Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

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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
Individual concerns: 568
Date range: 2008–2026
Stated actions: 780

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

7 Apr2017
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to record advice about inoculation and life-long antibiotic prophylaxis
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 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.
AI-generated summary

Theresa Mary Thompson · 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

Theresa Mary Thompson died on 9 October 2016 after admission with sepsis caused by a Streptococcus pneumonia infection, following a history of splenectomy and recent ventriculo-peritoneal shunt insertion. Concerns were raised that she was not receiving lifelong antibiotic prophylaxis and had no antibiotic cover for the shunt procedure, and that there was no evidence she had been advised or prescribed antibiotics before or after the procedure.

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 advice about inoculation and life-long antibiotic prophylaxis
Wider context from the report
“At the inquest, the pathologist advised that Streptococcus pneumonia infections were typical for patients having undergone splenectomy. The spleen was an important immune defence organ for this type of bacteria. Usually patients were given a vaccination to prevent this type of disease and life-time antibiotic prophylaxis. Both the Pathologist and Treating clinician at the time of death, expressed concerns to the inquest that Mrs Thompson was not on prophylaxis antibiotics and that she had no antibiotic prophylaxis cover for her recent procedure especially as the Streptococcus infection was Serum type 6C for which there was no currently available pneumococcal vaccines (Reference report from Public Health England, Colindale, The Respiratory and Vaccine Preventable Bacteria Reference Unit (RVPBRU)). The GP gave evidence that Mrs Thompson had been advised about inoculation and taking life-long antibiotic prophylaxis but at some point had declined (although there were no written records to support his evidence in her medical note). There was no evidence that she was advised or prescribed antibiotics prior to or after her Ventriculo-Peritoneal Shunt procedure in August 2016 at Kings College Hospital. The family acknowledged that a number of the family had had a splenectomy due to familial Acholuric Jaundice but they were unsure that the family members appreciated the necessity for inoculation or prophylaxis antibiotics. They were concerned that there were mixed messages being given out by the Health Agencies about the use of antibiotics and the need to not overuse antibiotics and this had led to them not being inoculated or accepting life time prophylaxis antibiotics or the necessity of cover during medical procedures (if they had been advised at all). ”
Source location
Theresa Mary Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
23 Mar2017
Manchester South
Concerns raised2
1. Failure to ensure retrieval of patient notes after death
2. Lack of a contemporaneous central record of patient condition and treatment
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.
AI-generated summary

Marian Dale · 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

Marian Dale injured both legs in separate accidents, developed cellulitis in both legs, and was admitted to Stepping Hill Hospital. She developed sepsis and died there on 17 November 2016. The report raised concerns that the District Nursing Team could not evidence the condition of her legs and treatment because records were not held centrally or retrieved after her 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
Failure to ensure retrieval of patient notes after death
Wider context from the report
“Marian Dale had been visited on a regular basis by the District Nursing Team. However, they were unable to give evidence of the condition of her legs and treatment on their visits prior to her death. This was due to the fact that all notes were retained at the patient’s address until a sheet in the hand held notes was completed. There was no system for a contemporaneous record to be held centrally. Her notes had not been retrieved after her death and there was no system in place to ensure that happened. ”
Source location
Marian Dale · Prevention of Future Deaths report
Page 1 · 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
Lack of a contemporaneous central record of patient condition and treatment
Wider context from the report
“Marian Dale had been visited on a regular basis by the District Nursing Team. However, they were unable to give evidence of the condition of her legs and treatment on their visits prior to her death. This was due to the fact that all notes were retained at the patient’s address until a sheet in the hand held notes was completed. There was no system for a contemporaneous record to be held centrally. Her notes had not been retrieved after her death and there was no system in place to ensure that happened. ”
Source location
Marian Dale · Prevention of Future Deaths report
Page 1 · concerns
Open source report
22 Mar2017
Inner West London
Concerns raised3
1. Failure to record inhaler technique checks
2. Lack of a co-ordinating record of asthma exacerbations
3. Failure to record frequency of reliever use
This report raised 22 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 1
1. Action
  Implement the community-pharmacy Quality Payments Scheme to identify patients overusing bronchodilators without corticosteroids and refer them for asthma review.
  Stated by NHS EnglandStated completed
AI-generated summary

Michael Uriely · 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 Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.

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 inhaler technique checks
Wider context from the report
“6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael. ”
Source location
Michael Uriely · 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
Lack of a co-ordinating record of asthma exacerbations
Wider context from the report
“2) There was:- i) No co-ordinating record of these occasions. ii) No analysis of the acute episodes in context with his chronic asthma condition. iii) No appreciation of the underlying severity and analysis of the level of medication prescribed. iv) No appreciation of the risk factors of near fatal or fatal asthma evident in this child. v) No appreciation of the deteriorating nature of his asthma. ”
Source location
Michael Uriely · 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 record frequency of reliever use
Wider context from the report
“6) The assessment and management of Michael’s chronic asthma condition was not in accordance with the BTS/SIGN Guidelines. In particular: lung function (peak expiratory flow/ PEF or spirometry) was not always measured when indicated; his medication was not optimised despite poor control; current asthma control was not always assessed using one of the tests recommended; Michael’s frequency of use of relievers was never recorded; inhaler technique checking was not recorded; and there was no evidence in the GP or hospital records that a Personal Asthma Action Plan (PAAP) detailing the use of medication, recognising danger and how and when to call for help, had been issues to Michael. ”
Source location
Michael Uriely · 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
Implement the community-pharmacy Quality Payments Scheme to identify patients overusing bronchodilators without corticosteroids and refer them for asthma review.

Verbatim wording from the response
“6. We have developed a Quality Payments Scheme for community pharmacy⁶ to encourage community pharmacists to systematically identify patients who receive more than six bronchodilator inhalers in six months without any corticosteroid inhaler and refer them for asthma review. There are over 11,600 pharmacies in England and we will be evaluating this scheme to look at the impact. This element of the Quality Payments scheme was incorporated as a direct result of the NRAD recommendations.”

Source location
Uriely-Response
Page 3 · response
Published 22 March 2017
Open published response
20 Mar2017
Portsmouth and South East Hampshire
Concerns raised1
1. Failure to record who made significant clinical decisions and why
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 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.
AI-generated summary

Scott Douglas Hooper · 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

Scott Douglas Hooper, aged 46, died on 22 March 2016 after sustaining complex pelvic fractures in an unwitnessed workplace forklift accident and later suffering a pulmonary embolism and deep vein thrombosis. The principal concerns were that his weight was incorrectly recorded, affecting the prescribed anticoagulant dose, and that a decision to withhold a dose was not recorded with the decision-maker identified.

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 who made significant clinical decisions and why
Wider context from the report
“1. On admission to SGH on 12 March, Mr Hooper's weight was incorrectly recorded as 80kg when the reality was his true weight was 107 kg – a difference of 27 kg (or 3.5lbs) which is a considerable difference. This is important as the amount of anti-coagulant drugs to be given according to the SGH thromboprophylaxis protocol is calculated on weight. 2. As stated above, on 15 March when the clinical decision was made to withhold the morning dose of Tpx medication it could not be ascertained who made the decision. This was a significant clinical decision and it is a basic requirement that all clinical decisions are recorded in order to capture capturing who made the decision and why. In respect of both of these concerns, during the investigation I learned through the Root Cause Analysis that a Trauma & Orthopaedic Morbidity & Mortality meeting had been held. In addition, I was told during the inquest that a nonogram was now in use to improve weight estimation for those patients where it was not possible to obtain actual weight and that training was underway in relation to its use for elderly patients. I also heard that some new beds with built in weight indicating scales were to be purchased within 2 months subject to cost and commissioning. Whilst a valuable tool, a single T&O M&M meeting is only effective for those doctors and nursing staff who attend. I was not given any other detail as to how the valuable lessons to be learned from this case were to be spread to clinical staff across the T&O department or the whole Trust as weight estimation can be equally important in many other medical specialisms. I was told during the inquest that training was currently taking place in respect of elderly patients but I was not given a plan or timetable for other high risk patients such as Mr Hooper who was only 46 years old and suffered from an acute crush pelvic trauma which had the potential to be life threatening. Mr Hooper died on 22 March 2016 but as yet no active steps have been taken to address patients who fall into the same category. The same principle can be said to apply to bed purchase and it did not appear to be an agreed action that beds with scales would be used to improve the problem of weight estimation in order to ensure accurate dosage of essential medication. ”
Source location
Scott Douglas Hooper · Prevention of Future Deaths report
Page 3 · concerns
Open source report
17 Mar2017
Brighton and Hove
Concerns raised1
1. Failure to record relevant disclosed cardiac history in psychiatric admission 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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Brief staff on documentation concerns through Trust-wide communications, team meetings and clinical supervision.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
2. Action
  Audit ward documentation to check compliance with expected recording standards.
  Stated by Sussex Partnership NHS Foundation TrustStated completed
AI-generated summary

Trevor John CURRY · 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

Trevor John CURRY died within 48 hours of admission to a psychiatric hospital. The concerns were that information about his heart problems was not recorded in his admitting note and that the trust did not obtain his full physical medical history until after his death, with particular concern about timely access to medical histories for psychiatric patients unable to provide them.

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 relevant disclosed cardiac history in psychiatric admission notes
Wider context from the report
“(1) It is nationally acknowledged that there are a growing number of patients in both acute and psychiatric hospitals and prisoners who have substantial mental health and physical problems. This is particularly the case in view of the ageing hospital and prison population. It is therefore incumbent upon those caring for such people to ensure that they have full mental and physical past medical histories. In this particular case at Inquest, I accepted that the deceased’s sister had informed the triaging and admitting staff at the psychiatric hospital of the fact that he was being seen by the Cardiologist and was suffering with heart problems (i.e. palpitations). No note was made of this in Mr Curry’s admitting note. It should have been. In addition, the psychiatric trust made no effort to ascertain his full past physical history until after he had died. Of course they were not expecting him to die within 48 hours of admission but that is not the point. Enquiries of this nature should be made at the earliest opportunity and if there are no reciprocal IT arrangements then the individual trusts must have arrangements between them so that they can access appropriate history speedily. This is particularly important in cases where a patient is admitted to a psychiatric hospital in an agitated, even psychotic state and unable to give an appropriate history him or herself. ”
Source location
Trevor John CURRY · 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
Brief staff on documentation concerns through Trust-wide communications, team meetings and clinical supervision.

Verbatim wording from the response
“I am sorry, the information from Mr Curry’s sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. ████████, General Manager - Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 23 February 2024
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
Audit ward documentation to check compliance with expected recording standards.

Verbatim wording from the response
“I am sorry, the information from Mr Curry’s sister that Mr Curry was being seen by a cardiologist and he was suffering with palpitations was not recorded in the health records. ████████, General Manager - Acute and Urgent Care Services for Brighton and Hove drafted a briefing for staff highlighting your concerns to ensure the lessons are widespread throughout the Trust. The briefing and ongoing team meetings and clinical supervision sessions have been used highlight the importance of good clear documentation in our new electronic health records system. This has assisted our learning and an improvement in our recording. Senior members of staff such as Ward Managers and Matrons at Mill View Hospital complete documentation audits to ensure the expected standards of documentation are met.”

Source location
Response from Sussex Partnership NHS Foundation Trust
Page 1 · response
Published 23 February 2024
Open published response
16 Mar2017
Norfolk
Concerns raised1
1. Failure to make contemporaneous nursing records
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 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.
AI-generated summary

James Charles MALLETT · 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

James Charles Mallett, aged 93, was admitted to hospital after a fall at home and later sustained a fatal head injury in a further inpatient fall. Concerns included delayed medical attendance, unclear and untimely neurological observations, inadequate contemporaneous records, insufficient falls prevention, and nursing staff training and experience that were considered inadequate.

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 make contemporaneous nursing records
Wider context from the report
“(3) The nursing staff made no contemporaneous notes for a period of five hours on the system so there was little information about the timings of their actions. The doctor did not arrive until over two hours later but did order an urgent CT scan, however when he had the results he then ordered neurological observations be done every two hours which is not as per hospital protocol. ”
Source location
James Charles MALLETT · Prevention of Future Deaths report
Page 1 · concerns
Open source report
8 Mar2017
Manchester City
Concerns raised1
1. Poor medical and nursing record keeping
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 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.
AI-generated summary

Mrs Kathleen Cooper · 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

Mrs Kathleen Cooper, aged 73, underwent elective sigmoid colectomy and later deteriorated, suffering an intra-operative cardiac arrest during emergency surgery on 11 July 2016. The report identified medical and nursing neglect, including communication and record-keeping failures, inadequate supervision, inaccurate observations and early warning scores, delayed tests and treatment, and failures to escalate deterioration. Concerns also related to out-of-hours and weekend care and the patient-safety impact of split-site hospital arrangements.

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 medical and nursing record keeping
Wider context from the report
“3. The RCA and the inquest process identified a significant number of errors, omissions and missed opportunities to treat the deceased – all of which, on the balance of probabilities, could and would have improved the deceased’s chances of survival, despite her pre-existing co-morbidities. Most of the failings identified in this case have been recognised in previous RCA’s conducted by the Trust over the last 6-12 months. Despite evidence as to ‘lesson learned’ action plans set etc. flowing therefrom, there appears to be little (if any) timely progress being made in terms of improving/driving up care standards and preventing future deaths. My concerns relate to the following in particular: - Poor communication by/between clinicians and nurses - Poor record keeping – medical and nursing - Poor leadership/supervision of nurses - Ward/Matron level - Inadequate supervision by on-call consultants of junior colleagues - Incorrectly calculated early warning scores - Baseline observations not recorded/inaccurately record/missing vital parameters (impacting upon the calculation of early warning scores) - outwith Trust guidance/deviation from the same not clinically justified - Inaccurate fluid balance charts (persistent basic arithmetical errors/lack of recording) - The absence of clinical judgement as a result of the over-reliance placed upon tools such as the early warning scores - Failure to repeat tests such as bloods and to act upon the results accordingly - Failure to escalate (by doctors and nurses) when signs of deterioration/change in the patient’s clinical condition become apparent - Delays in arranging urgent/additional tests and treatment (in this case radiological CT scanning, bloods and IV antibiotics) ”
Source location
Mrs Kathleen Cooper · Prevention of Future Deaths report
Page 2 · concerns
Open source report
14 Feb2017
Brighton and Hove
Concerns raised2
1. Failure to record dates of specialist referrals
2. Incomplete mental-capacity documentation at discharge
This report raised 24 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.
AI-generated summary

Derek LEE · 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

Derek LEE died on 5 June 2016 following an admission to Brunswick Ward. The report identified numerous concerns about his care, including medication management, incomplete assessments and documentation, falls and pressure-sore prevention, delayed referrals and treatment, nutrition, mobility, and the absence of a care co-ordinator. The inquest concluded that the death was from natural causes, and the report stated that the identified failings did not change the outcome.

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 dates of specialist referrals
Wider context from the report
“(9) There was no evidence of dates when Mr Lee was referred to the Occupational Therapist, the Physiotherapist, the dieticians or the Parkinson’s Specialist Nurse. At the Inquest I heard evidence that these referrals should have taken place as soon as possible after admission and certainly within the first three or four days. It is clear from the evidence that very little happened so far as Mr Lee was concerned until the 9th May. Too late. ”
Source location
Derek LEE · 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
Incomplete mental-capacity documentation at discharge
Wider context from the report
“(2) Re: Admission Documentation – Mental capacity was not properly assessed and when Mr Lee was discharged from the ward after three weeks on the 17th May the paperwork in that respect was still incomplete. ”
Source location
Derek LEE · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Jan2017
Cheshire
Concerns raised1
1. Failure to produce proper documentation
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.
AI-generated summary

Frederick Chisnall · 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

Frederick Chisnall was subject to a Deprivation of Liberty Order and receiving one-to-one nursing care from agency staff when he died following a myocardial infarction. Concerns were raised about agency staff producing proper documentation, recognising changes in clinical condition, and obtaining urgent medical or nursing help when appropriate; the adequacy of their training was questioned.

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 produce proper documentation
Wider context from the report
“During the inquest concerns were raised about the actions of the Agency staff regarding producing proper documentation, and being aware of how to monitor changes in clinical condition and obtaining medical or nursing help urgently when appropriate. Although in this case this did not cause any serious sequelae, I wonder if you could assess the adequacy of the training given to the staff you commission, to ensure this does not happen in the future. ”
Source location
Frederick Chisnall · Prevention of Future Deaths report
Page 1 · concerns
Open source report
27 Jan2017
Kent (North-West)
Concerns raised1
1. Inadequate clinical note keeping at the hospital
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 3
1. Action
  Audit postpartum-haemorrhage documentation annually and review the proforma, including its new theatre fluid-input and output section.
  Stated by Maidstone and Tunbridge Wells NHS TrustStated in progress
2. Action
  Provide documentation training through annual departmental training, mandatory Information Governance training, legal updates and clinical leadership programmes.
  Stated by Maidstone and Tunbridge Wells NHS TrustStated completed
3. Action
  Review documentation requirements and conduct regular local and national clinical documentation audits.
  Stated by Maidstone and Tunbridge Wells NHS TrustStated in progress
AI-generated summary

Frances Olwyn Coppaccini · 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

Frances Olwyn Coppaccini died on 9 October 2012 at Tunbridge Wells Hospital following the birth of her child. The report raised concerns about retained placental tissue after caesarean section, failure to follow the post-partum haemorrhage protocol, supervision of anaesthetic staff, delays in obtaining urgent specialist help, and inadequate hospital note keeping.

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
Inadequate clinical note keeping at the hospital
Wider context from the report
“5. The Inquest showed a number of examples of inadequate note keeping at the hospital – what actions have been taken to ensure this is not repeated in the future. ”
Source location
Frances Olwyn Coppaccini · Prevention of Future Deaths report
Page 1 · 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
Audit postpartum-haemorrhage documentation annually and review the proforma, including its new theatre fluid-input and output section.

Verbatim wording from the response
“We are always seeking to improve our service and minimise patient harm, and to that end we constantly review our processes, training and documentation. In light of the potential issues regarding drug use in PPH cases, our Pharmacy team have created a new guidance document for staff (copy enclosed). The Obstetric department is also reviewing fluid replacement at PPH, and undertakes yearly audits regarding PPH documentation including the regular review of the PPH Proforma to ensure it meets the needs of staff in the time critical situations they work in. The latest version of the PPH Proforma, which includes a new section for recording fluid input and output in theatre, is enclosed for your information.”

Source location
2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 3 · response
Published 19 February 2017
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
Provide documentation training through annual departmental training, mandatory Information Governance training, legal updates and clinical leadership programmes.

Verbatim wording from the response
“Documentation training underpins core training for nurses, doctors and allied health practitioners at all levels within the organisation. All staff are aware of the importance of clear, and contemporaneous record keeping and the balance that must be struck between this obligation and the immediate care and treatment to be provided to our patients.”

Source location
2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 5 · response
Published 19 February 2017
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
Review documentation requirements and conduct regular local and national clinical documentation audits.

Verbatim wording from the response
“We continually review the documentation to be completed in addition to noting in the healthcare records, to ensure they are easy to use in the highly-pressurised situations in which our staff work.”

Source location
2017-0020-Response-by-Maidstone-and-Tunbridge-Wells-NHS-Trust
Page 5 · response
Published 19 February 2017
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to record advice about inoculation and life-long antibiotic prophylaxis

Concerns raised2

Failure to ensure retrieval of patient notes after death

Lack of a contemporaneous central record of patient condition and treatment

Concerns raised3

Failure to record inhaler technique checks

Lack of a co-ordinating record of asthma exacerbations

Failure to record frequency of reliever use

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

Concerns raised1

Failure to record who made significant clinical decisions and why

Concerns raised1

Failure to record relevant disclosed cardiac history in psychiatric admission notes

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

Concerns raised1

Failure to make contemporaneous nursing records

Concerns raised1

Poor medical and nursing record keeping

Concerns raised2

Failure to record dates of specialist referrals

Incomplete mental-capacity documentation at discharge

Concerns raised1

Failure to produce proper documentation

Concerns raised1

Inadequate clinical note keeping at the hospital

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

Actions described in response 1

Actions described in response 2

Actions described in response 3