Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
Pin
Get email alerts
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.
-
Concerns raised1
Failure to make relevant and proper notes of reported symptoms
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.
-
Concerns raised1
Incomplete or inaccurate care records
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
-
Action
Implement and evaluate the e.care electronic care-planning system, with organisation-wide rollout scheduled for October 2018.
Stated by Hc-One Limited -
Action
Train care, nursing and management staff to use the e.care system effectively.
Stated by Hc-One Limited
-
Concerns raised1
Inadequate and disorganised choking risk assessment record keeping
This report raised 11 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.4
-
Action
Complete swallowing risk assessments with independent validation and Care Manager sign-off of updates.
Stated by Hc-One Limited -
Action
Rewrite residents’ care plans to specify detailed individual care requirements.
Stated by Hc-One Limited -
Action
Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.
Stated by Hc-One Limited
-
Action
Implement daily ‘Resident of the day’ care-plan reviews and report changing needs through the clinical risk register.
Stated by Hc-One Limited
-
Concerns raised1
Inadequate completion of nursing home records
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 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
-
Action
Revise daily handover procedures and provide written information for care staff and resident care records.
Stated by Adbolton Hall Limited -
Action
Monitor diabetes care-plan reviews directly through the Home Manager and Deputy Home Manager.
Stated by Adbolton Hall Limited -
Action
Place diabetic charts with medication records, update GP instructions, and ensure charts accompany residents for accurate completion and communication.
Stated by Adbolton Hall Limited
-
Concerns raised1
Failure to maintain contemporaneous and accurate nursing records
This report raised 8 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.
-
Concerns raised1
Failure to prominently record severe or life-threatening asthma on medical 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.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Position
Direct management of service delivery and oversight of independent primary care contractor staff falls outside the Health Board’s functions.
Stated by Aneurin Bevan University LHB
-
Position
Independent primary care contractors are responsible for safe service delivery, professional standards, regulatory compliance and patient accessibility.
Stated by Aneurin Bevan University LHB
-
Concerns raised1
Poor quality and incomplete clinical record keeping
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
-
Action
Train individuals to act as resuscitation scribes and accurately collate and record observations.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust -
Action
Obtain updated monitor software enabling automatic printing of observations during resuscitation.
Stated by Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
-
Concerns raised1
Lack of one consistent set of clinical records for inpatient and community use
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 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.
-
Concerns raised1
Gaps in clinical record keeping hindering treatment coordination and discharge accountability
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 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
-
Action
Establish strategic patient-flow leadership and review admission and discharge procedures.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Require formal discharge care plans, risk assessments and consultant oversight for high-risk discharges.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Introduce the approved PARIS electronic clinical record system across Manchester services.
Stated by Greater Manchester Mental Health NHS Foundation Trust
-
Action
Deliver rolling record-keeping training for Manchester healthcare professionals incorporating lessons from the death.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Include record-keeping standards in ongoing clinical-staff audit supervision.
Stated by Greater Manchester Mental Health NHS Foundation Trust
-
Concerns raised1
Inadequate continuity and completeness of hospital notes
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 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
-
Action
Review and circulate updated cystectomy pathway documentation covering enhanced recovery, patient information and discharge requirements.
Stated by East Sussex Healthcare NHS Trust -
Action
Amend postoperative daily-round documentation to capture greater detail on patient progress against the care plan.
Stated by East Sussex Healthcare NHS Trust -
Action
Conduct a urology specialty documentation audit to identify gaps, themes and improvements.
Stated by East Sussex Healthcare NHS Trust
Data last updated 7 September 2026