Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
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Request correctionFirst reported 13 Dec 2008•Latest report 26 Jun 2026
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
Not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
- Reports
- 474
- Individual concerns
- 568
- Date range
- 2008–2026
- Stated actions
- 780
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
Described in published responses
Reports over time
Reports over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Concerns and responses across reports
Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.
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Concerns raised1
Failure to record a surgeon's early departure in the surgical notes
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Lack of explicit flagging of high-risk pregnancies in notes and communication
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Action
Establish a uniform, interoperable format for maternity records across clinical systems.
Stated by Department of Health and Social Care
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Concerns raised2
Inadequate note taking
Inadequate documentation of visual checks on residents in their rooms
This report raised 14 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Carry out hourly checks of residents in their rooms and document the outcomes in contemporaneous notes.
Stated by Hill Care Group -
Action
Audit handover sheets and processes regularly to verify completion and consistency with care plans.
Stated by Hill Care Group
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Concerns raised1
Poor and inaccurate compilation of clinical documentation
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Insufficient availability, workability and accessibility of IT facilities for timely electronic record-keeping
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Action
Deploy the electronic patient record system and associated devices across inpatient areas.
Stated by Bolton NHS Foundation Trust -
Action
Trial additional computers on wheels to assess their effect on timely and accurate clinical documentation.
Stated by Bolton NHS Foundation Trust -
Action
Procure and deploy additional computers on wheels across all wards to improve access to electronic patient records.
Stated by Bolton NHS Foundation Trust
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Action
Conduct ward visits, educate clinical staff on equipment housekeeping, and audit equipment care, charging and fault reporting.
Stated by Bolton NHS Foundation Trust -
Action
Review ward-round processes and competing demands for computers on wheels, then develop and implement relevant action plans.
Stated by Bolton NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Equipment deployment was delayed by the global data-chip shortage affecting manufacturing and distribution.
Stated by Bolton NHS Foundation Trust
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Concerns raised1
Poor record keeping of safety-relevant care information
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
There were no reasonable grounds to suspect an offence under Regulations 12 and 22, so formal criminal investigation was not undertaken.
Stated by Care Quality Commission
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Concerns raised1
Failure to complete initial assessment and care plan documentation
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Delays in placing paper referrals in patient notes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Action
Plan and develop online presentation, triage and vetting of hospital referrals for Consultant review.
Stated by Cwm Taf Morgannwg University Local Health Board -
Action
Continue transitioning patient records to electronic access, reducing reliance on paper records.
Stated by Cwm Taf Morgannwg University Local Health Board
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
The missing referral information probably would not have changed the patient’s outcome.
Stated by Cwm Taf Morgannwg University Local Health Board
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Concerns raised1
Failure to record discussions about mode of delivery, maternal wishes and management-plan risks and benefits
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Action
Adopt the IDECIDE tool in the maternity information system to support and document informed mode-of-delivery decisions.
Stated by Worcestershire Acute NHS Trust -
Action
Introduce personalised care plans in the BadgerNotes app for discussion, review and professional authorisation.
Stated by Worcestershire Acute NHS Trust -
Action
Provide monthly multidisciplinary maternity training covering human factors, informed consent, Montgomery, balanced counselling and documentation.
Stated by Worcestershire Acute NHS Trust
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Concerns raised1
Incomplete nursing records
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026