Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
- Reports that mention this concern
- 474
- Times this concern has been raised
- 568
- Stated actions linked to this concern
- 780
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
What is not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 474 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure 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.
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.
Linked response
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Department of Health and Social Care
Establish a uniform, interoperable format for maternity records across clinical systems.
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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.
Linked response
- Hill Care Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Hill Care Group
Carry out hourly checks of residents in their rooms and document the outcomes in contemporaneous notes.
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Hill Care Group
Audit handover sheets and processes regularly to verify completion and consistency with care plans.
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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.
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
Linked response
- Bolton NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
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Bolton NHS Foundation Trust
Deploy the electronic patient record system and associated devices across inpatient areas.
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Bolton NHS Foundation Trust
Trial additional computers on wheels to assess their effect on timely and accurate clinical documentation.
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Bolton NHS Foundation Trust
Procure and deploy additional computers on wheels across all wards to improve access to electronic patient records.
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Bolton NHS Foundation Trust
Conduct ward visits, educate clinical staff on equipment housekeeping, and audit equipment care, charging and fault reporting.
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Bolton NHS Foundation Trust
Review ward-round processes and competing demands for computers on wheels, then develop and implement relevant action plans.
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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Bolton NHS Foundation Trust
Equipment deployment was delayed by the global data-chip shortage affecting manufacturing and distribution.
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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.
Linked response
- Care Quality Commission
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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Care Quality Commission
There were no reasonable grounds to suspect an offence under Regulations 12 and 22, so formal criminal investigation was not undertaken.
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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.
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.
Linked response
- Cwm Taf Morgannwg University Local Health Board
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
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Cwm Taf Morgannwg University Local Health Board
Plan and develop online presentation, triage and vetting of hospital referrals for Consultant review.
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Cwm Taf Morgannwg University Local Health Board
Continue transitioning patient records to electronic access, reducing reliance on paper records.
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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Cwm Taf Morgannwg University Local Health Board
The missing referral information probably would not have changed the patient’s outcome.
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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.
Linked response
- Worcestershire Acute NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
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Worcestershire Acute NHS Trust
Adopt the IDECIDE tool in the maternity information system to support and document informed mode-of-delivery decisions.
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Worcestershire Acute NHS Trust
Introduce personalised care plans in the BadgerNotes app for discussion, review and professional authorisation.
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Worcestershire Acute NHS Trust
Provide monthly multidisciplinary maternity training covering human factors, informed consent, Montgomery, balanced counselling and documentation.
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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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026