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.
Milton Keynes
Concerns raised1
Failure of treating doctors to make accurate clinical notes of major presenting symptoms
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 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.
North Northumberland and South Northumberland
Concerns raised1
Failure to make timely and complete clinical records documenting assessment, care planning and decision-making rationale
This report raised 12 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.
West Sussex, Brighton and Hove
Concerns raised1
Failure to complete the daily care log
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Introduce the new Record of Patient Leaving Ward document across Trust wards and provide local staff training on its consistent use.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Action
Review the new Record of Patient Leaving Ward document’s effectiveness after three months and report findings to the Acute Care Forum.
Stated by Sussex Partnership NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2023.
Essex
Concerns raised1
Inaccurate and outdated risk information in ward records
This report raised 15 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.3
Action
Audit inpatient and urgent-care record keeping, identify copying-and-pasting issues, and agree follow-up actions for affected care groups.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
Action
Conduct local clinical-record spot checks and daily-huddle and supervision reviews to identify and address inappropriate copying and pasting.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 March 2023.
Action
Disseminate record-keeping guidance through an animated video, live learning event and Safety Learning Alert, with managers completing resulting actions.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 March 2023.
East London
Concerns raised1
Poor maintenance of clinical records of fluid administration
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.5
Action
Conduct and continue unannounced cross-site fluid-management audits on every COTE ward, monitoring Careflow Vitals recording and appropriate follow-up.
Stated by BHRUTStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2023.
Action
Conduct peer fluid-monitoring audits between COTE wards and share results through governance meetings and daily huddles.
Stated by BHRUTStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2023.
Action
Provide nursing staff with Careflow Vitals training and one-to-one fluid-monitoring support.
Stated by BHRUTStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
Action
Train medical staff to access fluid balances in Careflow Vitals and discontinue completion of paper fluid charts.
Stated by BHRUTStated completedThe respondent said that this action was complete when they made their response on 24 February 2023.
Action
Carry out a clinical safety assessment to identify and mitigate hazards affecting entry or viewing of fluid-balance data.
Stated by BHRUTStated plannedThe respondent said that this action was planned when they made their response on 24 February 2023.
Inner North London
Concerns raised2
Failure to document hot debriefs in notes or medical records
Failure to record reasons for crisis-team pathway 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 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
Review how learning from incidents is investigated and recorded through implementation of the Patient Safety Incident Response Framework.
Stated by East London NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Hot debriefs are not recorded in clinical notes because they are informal staff-support processes; learning is captured through 48-hour and serious incident reports.
Stated by East London NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Hampshire, Portsmouth and Southampton
Concerns raised1
Poor completion of nursing care plan documentation
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.6
Action
Audit completion and updating of clinical documentation.
Stated by Portsmouth Hospitals University NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
Action
Update documentation systems to improve clinical record completeness and accessibility.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
Action
Deliver documentation education through the reviewed preceptorship programme for newly registered nurses and healthcare support workers.
Stated by Portsmouth Hospitals University NHS TrustStated completedThe respondent said that this action was complete when they made their response on 9 January 2023.
Action
Work with the Integrated Care Board and regional acute trusts towards a paper-free electronic patient record.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
Action
Continue ward accreditation assessments, including care-plan and patient-record reviews, feedback, action planning and governance reporting.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 9 January 2023.
Action
Complete the decision-making process on adopting electronic clinical-note forms to improve completion of mandated fields.
Stated by Portsmouth Hospitals University NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 9 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing ward accreditation and clinical audit processes are considered sufficient to address nursing documentation and care-plan completion concerns.
Stated by Portsmouth Hospitals University NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Berkshire
Concerns raised1
Failure to maintain complete records of fluid provision and pad status
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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The provider has taken sufficient action to mitigate risks and prevent future deaths.
Stated by Care Quality CommissionExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised2
Poor maintenance of clinical records
Failure to record identified CT Spine abnormalities
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
Audit documentation on the trauma neurosurgical pathway and provide refresher and induction training on record keeping.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 7 November 2022.
Action
Implement an electronic patient record system to improve access to records, communication, decision-making and patient planning.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 November 2022.
Worcestershire
Concerns raised2
Failure to improve record keeping and record retention
Failure to complete nursing records of residents’ medical conditions
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.
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.
