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 raised2
Failure to maintain consistent and adequately justified clinical records
Failure to record concerns about self-harm risk in patients with apparent capacity
This report raised 6 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.1
-
Action
Continue rolling out the SBAR structured record-keeping tool across all services.
Stated by Cornwall Partnership NHS Foundation Trust
-
Concerns raised1
Failure to maintain complete, consistent and non-conflicting patient and clinical records
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.6
-
Action
Establish zero-tolerance consultant recordkeeping requirements and communicate them to consultant staff.
Stated by South Buckinghamshire Hospitals -
Action
Audit consultant medical records monthly and apply potential practising-privilege sanctions for non-compliance.
Stated by South Buckinghamshire Hospitals -
Action
Provide monthly documentation training for staff at the Shelburne and Chiltern hospitals.
Stated by South Buckinghamshire Hospitals
-
Action
Undertake a corporate review of physiotherapist abbreviation use.
Stated by South Buckinghamshire Hospitals -
Action
Use the issued physiotherapy abbreviation list for outpatient documentation.
Stated by South Buckinghamshire Hospitals -
Action
Audit discharge follow-up phone-call documentation monthly.
Stated by South Buckinghamshire Hospitals
-
Concerns raised1
Lack of recording of reasons, requests or decisions to stop prescribing a drug in clinical records
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 raised2
Failure to document rationale for clinical discretion
Inadequate clinical record keeping
This report raised 12 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
Conduct rolling audits of communication and documentation to identify compliance gaps and remedial measures.
Stated by The Trust -
Action
Implement the commissioned improvement programme to embed reliable communication, handover and documentation processes in clinical practice.
Stated by The Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The NHS Trust, rather than the College, is responsible for responding on local communication, record keeping, policies and procedures.
Stated by Royal College of Paediatrics and Child Health
-
Concerns raised1
Failure to keep clear records of inpatient radiology transfers, purposes, procedures and ward returns
This report raised 6 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 the Radiology Requesting and Reporting Policy requiring documentation of radiology discussions, appointment changes and communication with responsible clinicians.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust -
Action
Develop and implement a radiology tracking and handover process documenting preparation requests, patient identification, scheduled investigations, completed investigations and return observations.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
The patient was not taken to radiology by mistake; Radiology records show his scan was scheduled and expected that day.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
-
Concerns raised1
Failure to record conclusions and advice from earlier calls
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 maintain accurate nursing and medical 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.2
-
Action
Install and roll out an electronic patient record integrating healthcare information and standardising documentation and care pathways.
Stated by Stockport NHS Foundation Trust -
Action
Undertake monthly live spot audits of 30 inpatient records to improve written-record quality during the electronic-record rollout.
Stated by Stockport NHS Foundation Trust
-
Concerns raised1
Unavailability of centile charts in handheld maternity records
This report raised 13 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 enter collateral history into the main clinical records
This report raised 15 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.1
-
Position
Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.
Stated by Care UK
-
Concerns raised1
Inconsistent or incomplete medical records
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.
Data last updated 7 September 2026