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
Poor recording of vomiting episodes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- the Dudley Group 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.1
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the Dudley Group NHS Foundation Trust
Complete a root cause analysis investigation into the failures concerning doctor contact, vomiting records, and family communication.
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Concerns raised1
Inaccurate and incomplete nursing notes and falls records
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Swansea Bay 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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Swansea Bay University Local Health Board
Falls management is devolved to directly managed units, while the Falls Management Group retains scrutiny and performance-review functions.
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Concerns raised2
Failure to record clinically relevant discussions and diagnostic information in medical notes
Failure to record clinical attendance and examination in medical notes
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Barts Health 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.1
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Barts Health NHS Trust
Brief all medical staff on the requirement to record patient events completely and contemporaneously in medical records.
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Concerns raised1
Failure to record the rationale and patient consent for a change of GP
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Hazelmere Medical Centre
- NHS Leicester, Leicestershire and Rutland Integrated Care Board
- Northfield Medical Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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NHS Leicester, Leicestershire and Rutland Integrated Care Board
Require providers to document discussions and information received from residents, record potential changes in care plans and clinical systems, and update records promptly.
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NHS Leicester, Leicestershire and Rutland Integrated Care Board
Contact care homes to recommend policies and documentation standards for staff signing on behalf of residents who can consent but cannot physically sign.
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NHS Leicester, Leicestershire and Rutland Integrated Care Board
Issue standard practice application forms to membership practices, including a section for signing on behalf of another person.
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Northfield Medical Centre
Require care homes to confirm patients’ awareness, consent and appropriate next-of-kin notification when capable residents change GP practice.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Hazelmere Medical Centre
There is usually no need to record the rationale for changing a patient's registered GP in the medical record.
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Northfield Medical Centre
Care homes are responsible for confirming patient awareness, consent and, where appropriate, next-of-kin notification when facilitating GP practice changes.
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Concerns raised1
Failure to record objections to sharing confidential medical information
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Pennine Care 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.3
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Pennine Care NHS Foundation Trust
Require Care Coordinators to assess risk-based information sharing with Personal Assistants and document this in wellbeing care plans.
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Pennine Care NHS Foundation Trust
Disseminate and deliver a briefing on Personal Assistant involvement in care planning and information-sharing records.
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Pennine Care NHS Foundation Trust
Discuss adding Personal Assistant care-planning and information-sharing guidance as an addendum to each community team’s operational policy at the Tier 4 meeting.
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Concerns raised1
Failure to effectively use Read Codes to flag significant patient-care risk factors
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Central and North West London 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.3
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Central and North West London NHS Foundation Trust
Deliver refresher training so CNWL staff can use SystmOne risk indicators and set the high-risk icon on patient records.
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Central and North West London NHS Foundation Trust
Review SystmOne use across Surrey sites and make it a standing item in local Clinical Quality Meetings.
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Central and North West London NHS Foundation Trust
Develop a SystmOne training package covering system functionality and READ codes, and incorporate homepage login requirements into the Standard Operating Procedure.
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Concerns raised1
Failure to sign and date handwritten clinical notes
This report raised 2 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
Inaccurate, infrequent, disjointed and incomplete clinical record keeping
This report raised 9 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
Failure to complete turning charts
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
Failings in documentation
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.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026