presentations during the current illness
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 2
1. Action
  Display an electronic patient record icon identifying attendances within the previous 30 days.
  Stated by Royal Free London NHS Foundation TrustStated completed
2. Action
  Run refresher and induction training on identifying electronic patient record icons for recent attendances.
  Stated by Royal Free London NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  NHS England should address emergency department electronic record configuration showing previous presentations with the same signs and symptoms.
  Stated by Royal College of Emergency MedicineRedirects responsibility
1. Position
  Responsibility for electronic patient records lies with the NHS, rather than the College.
  Stated by Royal College of Paediatrics and Child HealthRedirects responsibility
AI-generated summary

Daniel KLOSI · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Daniel died on his fourth presentation in a week to the Royal Free Hospital, with group A streptococcus sepsis recorded as the medical cause of death. Concerns included the delay in obtaining a full set of observations when he was distressed, and electronic records not showing how many times a patient had attended hospital with the same signs and symptoms during the current illness.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Emergency department electronic patient records failing to show repeat presentations during the current illness
Wider context from the report
“2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments. ”
Source location
Daniel KLOSI · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Display an electronic patient record icon identifying attendances within the previous 30 days.

Verbatim wording from the response
“2. “The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness – and of course this may be the case in other emergency departments”.”

Source location
Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Run refresher and induction training on identifying electronic patient record icons for recent attendances.

Verbatim wording from the response
“The Trust can confirm that for patients who reattend an icon is visible next to the patients name on EPR indicating previous attendances within 30 days. The Trust is running refresher training on identifying these icons, and this is covered at the digital training induction for all new medical staff.”

Source location
Response from Royal Free London Hospital
Page 2 · response
Published 21 August 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
NHS England should address emergency department electronic record configuration showing previous presentations with the same signs and symptoms.

Verbatim wording from the response
“With regards your specific concerns about emergency department electronic patient records (EPR) and their configuration to show how many times a patient has presented to hospital with the same signs and symptoms as their current presentation, we feel this question is best directed towards NHS England.”

Source location
Response from RCEM
Page 2 · response
Published 21 August 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Responsibility for electronic patient records lies with the NHS, rather than the College.

Verbatim wording from the response
“2. The trust emergency department electronic patient records do not show how many times a patient has presented to hospital with the same signs and symptoms during their current illness”

Source location
Response from RCPCH
Page 2 · response
Published 21 August 2024
Open published response
12 Aug2024
Manchester North
Concerns raised1
1. Failure to complete the discharge clinical entry and risk assessment
This report raised 13 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 1
1. Action
  Remind staff to complete discharge clinical entries, risk assessments, checklists and crisis-information provision in accordance with policy.
  Stated by Priory GroupStated completed
Respondent positions 1
1. Position
  The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.
  Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibility
AI-generated summary

Mr David Thompson · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete the discharge clinical entry and risk assessment
Wider context from the report
“5. A discharge clinical entry and discharge risk assessment was not completed and there was no evidence of crisis information having been provided. ”
Source location
Mr David Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Remind staff to complete discharge clinical entries, risk assessments, checklists and crisis-information provision in accordance with policy.

Verbatim wording from the response
“Priory Hospital Dorking are to evidence safe discharge planning in accordance with Priory policy H02 Admission, Transfer and Discharge - to include completion of a clinical entry, updated risk assessment on discharge and issue all patients with a crisis card with”

Source location
Response from Priory Group
Page 9 · response
Published 12 August 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The NHS sending provider is responsible for overseeing individual care, including engagement in communication, discharge and care planning for out-of-area patients.

Verbatim wording from the response
“GM ICB expect the NHS “sending” provider to oversee the individual care relating to any patient who is admitted as an Out of Area placement in line with National Host commissioner guidance. This includes attendance at ward rounds, face to face visits where appropriate and full engagement in discharge and care planning. The processes as described above have been implemented since December 2023 and have provided a much tighter grip and control and increased level of oversight of each individual patient.”

Source location
Response from Greater Manchester NHS
Page 2 · response
Published 12 August 2024
Open published response
6 Aug2024
Worcestershire
Concerns raised1
1. Failure to record whether required mealtime assistance was provided
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 7
1. Action
  Review all resident care plans and improve recording of changing mealtime assistance needs.
  Stated by Cardinal HC LimitedStated in progress
2. Action
  Train all staff to document mealtime assistance levels and complete accurate, timely care records.
  Stated by Cardinal HC LimitedStated planned
3. Action
  Implement Care Vision to prompt point-of-care documentation and flag incomplete or delayed records, then train staff to use it.
  Stated by Cardinal HC LimitedStated planned
1. Action
  Conduct daily Resident of the Day spot checks to identify documentation gaps and take corrective action until Care Vision operates.
  Stated by Cardinal HC LimitedStated in progress
2. Action
  Operate the newly recruited full-time Clinical Lead role with responsibility for care-plan, documentation and mealtime-assistance oversight.
  Stated by Cardinal HC LimitedStated completed
3. Action
  Continue staff reflective-practice sessions on accurate, timely documentation and accountability, including further sessions for relevant staff.
  Stated by Cardinal HC LimitedStated in progress
4. Action
  Assign senior staff to provide ongoing mentorship and supervision to new staff on prompt, accurate documentation.
  Stated by Cardinal HC LimitedStated in progress
AI-generated summary

Alfred SPARROW · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Alfred Sparrow, who lived with vascular dementia, became a resident at The Meadows Nursing Home on 11 September 2023 and died there on 1 December 2023 after fluctuating food and fluid intake, increasing frailty and a significant deterioration. Concerns included staff not always assisting him with food and fluid intake as required by his care plan, a care-note entry recording that he drank tea about two hours after his death, and the failure of the nursing home manager’s investigation to identify that false entry and the related deficiencies.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record whether required mealtime assistance was provided
Wider context from the report
“1) Mr. Sparrow had a longstanding diagnosis of vascular dementia, and his care plan stated that he required full assistance and support from staff at mealtimes with regard to his intake of food and fluids, and that he would not support himself if food and drink was placed in front of him. Despite the care plan, entries in Mr. Sparrow’s care notes, while recording his food and fluid intake, made no mention of whether a staff member at The Meadows Nursing Home was assisting him in this regard. Having heard the evidence at the inquest, I was satisfied, and found as a matter of fact, that staff at The Meadows Nursing Home did not always assist Mr. Sparrow with his food and fluid intake; ”
Source location
Alfred SPARROW · Prevention of Future Deaths report
Page 1 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review all resident care plans and improve recording of changing mealtime assistance needs.

Verbatim wording from the response
“Care Plan and Documentation Review: A full review of all resident care plans is underway to ensure they accurately reflect each resident’s needs and any changes in their condition. In Mr Sparrow’s case, we now realise that his ability to feed himself may have fluctuated, and such fluctuations should be recorded better in care notes.”

Source location
Response from Cardinal Healthcare
Page 2 · response
Published 5 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Train all staff to document mealtime assistance levels and complete accurate, timely care records.

Verbatim wording from the response
“Training in Person-Centered Documentation: All staff receive additional training to improve their documentation of the level of assistance provided during meals. It is critical that staff not only record food and fluid intake but also specify the level of support provided to the resident, whether full assistance or encouragement.”

Source location
Response from Cardinal Healthcare
Page 2 · response
Published 5 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement Care Vision to prompt point-of-care documentation and flag incomplete or delayed records, then train staff to use it.

Verbatim wording from the response
“Implementation of Care Vision: We are in the final stages of contracting a new care planning system, Care Vision, which we hope will be fully operational by January 2025. Care Vision will prompt staff in real time to record food and fluid intake and flag incomplete entries to the management team. This system will ensure that detailed, accurate information about the level of assistance provided is recorded at the point of care.”

Source location
Response from Cardinal Healthcare
Page 2 · response
Published 5 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Conduct daily Resident of the Day spot checks to identify documentation gaps and take corrective action until Care Vision operates.

Verbatim wording from the response
“Spot Checks through the “Resident of the Day” System: Until Care Vision is fully implemented, the home manager will conduct daily spot checks of care notes as part of the “Resident of the Day” system. These checks will help identify any documentation gaps and ensure corrective actions are taken where necessary.”

Source location
Response from Cardinal Healthcare
Page 2 · response
Published 5 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate the newly recruited full-time Clinical Lead role with responsibility for care-plan, documentation and mealtime-assistance oversight.

Verbatim wording from the response
“Recruitment of new full-time clinical lead: We have recently recruited a full-time clinical lead at The Meadows, who is now part of our management team. The introduction of this Clinical Lead will allow the Home Manager to focus more on overseeing the overall operations of the home and strategic planning while ensuring a more effective delegation of clinical responsibilities. The Clinical Lead will provide enhanced support to nursing staff, ensuring that care plans, including mealtime assistance, are regularly reviewed and accurately documented. This addition to the management team will ensure that care is delivered according to each resident’s needs and that documentation standards are rigorously upheld.”

Source location
Response from Cardinal Healthcare
Page 2 · response
Published 5 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue staff reflective-practice sessions on accurate, timely documentation and accountability, including further sessions for relevant staff.

Verbatim wording from the response
“Reflective Practice and Staff Accountability: All staff have already participated in reflective practice sessions, which focus on the importance of timely and accurate documentation. During these sessions, staff discussed the impact of inaccurate entries on resident safety and the legal and ethical responsibilities they carry in their role. In the future, staff who fail to complete documentation in real time will be subject to disciplinary action.”

Source location
Response from Cardinal Healthcare
Page 3 · response
Published 5 August 2025
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Assign senior staff to provide ongoing mentorship and supervision to new staff on prompt, accurate documentation.

Verbatim wording from the response
“Supervision and Mentorship: Senior staff mentor new staff members to ensure they know the importance of recording notes promptly. We will also ensure that staff have the time and support needed to document care without feeling pressured by other duties.”

Source location
Response from Cardinal Healthcare
Page 3 · response
Published 5 August 2025
Open published response
24 Jul2024
Central and South East Kent
Concerns raised1
1. Failure to record vomiting before hospital discharge
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 3
1. Position
  No actions by NICE are considered necessary to address the issues raised in the report.
  Stated by National Institute for Health and Care ExcellenceNo action considered necessary
1. Position
  The concerns are local Trust issues outside NHS England’s remit.
  Stated by NHS EnglandOutside remit
2. Position
  East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Megan Ceris Williams · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Megan Ceris Williams developed abdominal pain and repeated vomiting between 1 and 5 May 2022, attended hospital twice, and died at home on 5 May 2022 after becoming breathless and losing consciousness. The inquest identified an undiagnosed small bowel obstruction apparently caused by adhesions from previous abdominal surgery. Concerns included possible missed opportunities for investigation, limited staff knowledge and clarity of the Acute Abdominal Pain Pathway, the lack of a signed self-discharge record, and the hospital investigation process not including information from family members.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record vomiting before hospital discharge
Wider context from the report
“Independent expert evidence was heard that indicated that the deceased likely had band adhesions - a known complication of her past abdominal surgery. It was the expert’s opinion that a small loop of bowel had become trapped in the adhesions causing pain and obstruction. The expert stated that this loop of bowel may have slid in and out explaining why the deceased’s symptoms were transient across the period of time that was examined (between 1st and 5th May 2022) and why clinicians suspected gastritis rather than a bowel obstruction. The inquest examined whether or not it would have been appropriate for a CT scan to have been done on the first hospital admission on 2nd May 2022. The lack of any record of a bout of vomiting by the deceased shortly before she left hospital on that date was relevant inasmuch as, had it been noted by hospital staff, may have lead to the deceased remaining in hospital with the potential for further investigations have been carried out which may have provided opportunities to intervene. The inquest also examined East Kent Hospital’s Acute Abdominal Pain Pathway (AAPP) including knowledge of this pathway among clinicians and the clarity of the pathway as it was documented included about a patient being referred directly back to any specialist department (such as surgeons) if returning to hospital within 48 hours of having been discharged. The lack of any signed record of the deceased self-discharging from hospital on 5th May was concerning. The inquest also examined the EKHT SI process and heard from an emergency department consultant who spoke as to the process. It was suggested that the SI process had not taken account of information which had been provided by the deceased’s family. (a) That there was a lack of knowledge, among clinical staff, of the Acute Abdominal Pain Pathway (AAPP). (b) Given what was said about how clear the AAPP was, that EKHT should provide evidence of what further work has been done make it clearer and accessible to clinicians. (c) That the hospital SI process did not include information from family and other interested persons or parties as part its fact-finding exercise. (d) There was not a clearly documented and recorded process for patients who self-discharge from hospital. ”
Source location
Megan Ceris Williams · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
No actions by NICE are considered necessary to address the issues raised in the report.

Verbatim wording from the response
“On this occasion, we do not consider that there are any actions from NICE that would address the issues raised.”

Source location
Response from NICE
Page 1 · response
Published 30 September 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The concerns are local Trust issues outside NHS England’s remit.

Verbatim wording from the response
“I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.”

Source location
Response from NHS England
Page 1 · response
Published 30 September 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
East Kent Hospitals University NHS Foundation Trust should respond to and address the concerns.

Verbatim wording from the response
“I note that you have also addressed your Report to East Kent Hospitals University NHS Foundation Trust (EKHT), and it is appropriate that they respond to each of the concerns raised by the Coroner, as these concerns do not fall under NHS England’s remit and are all local issues for the Trust to address.”

Source location
Response from NHS England
Page 1 · response
Published 30 September 2024
Open published response
18 Jul2024
Inner North London
Concerns raised1
1. Falsification of safe and supportive observation records
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 7
1. Action
  Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.
  Stated by East London NHS Foundation TrustStated completed
3. Action
  Deliver face-to-face Honesty in Documentation training across inpatient services.
  Stated by East London NHS Foundation TrustStated completed
1. Action
  Continue work promoting honesty in documentation.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.
  Stated by East London NHS Foundation TrustStated planned
3. Action
  Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.
  Stated by East London NHS Foundation TrustStated in progress
4. Action
  Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.
  Stated by East London NHS Foundation TrustStated planned
AI-generated summary

Anna Vivien Elliott · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Anna Vivien Elliott, who had severe recurrent depression with psychotic features and autism spectrum disorder, was detained under the Mental Health Act after having thoughts and plans to end her life. She was found deceased in her room on 24 November 2021 after safe and supportive observations were missed and her safety plan was ended without an adequate risk assessment. Concerns included inadequate handover and staffing, missed and falsified observation records, poor record keeping, and uncertainty about the management of safety plans.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Falsification of safe and supportive observation records
Wider context from the report
“Concern 4 In Anna’s case, observation records were backfilled despite the observations not having been conducted. All of the witnesses who gave evidence had received training, were aware of a previous PFD on missed and falsified observations, could tell me the purpose and importance of the observations, knew that observations should not be falsified and knew that if observations were missed, this should be reported that to the nurse in charge. I was also provided with screenshots of training which included a message from the Chief Nurse appearing to be dated May 2024 which refer to “an increase in occasions where observation records have not been completed but records falsified to reflect that they had been done”. As the spot checks described to me only look at the quality and timings of the written observations, I am not reassured that records are not still being falsified or about how this is being identified and addressed. ”
Source location
Anna Vivien Elliott · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and test an electronic observations platform with prompts, daily checks and safeguards against delayed, missed or falsified entries.

Verbatim wording from the response
“19. The Trust is currently developing a new E-observations (e-obs) platform which has in-built prompts to ensure staff capture the location of a patient, what they observe and their interactions with a patient. Daily spot checks will be undertaken by the clinical nurse manager or the most senior nurse on shift out of hours. It is hoped that this will be in place in the coming six months.”

Source location
Response from ELFT
Page 3 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the essential Inpatient Safety Suite covering observation practice and honesty in documentation.

Verbatim wording from the response
“The Inpatient Safety Suite of training is now ‘live’ and classed as essential for all inpatient nursing staff. This gives the ability to have oversight of compliance via Trust-wide training reporting. This suite includes training on observations and honesty in documentation.”

Source location
Response from ELFT
Page 5 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Deliver face-to-face Honesty in Documentation training across inpatient services.

Verbatim wording from the response
“Honesty in Documentation training was developed in Dec 2023 and rolled out face to face across all inpatient services over the period from December 2023 to April 2024.”

Source location
Response from ELFT
Page 5 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue work promoting honesty in documentation.

Verbatim wording from the response
“Continued work on honesty in documentation.”

Source location
Response from ELFT
Page 7 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Explore non-CCTV tools for assuring observation authenticity and review relevant national improvement workstreams.

Verbatim wording from the response
“Further explore possible tools for assurance against falsification of observation that does not rely on CCTV, although this may be difficult to design. This should include a review of national improvement workstreams.”

Source location
Response from ELFT
Page 8 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue communications discouraging falsified observations, encouraging honest reporting and clarifying missed-observation reporting requirements.

Verbatim wording from the response
“Communication To continue the Trust-wide campaign and consistent program of communications to staff discouraging the falsification of observations, encouraging honest reporting and improving staff awareness of reporting requirements for missed observations.”

Source location
Response from ELFT
Page 8 · response
Published 31 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop a consistent process supporting reflection, personal accountability and regulatory referral where indicated, alongside disciplinary procedures.

Verbatim wording from the response
“Standardised processes To develop a consistent approach to supporting staff to learn from their observations practice through reflection, personal accountability and if indicated onward referral to regulatory body. This will be followed in parallel to the Trust Disciplinary process.”

Source location
Response from ELFT
Page 9 · response
Published 31 July 2024
Open published response
4 Jul2024
East London
Concerns raised1
1. Poor or absent clinical records
This report raised 8 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 4
1. Action
  Prepare for adoption of an Electronic Patient Records system supporting contemporaneous, clear clinical documentation.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progress
2. Action
  Make contemporaneous, clear clinical documentation a mandatory part of medical and nursing induction for new starters.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated planned
3. Action
  Operate a Quarterly Health Records Group to present and review best practice and learning opportunities.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completed
1. Action
  Review the feasibility of CRABEL audits and prepare a plan for approval to assess medical record-keeping quality.
  Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progress
Respondent positions 2
1. Position
  Medical advice and guidance on medical practice or care quality fall outside the respondent’s remit.
  Stated by Medicines and Healthcare products Regulatory AgencyOutside remit
1. Position
  The Trust will respond separately to the concerns about care and processes.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

David John Morris · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

David John Morris, aged 78, developed oesophageal cancer after delays in diagnosis and treatment, later undergoing gastrostomy surgery. He developed a gastrostomy leak, peritonitis and septic shock, and died in hospital on 16 May 2022 after further surgery. The concerns included delayed recognition and treatment of the leak and sepsis, poor clinical records, deficiencies in the investigation, and ineffective controlled-drug management systems.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor or absent clinical records
Wider context from the report
“3. During Mr Morris’s ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent. The absence of clear records impeded the effective investigation of this death by the Trust’s governance teams and the Coroner. ”
Source location
David John Morris · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Prepare for adoption of an Electronic Patient Records system supporting contemporaneous, clear clinical documentation.

Verbatim wording from the response
“The standard of documentation was highlighted as being of a poor quality. The Trust is in the process of preparing for the introduction of an Electronic Patient Records (EPR) system, which is due to be adopted in May 2025. Adopting the EPR system will involve a process where contemporaneous and clear clinical documentation is made during clinical episodes of care; and this practice will be highlighted as a mandatory part of the medical and nursing induction process for all new starters.”

Source location
2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Make contemporaneous, clear clinical documentation a mandatory part of medical and nursing induction for new starters.

Verbatim wording from the response
“The standard of documentation was highlighted as being of a poor quality. The Trust is in the process of preparing for the introduction of an Electronic Patient Records (EPR) system, which is due to be adopted in May 2025. Adopting the EPR system will involve a process where contemporaneous and clear clinical documentation is made during clinical episodes of care; and this practice will be highlighted as a mandatory part of the medical and nursing induction process for all new starters.”

Source location
2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Operate a Quarterly Health Records Group to present and review best practice and learning opportunities.

Verbatim wording from the response
“In August 2024, the Medical Directorate has established a Quarterly Health Records Group where both best practice and learning opportunities will be presented and reviewed with action plans as appropriate.”

Source location
2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Review the feasibility of CRABEL audits and prepare a plan for approval to assess medical record-keeping quality.

Verbatim wording from the response
“In addition, the Trust lead for mortality is reviewing the possibility of performing CRABEL audits (an audit tool designed by CRawford – BEresford – LAfferty) as a tool for the assessment of the quality of medical record keeping, with the ability to standardise audit and improvement across areas. A plan is due to be presented for approval in November 2024 following the second meeting of the Health Records Group.”

Source location
2024-0360 - Response from Barking Havering and Redbridge NHS Trust
Page 2 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Medical advice and guidance on medical practice or care quality fall outside the respondent’s remit.

Verbatim wording from the response
“The MHRA assesses the balance of risks and benefits of medical devices throughout their use in clinical practice through the collection of information and assessment of any potential risks, followed, when necessary, with communications and regulatory action to minimise those risks. The MHRA does not have a role in providing medical advice or guidance relating to medical practice or care quality and therefore cannot comment on those aspects of this case.”

Source location
2024-0360 - Response from MHRA
Page 1 · response
Published 4 July 2024
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The Trust will respond separately to the concerns about care and processes.

Verbatim wording from the response
“I understand that the Barking, Havering & Redbridge University Trust will also be responding separately to your concerns and that the London region of NHS England is”

Source location
2024-0360 - Response from DHSC
Page 1 · response
Published 4 July 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure to ensure that consultation notes fully record discussions and assessments

Omissions from medical records

Concerns raised1

Failure to ensure internal care documentation reflects the correct care position

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

Concerns raised2

Insufficient detail in neurology notes to communicate advice and clinical contact

Failure to store neurology notes in the patient record in an accessible location

Concerns raised1

Failure to record fluctuations in presentation relevant to diagnosis and pre-discharge review

Concerns raised1

Emergency department electronic patient records failing to show repeat presentations during the current illness

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to complete the discharge clinical entry and risk assessment

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to record whether required mealtime assistance was provided

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.7

Concerns raised1

Failure to record vomiting before hospital discharge

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Actions described in response 1

Actions described in response 2

Respondent positions 2

Actions described in response 1

Respondent positions 1

Actions described in response 7

Respondent positions 3