Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

First to latest report 13 Dec 2008 — 26 Jun 2026

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

Reports and published responses 474 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Norfolk

    AI-generated summary

    Tracy Dawn WOOD · 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

    Tracy Wood was admitted to Hellesdon Hospital with a history of self-harm and suicidal ideation and died on 3 June 2021 after being found unresponsive in her room following an earlier incident involving a prohibited item. The principal concerns included insufficient staffing and one-to-one support, failures in clinical assessment and risk management, inadequate record keeping, delayed emergency response, and shortcomings in the investigation and incident report.

    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 important clinical events and patient discussions

    Wider context from the report

    “8. Certain events are not included in the records, for example that a ████████ had been given to Tracy on 1 June 2021 on her going off ward, contrary to the instruction contained in the SBAR records and of 121 Talk times with Tracy. Evidence was heard that steps are being taken to improve record keeping. However this matter has been raised with NSFT previously and evidence from one witness at the inquest was that “every discussion” with a service user is recorded in the Clinical Record and that entries are made by one allocated person on a shift who will be told orally what to put by members of staff. This witness had had a 30 to 40 minute one to one meeting with Tracy the day prior to her ████████ on 1 June and talk time with Tracy on the day following her ████████ on 1 June, details of which may have been helpful to other staff and regarded of some importance to Tracy’s care ”

    Source location

    Tracy Dawn WOOD · 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

    Inaccurate dates and times in clinical records

    Wider context from the report

    “7. Written records did not specify correct dates and times as to events, for instance the Event Date/Time of the ████████ incident on 1 June 2021 at 20:53 hours is recorded in the Clinical Notes as “02 Jun 2021 06:49”. Tracy’s date of death is recorded as 5 June 2021 and her date of birth in the SBAR records is recorded as 1 May 1981, when it is the 1 June 1981. ”

    Source location

    Tracy Dawn WOOD · 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 document multidisciplinary observation decisions in clinical notes

    Wider context from the report

    “12. The PSII report refers to the notes of the incident on 1 June 2021 that Tracy ████████ with a ████████ but goes on to say that in interviews a cord from her ████████ was used. Confusion remains as between the events on the 1 June 2021 and the 2 June 2021. The report refers to the view of the MDT meeting on 2 June was to keep Tracy on hourly observations. There is no reference in the Clinical Notes to observations being discussed. Witnesses asked about observations at the inquest could not recall observations being discussed or that they were not discussed. ”

    Source location

    Tracy Dawn WOOD · 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

    Provide staff training on contemporaneous, high-standard record keeping through an external law firm.

    Verbatim wording from the response

    “The issue of contemporaneous record keeping of a high standard is a priority for the Trust and we have commissioned an external law firm to provide training to staff on this subject. This will be underway within the next 6-8 weeks.”

    Source location

    Response from Hellesdon Hospital
    Page 3 · response
    Published 26 April 2022

    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

    Ensure agency staff can access electronic patient records and understand expectations to record contemporaneous notes individually and comprehensively.

    Verbatim wording from the response

    “There have been some ICT barriers to agency staff accessing the electronic patient record historically however this is being corrected to ensure that all staff have access and are aware of the expectation to record contemporaneous notes individually and comprehensively, see response to question 7.”

    Source location

    Response from Hellesdon Hospital
    Page 3 · response
    Published 26 April 2022

    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

    Routinely upload the SBAR tool onto the electronic patient record.

    Verbatim wording from the response

    “The SBAR tool is now routinely uploaded onto the electronic record.”

    Source location

    Response from Hellesdon Hospital
    Page 5 · response
    Published 26 April 2022

    Open published response

  2. West Yorkshire (Western)

    AI-generated summary

    Edward Arthur AKROYD · 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

    Edward Arthur Akroyd was delivered by forceps on 13 January 2018 at Calderdale Royal Hospital after concerns arose during his mother’s labour, including pre-eclampsia and abnormal CTG tracing. He was transferred to Leeds General Infirmary for intensive treatment and died there on 17 January 2018. The principal concerns included inadequate monitoring and treatment of his mother’s elevated blood pressure, incomplete handover and medical records, failure to communicate laboratory results, and delayed recognition and interpretation of non-reassuring CTG findings.

    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 handover records in patients’ notes

    Wider context from the report

    “2. At the time of transfer of care between midwives, following arrival at Calderdale Royal hospital, the attendant midwife did not enter a complete handover record in Mrs Akroyds notes, as she understood that it was the duty of the receiving midwife to make a record within the notes. At the inquest, the same midwife who continues to practise, gave evidence that she remained of the view that that was trust policy. The lack of entry in the notes led to confusion and a lack of clarity of the previously prescribed medication I heard evidence at the inquest, that the practise undertaken by the midwife was not trust policy at the time nor subsequently and it is the role of the midwife handing over care to complete a medical record within the patients notes . I am concerned that if complete and effective medical notes and records are not made, this may impact on decision making and treatment and in turn to the wellbeing of expectant mothers and their unborn child. ”

    Source location

    Edward Arthur AKROYD · 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

    Implement structured SBAR handover documentation by transferring midwives, supported by a designated section in electronic patient records.

    Verbatim wording from the response

    “This process remains the same. It is the responsibility of the transferring midwife to complete a documented structured (SBAR) handover in the clinical records, as well as giving a verbal handover. Since 2018 the Trust has done a lot of work within the Maternity Service and more widely on SBAR handovers, including what to document; where to put the information in the computer records and how to access the information. There is now a specific designated part of the computer records for the recording of the information.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 3 · response
    Published 8 March 2022

    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 established requirement for transferring midwives to document structured handovers, supported by SBAR systems and training, is considered sufficient.

    Verbatim wording from the response

    “The lack of entry in the notes led to confusion and a lack of clarity of previously prescribed medication I heard evidence at the inquest, that the practise undertaken by the midwife was not trust policy at the time nor subsequently and it is the role of the midwife handing over care to complete a medical record within the patients notes.”

    Source location

    Response from Calderdale and Huddersfield NHS Foundation Trust (1)
    Page 3 · response
    Published 8 March 2022

    Open published response

  3. Surrey

    AI-generated summary

    Michael John Humphries · 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

    Michael John Humphries, who was quadriplegic and diabetic, was admitted to hospital on 20 March 2019 with severe sepsis and died on 30 March 2019 after being placed into palliative care. Concerns included the lack of information about the proper use of a Tbar cushion, inadequate wound-care knowledge and documentation, limited access to suitable dressings, and an ineffective initial referral process to tissue viability nurses.

    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 maintain accurate wound tracking documentation

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”

    Source location

    Michael John Humphries · Prevention of Future Deaths report
    Page 4 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    Joyce May DENNIS · 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

    Joyce May Dennis, a resident of Roseacre Care Home, became unwell on 9 September 2019 and deteriorated over the following days before being admitted to hospital with sepsis and the onset of a heart attack. She died at 15.30 on 13 September 2019. The principal concerns were inadequate monitoring and record-keeping, failure to investigate or escalate worsening symptoms, insufficient staff training about illness and sepsis in older people, poor liaison, and failure to record family concerns.

    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

    Lack of care notes

    Wider context from the report

    “1. There was a lack of continuous oversight, a lack of notes, a lack of review of those notes and no investigations at the Care Home. It has been underlined to me heavily throughout the proceedings that the care staff are not medically qualified. I accept that and would not expect them to be so in a residential care home setting. However, they had a duty of care for Joyce and that included keeping her under sufficient observation to allow for medical assistance to be called promptly as necessary. ”

    Source location

    Joyce May DENNIS · Prevention of Future Deaths report
    Page 6 · concerns

    Open source report

  5. Birmingham and Solihull

    AI-generated summary

    Dorothy Ann SPIBY · 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

    Dorothy Ann Spiby, a nursing home resident with dementia, frailty and type 1 diabetes, suffered an unwitnessed fall in her bedroom on 22 October 2021. She sustained an eye-socket fracture and two rib fractures, developed pneumonia in hospital, and died on 28 October 2021. Concerns included unclear and undocumented accounts of the incident, no incident form, no investigation, and no evidence of learning to safeguard residents in future.

    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 incidents in nursing records

    Wider context from the report

    “1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”

    Source location

    Dorothy Ann SPIBY · 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

    Complete documentation and record-keeping training for nursing and care staff, including policy reissue and good-practice requirements.

    Verbatim wording from the response

    “• Defensible Documentation Training for Registered Nurses initiated by Nurse Advisor ████████ ████████. Training included: NMC Code, Accountability, Effective communication, Examples of good and poor documentation, NMC Hearings and clinical negligence. Training was planned in to be completed by 15.4.22 and actions have been completed with all Tanworth Court nurses.”

    Source location

    Response from Prime Life Ltd
    Page 1 · response
    Published 24 February 2022

    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 regular competency checks to confirm staff retain documentation training and demonstrate good practice.

    Verbatim wording from the response

    “• Further competency checks are being conducted to ensure continued learning. This will be completed by the nurse advisor/trainer on a regular basis (weekly at present) and will cover a period of 3 months or longer if issues arise from the competency checks. Competency checks will only be ceased if the advisor/trainer is confident that the information has been retained and good practice demonstrated.”

    Source location

    Response from Prime Life Ltd
    Page 1 · response
    Published 24 February 2022

    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

    Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.

    Verbatim wording from the response

    “• Any shortcomings in documentation are addressed immediately by the home management team. Conversations with staff are formally recorded within supervisions and any disciplinary action taken, as necessary. Where there is non-compliance found the staff members will be given supervisions and learning sheets will be completed with them to encourage adherence to best practice. Actions in this regard were completed by 18.3.22 as planned.”

    Source location

    Response from Prime Life Ltd
    Page 2 · response
    Published 24 February 2022

    Open published response

  6. Hertfordshire

    AI-generated summary

    David Clark · 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 Clark died at Lister Hospital on 5 January 2020 after being readmitted in a drowsy state and in respiratory failure. The report identified concerns that his worsening condition was not accurately assessed or escalated appropriately, NEWS were not calculated or documented accurately, and his treatment was poorly documented. It was unclear whether these matters contributed to his death.

    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 completion of clinical documentation

    Wider context from the report

    “(3) That documentation, more generally, was poorly completed. ”

    Source location

    David Clark · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Norfolk

    AI-generated summary

    Sheila Elizabeth Steggles · 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

    Sheila Elizabeth Steggles, who had reduced mobility and several risk factors for thrombosis, collapsed on 5 November 2019 and died in an ambulance after suffering a cardiac arrest. The cause of death was recorded as acute pulmonary embolus arising from deep vein thrombosis. Concerns included the absence of a documented VTE risk assessment, insufficient consideration of reduced mobility and past DVT, inadequate staff training, and missed opportunities to provide prophylactic heparin.

    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 about patients in clinical notes

    Wider context from the report

    “All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts. ”

    Source location

    Sheila Elizabeth Steggles · 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 document specific staff concerns in clinical notes

    Wider context from the report

    “All staff should raise concerns and if they have specific ones, document what these are in the clinical notes. Clinical notes should contain more detail about the patient since they are what is relied upon (with a verbal handover) to inform staff on later shifts. ”

    Source location

    Sheila Elizabeth Steggles · 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

    Use and build the SBAR tool in patient records during handovers and ward reviews to capture patient history, concerns and required escalation.

    Verbatim wording from the response

    “Handover between junior Doctors and other medical staff will be underpinned by the Situation Background Assessment Recommendation (SBAR) framework. This will ensure that patient history, emerging concerns and necessary action including escalation where necessary are known, recorded and acted on. Inpatient wards across the organisation utilise and upload the SBAR tool into patient records to assist with ward reviews and handovers. The SBAR document is built upon at each handover, therefore building up a comprehensive history of the patient.”

    Source location

    2022-0042-Response-from-Hellesdon-Hospital_Published
    Page 2 · response
    Published 14 February 2022

    Open published response

  8. Essex

    AI-generated summary

    Benjamin Lee Stroud · 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

    Benjamin Lee Stroud died at his home on 19 March 2021 after an overdose involving multiple drugs, including tramadol and alprazolam, with empty medication blister packets and insulin pens found around him. The report raised concerns that his case was not referred to the multidisciplinary team despite escalating psychosis, that the Care Coordinator made the referral decision without a recorded rationale, and that this practice posed a risk of future deaths.

    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 document the rationale for non-referral to the MDT

    Wider context from the report

    “That in all cases must go before the MDT, the evidence in this inquest, made it clear that had Mr Stroud’s case had been discussed at an MDT then more help would have been made available to him, that he would have been seen by a psychiatrist and may have prevented his death. On the evidence from EPUT and the PSIIR it was clear that the Care Coordinator makes the decisions as to whether to refer a case to the MDT, in this case, no entries were made around the rationale for none referral and no explanation was provided at the inquest. This is not the first time this issue has arisen at an Inquest and the reliance on a Care Coordinator to make a clinical decision and no written explanation provided on any clinical notes documented appears to be a way of working. If these practices continue there is a real risk of future deaths occurring. ”

    Source location

    Benjamin Lee Stroud · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  9. South Wales Central

    AI-generated summary

    Manon Edie Jones · 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

    Manon Edie Jones, aged 16, died from ligaturing shortly after being admitted to a mental health unit following self-harm and a deterioration in her mental health. The report identified concerns that clinicians did not have access to relevant community and hospital records, that clinical records were not entered contemporaneously in a single record, and that this impaired assessment, observation decisions and safeguarding.

    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 enter clinical records contemporaneously in a single clinical record

    Wider context from the report

    “(2) The Clinical records in the Ty Llidiard Unit were not all entered contemporaneously in a single clinical record ”

    Source location

    Manon Edie Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Nottinghamshire

    AI-generated summary

    Michelle Whitehead · 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

    Michelle Whitehead died on 7 May 2021 from a hypoxic brain injury after experiencing deterioration in her breathing and oxygen saturation while detained under Section 2 of the Mental Health Act. The report identifies concerns about unclear sedation medication and documentation, delayed recognition and treatment of her deterioration, lack of medical and consultant involvement, difficulty contacting the duty doctor, and delays in calling and admitting paramedics.

    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 documentation of sedation medication

    Wider context from the report

    “1. Unclear dose/type of sedation medication given, possible excess dose given, poor documentation 2. Delayed recognition of Mrs Whitehead’s declining condition 3. No medical clerking from admission until her collapse 4. No Consultant involvement after admission 5. Inability to reach Duty Doctor for deteriorating patient 6. Delay in calling paramedics 7. Delay in Paramedics gaining access to the ward Many of these issues have been the subject of scrutiny in at least two previous Inquests, that have followed deaths on inpatient wards of the Trust. I have received reassurance during these Hearings that the issues have been addressed, but this case illustrates that they clearly remain. The issues are very serious in my view. ”

    Source location

    Michelle Whitehead · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026