Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

First to latest report 13 Dec 2008 — 26 Jun 2026

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

Reports and published responses 474 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Surrey

    AI-generated summary

    Mr Critall · 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

    Mr Critall, an 80-year-old man, developed a haemothorax after insertion of a chest drain while being treated for pneumonia and died on 6 July 2014 after further deterioration and emergency treatment. The report raised concerns about the necessity and technique of the drain insertion, the failure to confirm its position, inadequate monitoring and resuscitation, and the hospital’s lack of appropriate emergency facilities and protocols. It also recorded that his family were not contacted after he became unwell or died.

    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

    Minimal respiratory consultant documentation

    Wider context from the report

    “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

    Source location

    Mr Critall · Prevention of Future Deaths report
    Page 3 · 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 document clinical examination

    Wider context from the report

    “11. There was minimal documentation by the consultant respiratory consultant, with only a brief entry in the notes on admission. There was no management plan in place, no record of any clinical examination undertaken and no request to check inflammatory markers which had been elevated to see whether they had improved which may have assisted in the necessity for the chest drain. It appeared to be an understanding a chest drain would be sited as a joint enterprise between the physician and radiologist. ”

    Source location

    Mr Critall · Prevention of Future Deaths report
    Page 3 · 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

    Reinforce contemporaneous consultant documentation of management plans, interventions and clinical examinations.

    Verbatim wording from the response

    “1. There have been a number of initiatives across the hospital in the last 2 years to reinforce the standard and ensure that all consultants are aware of the requirement to make contemporaneous notes regarding their patients.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 8 · response
    Published 16 May 2016

    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

    Conduct monthly sample audits of consultant medical-record documentation and refer non-compliance for appropriate action.

    Verbatim wording from the response

    “2. Consultant input into the medical record is subject to a monthly audit on a sample basis and audit results indicate significant improvement.”

    Source location

    2016-0187-Response-by-Mount-Alvernia-Hospital
    Page 8 · response
    Published 16 May 2016

    Open published response

  2. Manchester South

    AI-generated summary

    Geoffrey Ellis · 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

    Geoffrey Ellis was admitted for a left-sided laparoscopic nephro-ureterectomy, which was completed by open laparotomy. He died in hospital on 8 September 2015; the inquest concluded that misadventure contributed to by neglect contributed to his death. The principal concern was that illegible clinical records or incomplete important documents could cause communication breakdown and misinformation in a patient’s care pathway.

    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 complete important clinical documents

    Wider context from the report

    “Illegible clinical records and/or a failure to complete important documents creates a serious risk of a breakdown in communication and misinformation within a patient’s care pathway. ”

    Source location

    Geoffrey Ellis · 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

    Illegible clinical records

    Wider context from the report

    “Illegible clinical records and/or a failure to complete important documents creates a serious risk of a breakdown in communication and misinformation within a patient’s care pathway. ”

    Source location

    Geoffrey Ellis · 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

    Complete the rollout of the TrakCare electronic patient record system to consolidate patient information and prevent incomplete or illegible records.

    Verbatim wording from the response

    “The Trust is currently in the process of installing an electronic patient record system (EPR); this is a computerised version of the entire healthcare record. Instead of hospital staff using a mixture of paper and electronic records, information will be available to them online in one place. We already use a variety of electronic systems to help staff look after our patients but the EPR will bring all this information about our patients together into one system for better and safer care.”

    Source location

    2016-0186-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 13 May 2016

    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

    Undertake monthly live spot audits of 30 inpatient records to improve written record quality and communication.

    Verbatim wording from the response

    “In the meantime we will continue to endeavour to improve written records and communication by undertaking monthly ‘live’ spot audits, of 30 records per audit, relating to inpatients on our wards.”

    Source location

    2016-0186-Response-by-Stockport-NHS-Trust
    Page 1 · response
    Published 13 May 2016

    Open published response

  3. Brighton and Hove

    AI-generated summary

    Christine Valerie STREET · 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

    Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.

    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

    Inaccurate handover documentation

    Wider context from the report

    “(2) Mrs. Street was being specialised. She was on arm’s length observation and had been since just after her biopsy on the 28th August 2015. These observations had apparently been carried out successfully over the following days until early on the morning of the 11th September when an experienced HCA was specialling her. It was clear that he knew exactly how he should be specialling her, it was clear that the handover to him on the 10th September had been effective. It comprised a general handover, a bedside handover and a handover sheet. The handover sheet was flawed since it suggested that Mrs. Street had, had a fall already on the 9th September. There was no evidence to suggest that this was in fact the case. For some reason on the occasion when he escorted Mrs. Street to the toilet, a few steps from her bed in bay 9 on Level 8A West and indeed a few steps from the nurses station because bay 9 is a high dependency bay, he left her in the toilet, closed the door and did not wait outside. A few moments later she had an unwitnessed fall, the nurse at the nursing station heard the noise and rushed in to find her on the floor with a head injury which was immediately obvious. He looked after her and she was taken by wheelchair back to her bed once it had been established that she did not appear to have any injury other than the head injury. Thereafter, on the 11th she was appropriately managed. The Trust policy on observations for patients with mental health illness (this lady was deemed not to have mental capacity due to the extent of the symptoms produced by the brain tumour and was the subject of a Deprivation of Liberty Safeguarding Order put in place urgently on the 31st August 2015) was not adhered to by the HCA. The Trust policy on observations includes good paperwork for specialling including a specialling document which will stay with the care plan and daily documentation as to the specialling, plus an observation sheet. Apart from one or two observation sheets which appear to have been done on the 31st August, there was absolutely no documentation at all. This was in direct contravention of the Trust's own policy and indeed of the NICE guidance on observations, i.e., the national policy. There was another problem in connection with specialling and that is that the HCA involved was a bank employee and therefore the Trust has apparently no power over his training but must rely on the assurance of the agency that their staff have been appropriately trained for the tasks they are to perform. This gives no guarantee of course that they are trained to the standards set out in the Trust’s own policies and although the policies are handed to these members of staff or their existence made known to them, so that they can access them through the intranet, it seems highly unlikely that they would necessarily have had time or inclination to access every single one of the many protocols which exist in any acute hospital Trust. The problem was overcome here and was not a direct matter for the Jury to explore in this Article 2 Inquest because from the evidence, it was clear that the HCA concerned was experienced, had worked in the neurosurgical unit before and had done specialling on many occasions before and so would have known exactly what was expected of him. Nonetheless, important documentation such as this must be completed appropriately. ”

    Source location

    Christine Valerie STREET · 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 complete admission and fall documentation

    Wider context from the report

    “(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed). The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street’s notes. ”

    Source location

    Christine Valerie STREET · 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

    Organise a monthly neurosurgical records audit to improve documentation quality.

    Verbatim wording from the response

    “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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

    Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.

    Verbatim wording from the response

    “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 2 · response
    Published 10 May 2016

    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

    Follow up poor documentation with nursing and medical staff.

    Verbatim wording from the response

    “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    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

    Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.

    Verbatim wording from the response

    “It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has”

    Source location

    2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
    Page 1 · response
    Published 10 May 2016

    Open published response

  4. Surrey

    AI-generated summary

    Ernest Higgs · 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

    Ernest Higgs, a resident of a nursing home, was admitted to hospital after his health deteriorated and died there on 20 January 2015 from aspiration pneumonia. Concerns included unclear and poorly recorded telephone advice from a GP, uncertainty over responsibility for recording clinical advice, and conflicting information about out-of-hours pathology services that contributed to a delay in blood testing.

    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

    Lack of clarity about responsibility for recording visiting GPs' advice in multidisciplinary notes

    Wider context from the report

    “(1) It was clear from the evidence that confusion arose over what advice had been given by the GP on the 15th January 2015. No record was made in the multi-disciplinary notes by the GP of her attendance at Milner House. Care UK the parent company of Milner House offered to liaise with their local surgeries to ensure the records were made by visiting GPs. However it appears that the BMA advice to GPs “Quality First Managing Workload To Deliver Safer Patient Care” advises against GPs filling in multi-disciplinary notes. There was no clarity about whose responsibility it was to fill in the notes. ”

    Source location

    Ernest Higgs · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The practice will not commit to a position on multidisciplinary notes until the BMA clarifies its guidance.

    Verbatim wording from the response

    “1) Confusion over multi-disciplinary notes: We feel we need to await clarity from the BMA on their position regarding writing in the multi-disciplinary notes before committing to a stance.”

    Source location

    2016-0181-Response-by-The-Ashlea-Medical-Practice
    Page 1 · response
    Published 27 April 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Nurses attending with the doctor, and nursing-home staff, are responsible for recording contemporaneous multidisciplinary notes.

    Verbatim wording from the response

    “It is currently the practice view that it should be the responsibility of the nurses attending with the doctor to be writing contemporaneous notes of the interaction. We are happy to clarify any issues regarding instructions at the time of the visit however if the advice of the BMA differs from this we will consider a policy to address this. We have discussed this with the nursing home in question and they are in agreement that staff will be responsible for writing contemporaneous notes while we are in attendance.”

    Source location

    2016-0181-Response-by-The-Ashlea-Medical-Practice
    Page 1 · response
    Published 27 April 2016

    Open published response

  5. Manchester West

    AI-generated summary

    Mary Walker · 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

    Mary Walker, who had dementia and had been admitted to hospital after a stroke before being discharged to a care setting, was found dead on 10 October after overnight checks. She had died of bronchopneumonia. Concerns were raised about the lack of detail recorded during night-time checks and unclear procedures for Care Assistants escalating health concerns.

    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 patients’ condition during night-time checks

    Wider context from the report

    “(1) At the inquest there was no specific evidence about what was revealed in the night time checks that had been carried out upon the deceased. There was a global summary stating the times at which checks had been carried out but there was no information as to what the patient’s condition was at the checks. This procedure requires review. ”

    Source location

    Mary Walker · 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

    Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.

    Verbatim wording from the response

    “Following receipt of this Report we held a management review meeting to look at the information we held in relation to this case. At this meeting we took the decision to:”

    Source location

    2016-0150-Response-by-Care-Quality-Commission
    Page 1 · response
    Published 21 April 2016

    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 refresher training to Belong Wigan staff on safe records management and accurate date-and-time recording.

    Verbatim wording from the response

    “• Refresher training has been provided by the management team to all staff in Belong Wigan, on the ‘Safe management of records’ policy and procedures with an emphasis on the importance of accurate recording of progress against dates and times.”

    Source location

    2016-0150-Response-by-Belong
    Page 1 · response
    Published 21 April 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.

    Verbatim wording from the response

    “We noted the response provided to you by the registered provider, CLS Care Services Limited known as Belong on 27 April 2016. In light of this response it was not felt necessary for CQC to contact the registered provider to request written confirmation and”

    Source location

    2016-0150-Response-by-Care-Quality-Commission
    Page 1 · response
    Published 21 April 2016

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Following inspection and document review, no further investigation into the death or regulated activities was considered necessary.

    Verbatim wording from the response

    “Thank you for providing us with disclosure during the Coronial investigation. We can confirm that following our inspection and a review of these documents we do not intend to undertake further investigations in relation to the death of Mary Walker or the provision of regulated activities by CLS Care Services Limited.”

    Source location

    2016-0150-Response-by-Care-Quality-Commission
    Page 2 · response
    Published 21 April 2016

    Open published response

  6. Mid Kent and Medway

    AI-generated summary

    Alwyn Ann Head · 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

    Alwyn Ann Head was admitted to hospital after falls caused a fractured femur at the site of a prosthesis. She underwent surgery, developed an MRSA wound infection, deteriorated after further surgery, and died on 20 August 2015. Concerns included failure to establish her MRSA history, lack of prophylactic Teicoplanin, absence of a post-operative wound care plan, inadequate evidence of wound inspection, and meaningless nursing documentation about the wound.

    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 meaningful nursing information about dressing and wound condition

    Wider context from the report

    “(5) Entries in the nursing notes relating to dressing and wound were meaningless and would not assist a determination of whether there was deterioration in the wound ”

    Source location

    Alwyn Ann Head · 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

    Incorporate infection-status and wound-care documentation into the new nursing assessment and care-planning document.

    Verbatim wording from the response

    “• The new documentation will be incorporated into a new nursing patient assessment / care planning document which is due to be implemented in July 2016.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    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

    Update tissue-viability policy and procedures with NICE guidance and post-operative surgical-wound management standards.

    Verbatim wording from the response

    “We are updating our tissue viability policy and associated standard operating procedures (SOPs) to include NICE guidance and standards for post-operative surgical wound management.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    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 wound-care documentation, care plans and wound-assessment standards.

    Verbatim wording from the response

    “Wound care documentation, care plans and wound assessment standards have all been reviewed. The wound care documentation will be incorporated into the new nursing assessment / care planning document in July 2016.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    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

    Present wound-care documentation and standards to safety and nursing quality forums and cascade them through directorates.

    Verbatim wording from the response

    “The documentation and standards will be presented to the Trust Patient Safety Group and the Nursing & Midwifery Quality Forum. Directorate representatives will be responsible for cascading the information through their Directorate.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    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

    Monitor compliance with wound-care policies and procedures through established assurance audits and governance forums.

    Verbatim wording from the response

    “Compliance with the policies and SOPs will be monitored as part of our established assurance audits. Results of audits are presented at Patient Safety Group which has responsibility for monitoring compliance in this area and the Nursing & Midwifery Quality Forum.”

    Source location

    A-head-Response
    Page 2 · response
    Published 23 March 2016

    Open published response

  7. West Yorkshire (Western)

    AI-generated summary

    June Elsie Parkes · 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

    June Elsie Parkes became unwell with symptoms of an upper gastrointestinal bleed and was admitted to hospital on 14 December 2014. She later deteriorated and died shortly after being transferred to Huddersfield Royal Infirmary on 17 December 2014. The concerns included delays and gaps in systems for urgent or emergency endoscopy and surgery, monitoring and escalation, record keeping, and the transfer of critically ill patients.

    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

    Deficient doctor record keeping

    Wider context from the report

    “(6) Record keeping of doctors ”

    Source location

    June Elsie Parkes · Prevention of Future Deaths report
    Page 3 · 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

    Deficient nursing staff record keeping

    Wider context from the report

    “(5) Record keeping of nursing staff ”

    Source location

    June Elsie Parkes · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  8. South Yorkshire (Eastern)

    AI-generated summary

    Jason Derek Vaughan · 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

    Jason Derek Vaughan died by suicide by hanging at his home on 23 September 2015. The principal concerns were limitations in the IAPT electronic clinical records, a risk assessment tool that did not capture deterioration below its highest-risk level, and insufficient recognition of factors associated with suicide among middle-aged men and socio-economic groups.

    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

    Insufficient written narrative detail accompanying coded clinical record entries

    Wider context from the report

    “(1) The effectiveness of the IAPT electronic patient clinical records system (SystemOne) may be limited, in some instances, by there being insufficient written narrative detail (eg. As to medication commencement dates, doses, changes etc.) to accompany the coded data entries in the drop down box selection ”

    Source location

    Jason Derek Vaughan · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The SystmOne system does not have a systemic defect preventing staff from recording important medication-management information.

    Verbatim wording from the response

    “Electronic systems can support adequate record keeping but ultimately it still depends upon a staff member to input data. In your Regulation 28 report you gave examples regarding medications management. Recording adequate data regarding medication management is absolutely key in healthcare. This is because it is an essential part of the management of the majority of patients with severe mental disorder, and often plays a part in those with less severe mental health conditions. All medications have side effects, some of them serious. It is for this reason that I would agree with you wholeheartedly that recording adequate data regarding medications management is essential. However there does not appear to be a systemic issue with the SystmOne tool which prevents the recording of invaluable data.”

    Source location

    2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 2 · response
    Published 11 March 2016

    Open published response

  9. West Yorkshire Eastern

    AI-generated summary

    Max James Haigh · 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

    Max Haigh, who had a complex congenital cardiac defect and had undergone cardiac surgery, became unwell with vomiting and deteriorated in hospital. He died on 12 June 2013 after unsuccessful resuscitation; concerns were raised that the surgeon’s operative note lacked potentially vital information for any future surgery.

    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 complete cardiac surgical anatomy and operative techniques in surgical notes

    Wider context from the report

    “(1) Following surgery the surgeon prepared a note of his operation for the medical records. It was anticipated that Max may, in the future, require further surgery. The note of the surgery was unsatisfactory and failed to set out:- (a) The position of the ventricular septal defect (”VSD”) and how it was enlarged; (b) A full description of the VSD; (c) The position of the tricuspid valve; (d) The techniques that were used by the surgeon himself. (2) There is a real concern that any other surgeon performing surgery in the future faced with inadequate surgical notes would be deprived of potentially vital information to assist in the forthcoming surgery. ”

    Source location

    Max James Haigh · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. Manchester (North)

    AI-generated summary

    Susan Beverley George · 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

    Susan Beverley George had longstanding mental health problems and was discharged from a mental health unit on 10 November 2014 despite concerns about her safety, anxiety, suicidal feelings and calls to emergency services. She left home the following day, went to Healey Dell and ingested an excessive quantity of prescribed medication, later being found deceased. Concerns included failures in reviewing and coordinating the discharge, inadequate record keeping and risk-management guidance, inappropriate staff attitudes, poor advocacy, and a gap in inpatient clinical psychology provision.

    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 nursing record keeping

    Wider context from the report

    “4. Poor record keeping, predominantly on the part of the nursing staff. ”

    Source location

    Susan Beverley George · Prevention of Future Deaths report
    Page 3 · 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

    Pilot a nursing shift pattern assigning the meetings nurse dedicated time to complete discharge documentation.

    Verbatim wording from the response

    “All relevant parties are informed of the planned discharge with the patients’ consent. This is also in line with the revised Mental Health Act Code of Practice 2015. We are also undertaking a pilot of shift pattern for nurses which means the ‘meetings’ nurse will work 08:30–10:00 in order to ensure full completion of discharge documentation by the same staff member and thus avoids this task being handed over to a nurse who may not have been involved in the discharge meeting. This is supported with the development of the Triangle of Care initiatives, in which the involvement of family members providing information regarding the patient, even if the service user does not give consent to share information, is still included in the information that informs the discharge process.”

    Source location

    Susan-George-Response
    Page 4 · response
    Published 29 February 2016

    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

    Fully implement monthly ward-level Standard of Record Keeping audits with supervision feedback, performance monitoring and benchmarking.

    Verbatim wording from the response

    “Since this case the ward has now appointed a substantive ward manager and has fully implemented the Standard of Record Keeping audit on the ward. This process includes each set of notes being audited on a monthly basis with individual results being fed back to each named nurse/qualified nurse during their supervision with any performance issues being addressed and monitored through this process. This”

    Source location

    Susan-George-Response
    Page 4 · response
    Published 29 February 2016

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026