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.
North Northumberland and South Northumberland
Concerns raised1
Failure of record keeping to reflect residents’ needs
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.2
Action
Review and implement new compliance systems and reporting processes.
Stated by Alcyone Healthcare North East LtdStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
Action
Review and implement new care-planning processes.
Stated by Alcyone Healthcare North East LtdStated in progressThe respondent said that this action was in progress when they made their response on 27 April 2022.
West Yorkshire Western Division
Concerns raised1
Inaccurate computer coding of procedures
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.5
Action
Review the coding process against best-practice guidance and practice policy.
Stated by Wilsden Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
Action
Discuss coding-process learning and audit findings with the data and clinical teams.
Stated by Wilsden Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
Action
Operate a digital coding workflow with Data Quality team checks and GP review of patient records, codes and associated tasks.
Stated by Wilsden Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
Action
Audit the accuracy of coding and associated tasks for incoming clinical letters using a GP-reviewed sample.
Stated by Wilsden Medical PracticeStated completedThe respondent said that this action was complete when they made their response on 28 June 2021.
Action
Repeat the coding audit after three months and review the required audit scale, scope and frequency.
Stated by Wilsden Medical PracticeStated plannedThe respondent said that this action was planned when they made their response on 28 June 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing record-correction methods allow inaccurate codes to be corrected, retrospectively amended and clarified with free text.
Stated by Wilsden Medical PracticeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Manchester South
Concerns raised1
Failure to clearly report and record scan findings
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Conduct the commissioned serious incident investigation and present its findings to the Executive Scrutiny Panel.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Action
Complete the Trust-wide rollout of the Results Governance Tracker requiring timely PACS acknowledgement of imaging results.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 24 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Existing radiology policy sufficiently requires clinicians to review CT scan reports directly on PACS rather than rely on transcribed medical records.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Poor medical record keeping and documentation in the emergency department and observation unit
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.3
Action
Maintain monthly nursing documentation audits and a peer-review process between both Emergency Departments.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Provide documentation training through handovers, training sessions and staff discussions.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 May 2021.
Action
Introduce consultant clinical-note reviews and direct feedback through supervision and appraisal meetings.
Stated by Barking, Havering and Redbridge University Hospitals NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 18 May 2021.
Manchester South
Concerns raised1
Lack of designated time for care coordinators to record detailed notes contemporaneously
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.
Stoke-on-Trent and North Staffordshire
Concerns raised1
Failure to consistently document the content and timing of inter-hospital clinical conversations
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Develop a structured electronic Paediatric Advice Proforma with mandatory fields and prompts for documenting inter-hospital clinical advice.
Stated by University Hospitals of North Midlands NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Scope improvements to recording patient information for patients needing specialist advice while off site.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Work with the Norse supplier to transition to the system’s latest version and additional features.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Roll out Norse across a number of clinical services to strengthen required documentation of inter-centre clinical advice.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
Action
Remind clinicians to keep contemporaneous notes of advice given to district general hospitals by placing a note in patients’ records.
Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 7 May 2021.
Norfolk
Concerns raised4
Failure of consent forms and anaesthetic checklists to prompt documentation of tube presence
Lack of medical-record method for identifying a salivary bypass tube in situ
Poor-quality pre- and post-operative treatment documentation
Failure of clinical specialist nurses to document patient concerns
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.4
Action
Adapt the ORSOS surgical-notes template to record retained or implanted items and their planned management across surgical specialties.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 7 May 2021.
Action
Audit documentation for salivary bypass tubes, including insertion, patient discussion, follow-up presence and procedural records.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Develop operational workarounds to share and transfer information across regional clinical IT systems.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Action
Implement the regional shared-care record programme by scanning active patient records into the electronic document-management system for provider access.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 7 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
A rubber stamp may not fully address salivary-tube documentation because multiple printed notes and electronic records may not display it.
Stated by Norfolk and Norwich University Hospitals NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised1
Tolerance of inaccurate and misleading clinical record keeping
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Provide medical-record-keeping training to Borough Lead Nurses and cascade the learning to staff during induction and away days.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 May 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Professional concerns about nurses’ conduct and registration are for the NMC to investigate and sanction.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
County Durham and Darlington
Concerns raised1
Failure to upload PDF medical records and important information promptly in original form to the electronic notes system
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.1
Action
Implement Cito electronic records functionality for scanning, uploading and viewing documents.
Stated by Tees, Esk and Wear Valleys NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.
Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.
Stated by Department of Health and Social CareNo action considered necessaryThe respondent said that no further action was needed.
West Sussex
Concerns raised1
Failure to regularly update and review A&E paper notes
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
Update Emergency Department mental-health triage documentation and adopt the revised version across all Emergency Departments in the merged Trust.
Stated by University Hospitals Sussex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 April 2021.
Action
Audit use of the new Emergency Department documentation to ensure sustained improvement.
Stated by University Hospitals Sussex NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 13 April 2021.
Action
Emphasise in staff training the need for high-quality, regularly updated records for patients with mental-health illnesses awaiting beds.
Stated by University Hospitals Sussex NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 13 April 2021.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
