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

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

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

Reports and published responses 474 reports

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

4 Jan2016
Plymouth, Torbay and South Devon
Concerns raised2
1. Failure to document headache assessment and clinical reasoning
2. Inadequate and incomplete recording of clinical events
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Thomas Alexander Burchell · 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

Thomas Alexander Burchell had a brain tumour and developed progressive seizures after transfer for neurosurgical treatment; the post-mortem medical cause of death was brain swelling and infarction associated with glioblastoma. Concerns included incomplete records of the seizures and inadequate documentation and assessment of earlier headaches and weakness, including delays in processing prior medical records and uncertainty about referral guidance.

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 document headache assessment and clinical reasoning
Wider context from the report
“(1) There is nothing in the records to explain how ████████ came to the view that Thomas was suffering from stress related headaches. Further, there is nothing in the notes to confirm whether or not he asked Thomas any questions at all about his headaches. In his evidence, ████████ had to accept that it was possible he did not do so. ”
Source location
Thomas Alexander Burchell · 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
Inadequate and incomplete recording of clinical events
Wider context from the report
“(1) Inadequate and incomplete record keeping. This is in respect of both medical and nursing records. In particular, the seizure chart stated late and finished early. It is far from an accurate or complete record of what happened to Thomas. (2) In a neurosurgical unit I understand there will be patients having seizures on a regular basis. I further understand that it is extremely rare for those seizures to progress as befell Thomas and then prove resistant to treatment. Where a patient does develop seizures, however, I consider that there should be a far more robust and complete record of the relevant events. ”
Source location
Thomas Alexander Burchell · Prevention of Future Deaths report
Page 2 · concerns
Open source report
30 Dec2015
Manchester West
Concerns raised2
1. Failure to record family concerns, clinical attendances and observed symptoms in patient notes
2. Failure to document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

The Trust
Stated actions 5
1. The Trust
  Provide Darley Court staff direct access to an out-of-hours GP and require consultation details to be documented in Darley Court medical notes.
2. The Trust
  Disseminate record-keeping guidance and escalation guidance, and remind staff to document and escalate patient concerns appropriately.
3. The Trust
  Provide weekly and monthly documentation and record-keeping training for Darley Court staff.
1. The Trust
  Conduct monthly documentation audits to monitor compliance and improve record-keeping quality.
2. The Trust
  Review multidisciplinary team meetings and paperwork, and address poor documentation and failures to follow up meeting actions through a task-and-finish group.
AI-generated summary

Mollie Bentham · 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

Mollie Bentham died at Rivington View Nursing Home on 1 May 2015 after deteriorating following her transfer there from Darley Court Intermediate Care Centre. Concerns included failures to record and communicate family reports of abdominal pain, inadequate clinical review and documentation, absent or incomplete handovers, and insufficiently detailed multidisciplinary meeting records. The report identified risks to future patients, particularly those unable to communicate their symptoms.

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 family concerns, clinical attendances and observed symptoms in patient notes
Wider context from the report
“1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”
Source location
Mollie Bentham · 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 attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes
Wider context from the report
“1. During the Inquest evidence was heard that i. The notes at Darley Court Intermediate Care Centre did not refer to the family concerns expressed to the nursing staff from the 23rd April 2015 onwards and the notes did not include a note from the out of hours General Practitioner, who attended Darley Court on the 26th April 2015, nor the attendance of ████████ on the 27th April 2015. The notes did not make any reference to abdominal pain suffered by Miss Bentham until the 28th April 2015, even though the family expressed concerns with regard to abdominal pain on the 23rd April 2015. ii. There was no evidence of liaison between the nursing staff and the medical staff at Darley Court Intermediate Care Centre, particularly in relation to the concerns expressed by the family and with regard to the attendance of the out of hours General Practitioner on the 26th April 2015. iii. There was no evidence of handovers at shift changes as between nursing staff and medical staff particularly in relation to the concerns expressed by the family and the attendance of the out of hours General Practitioner on the 26th April 2015. iv. The notes of the Multi-Disciplinary Team Meetings, including the Meeting on the 27th April 2015, did not give details of who was present at the Meeting, the actions to be taken following the Meeting together with the person who was given responsibility to take the actions and a timescale in relation to the actions. The above concerns are particularly relevant in relation to a patient, like Miss Bentham, who was unable to communicate with either nursing staff or medical staff. In such circumstances and in the absence of documented and noted information in relation to family concerns a condition suffered by the patient may be left untreated without consideration by a reviewing doctor or a Multi-Disciplinary Team Meeting. v. The above issues raise training issues in relation to staff, both nursing and medical, at Darley Court Intermediate Care Centre. vi. The evidence raised concerns that there is a risk that future deaths will occur unless action is taken to review the above issues, particularly where known symptoms observed by the family are not brought to the attention of the reviewing medical team and no investigations are conducted with regard to the observed symptoms. ”
Source location
Mollie Bentham · 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
Provide Darley Court staff direct access to an out-of-hours GP and require consultation details to be documented in Darley Court medical notes.

Verbatim wording from the response
“The Darley Court staff now have direct access to an Out of Hours (OOH) General Practitioner (GP) who is attached to the Admission Avoidance Team (AAT). The GP is with the AAT from 18:30 to 22:00 Monday to Friday and 9:00 to 22:00on Saturday and Sunday. Patients that require urgent medical attention outside of the hours of medical cover by the doctor at Darley Court but within the hours stipulated above will be seen by the OOH GP based at the AAT. It has been agreed with BARDOC (OOH GP Provider) that the GP will document details of the consultation in the medical notes at Darley Court. This will ensure that both the nursing and medical staff are informed of the treatment plan for the patient. I understand that this service has been utilised and positive feedback has been received from staff at Darley Court.”

Source location
Mollie-Bentham-Response
Page 1 · response
Published 30 December 2015
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
Disseminate record-keeping guidance and escalation guidance, and remind staff to document and escalate patient concerns appropriately.

Verbatim wording from the response
“Matron ████████ has reminded all staff that any concerns raised regarding a patient need to be clearly documented in the patient’s ongoing records and escalated where appropriate. A copy of the NMC guidelines has been circulated to all nursing staff highlighting the importance of accurate record keeping. Escalation guidance has also been produced to be read in conjunction with National Early Warning Score (NEWS) guidance.”

Source location
Mollie-Bentham-Response
Page 2 · response
Published 30 December 2015
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 weekly and monthly documentation and record-keeping training for Darley Court staff.

Verbatim wording from the response
“Documentation training is also now included in the new weekly training programme, furthermore additional training is being provided on a monthly basis in respect of documentation and record keeping. Monthly documentation audits are now being undertaken to ensure compliance with this action and ensure the quality of record keeping is improved.”

Source location
Mollie-Bentham-Response
Page 2 · response
Published 30 December 2015
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 documentation audits to monitor compliance and improve record-keeping quality.

Verbatim wording from the response
“Documentation training is also now included in the new weekly training programme, furthermore additional training is being provided on a monthly basis in respect of documentation and record keeping. Monthly documentation audits are now being undertaken to ensure compliance with this action and ensure the quality of record keeping is improved.”

Source location
Mollie-Bentham-Response
Page 2 · response
Published 30 December 2015
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 multidisciplinary team meetings and paperwork, and address poor documentation and failures to follow up meeting actions through a task-and-finish group.

Verbatim wording from the response
“A review of the conduct of MDT meetings including evaluation of the paperwork used at the meetings has been lead by Ann Lloyd, Consultant Nurse for Older People. ████████ has set up a task and finish group and taken steps to address the issues of poor documentation and failure to follow up actions identified at MDT meetings. I am advised this work is still ongoing however its purpose will be to ensure there is improved clinical decision making from all disciplines attending the MDT with appropriate timescales set for actions to be taken and completed, ultimately this will facilitate the safe discharge of our patients. It is expected that this work will be complete by 31 March 2016.”

Source location
Mollie-Bentham-Response
Page 2 · response
Published 30 December 2015
Open published response
29 Dec2015
Inner South London
Concerns raised1
1. Failure to record clinical history and examination
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Imran DOUGLAS · 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

Imran Douglas died by suicide on 13 November 2013, on the fifth day of his detention at HMP Belmarsh, after being sentenced to 18 years. The report identified concerns about transition and placement arrangements, communication and information-sharing between agencies, access to electronic records, and the adequacy of a medical assessment and response to suicide risk.

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 clinical history and examination
Wider context from the report
“The GP did not record history or examination or propose any interventions despite being aware of the young age, long sentence and suicide warning form. The clinical review conducted as part of the Prison and Probation Ombudsman’s Report concluded that health care provision in HMP Belmarsh was below the standard expected. ”
Source location
Imran DOUGLAS · Prevention of Future Deaths report
Page 3 · concerns
Open source report
15 Dec2015
West Yorkshire (Western)
Concerns raised2
1. Inadequate medical record keeping
2. Inadequate nursing record keeping
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Calderdale and Huddersfield NHS Foundation Trust
Stated actions 1
1. Calderdale and Huddersfield NHS Foundation Trust
  Use Nerve Centre mobile observations to record patient observations, trigger escalation for raised NEWS scores, and monitor response trends.
AI-generated summary

Ruth Hilda Smith · 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

Ruth Hilda Smith died on 16 April 2014 at Huddersfield Royal Infirmary after developing a haemothorax following insertion of a central venous line, with sepsis, altered liver function and pneumonia also recorded as causes. Concerns included delays in medical review, inadequate nursing observations, and poor nursing and medical record keeping during the evening of 15 April and early hours of 16 April 2014.

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 medical record keeping
Wider context from the report
“Medical Care A doctor attended at 18.40 upon Mrs Smith but did not make a full record within the medical records. Nursing staff requested a doctor review at 22.30 hours. No doctor attended until 00.30 hours. When a doctor did attend a fluid challenge was implemented. The doctor did not return to review Mrs Smith or put in place arrangements for another doctor to review. At 2.00 hours an FY2 doctor attended following a request by nursing staff. The FY2 doctor determined that Mrs Smith’s bloods and blood gases should be checked. I heard evidence that nursing staff advised the FY2 doctor that Mrs Smith needed more senior medical review by a registrar. The FY2 made no entries within Mrs Smith’s medical records. I have the following concerns: 1. The 2 hour time lapse between a request for a doctor review and a doctor attending upon Mrs.Smith. 2. No review was put in place following the implementation of the fluid challenge. 3. The standard of record keeping and lack of records being made by the doctors who attended up Mrs. Smith on the evening of the 15th April and early hours of the 16th April up until the Registrar’s involvement at 03.25 a.m. on the 16th April. ”
Source location
Ruth Hilda Smith · 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
Inadequate nursing record keeping
Wider context from the report
“Nursing Care At 22.05 Mrs Smith was found to have an elevated MEWS score and as a result a request was made for an FY 1 Doctor to review. Evidence was given by a senior charge nurse( who provided an overview of nursing care to Mrs Smith, but who was not directly involved in her care) that following this Mrs Smith should have undergone hourly observations. This did not happen. There was reference to observations being undertaken at 00.30 but these were not recorded. Further observations were incomplete The FY1 Doctor did not attend the ward until 00.30. There was no record within the notes to suggest that enquiries were undertaken between 22.30 and 00.30 to chase up the attendance of the FY 1 Doctor. I have the following concerns: 1. No attempts were made to ensure a doctor attended and reviewed Mrs. Smith between 22.30 and 00.30. 2. The level of nursing monitoring (hourly observations) taking place for much of the period between 22.30 on the 15th April and 03.25 on the 16th April. 3. The standard of the nursing record keeping. ”
Source location
Ruth Hilda Smith · 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
Use Nerve Centre mobile observations to record patient observations, trigger escalation for raised NEWS scores, and monitor response trends.

Verbatim wording from the response
“1. “Nerve Centre” – Nerve Centre is the use of mobile electronic observations and hospital at night software to improve patient safety and staff communication anywhere within our hospitals 24 hours a day, 7 days a week. All patient observations are recorded on an IPAD. The use of mobile technology also allows doctors and nurses to have all the tools and information at hand to be able to respond rapidly and effectively to deteriorating patients.”

Source location
Ruth-Smith-Response
Page 1 · response
Published 15 December 2015
Open published response
14 Dec2015
North Wales (East and Central)
Concerns raised1
1. Lack of recording the type of issue in the notes
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Alan 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

Alan Walker died after a nasogastric feeding set was connected to an intravenous line, resulting in the infusion of liquid feed. The report raised concern that equipment connectivity issues were not recorded in nursing notes and might not be relayed during staff handovers.

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 recording the type of issue in the notes
Wider context from the report
“That by not recording within the notes the type of issue referred to in paragraph 4 (b) above and then by not conducting handovers by reference to the nursing notes there is a risk that potentially significant information is not relayed to staff who come on duty at a later time. ”
Source location
Alan Walker · Prevention of Future Deaths report
Page 1 · concerns
Open source report
25 Nov2015
Manchester South
Concerns raised1
1. Failure to accurately record the professional identity of the clinician who assessed the patient
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Haughton Thornley Medical Centres
Stated actions 3
1. Haughton Thornley Medical Centres
  Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.
2. Haughton Thornley Medical Centres
  Complete a medical record-keeping course for GPs and reflect on its learning.
3. Haughton Thornley Medical Centres
  Review medical records to ensure relevant information is recorded clearly.
AI-generated summary

Thomas Anthony Collins · 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

Thomas Anthony Collins lived in a care home and fell on 22 June 2015, sustaining chest injuries. He was not admitted to hospital at that time, was later admitted on 25 June, and died on 15 July 2015 after treatment for complications including sepsis, pneumonia and respiratory distress. The report raised concerns about paramedic decision-making and the GP’s assessment, including failures to recognise the seriousness of the injury and signs of a flail chest.

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 accurately record the professional identity of the clinician who assessed the patient
Wider context from the report
“2. The GP attended the patient on the 24th June and she assumed that he had been seen by a doctor on the 22nd because the record showed that he had been seen by a “practitioner”. In fact he had only been seen by the paramedic. This assumption very much detrimentally influenced her subsequent decision making.(Haughton Thornley Medical Centres) ”
Source location
Thomas Anthony Collins · 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
Record clear findings, admission or transfer rationale, fall circumstances, and responsibility for complete clinical notes.

Verbatim wording from the response
“• When accidents happen in homes and care homes, we will ensure we record very clearly the findings and our rationale for not admitting the patient to hospital or transferring them to hospital. We will obtain more information surrounding the circumstances of a fall. The clinician who makes this decision will take responsibility for ensuring that the notes are complete and clear. We will ask for a detailed account from care home staff of witnessed falls and will obtain information from relatives where appropriate.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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
Complete a medical record-keeping course for GPs and reflect on its learning.

Verbatim wording from the response
“• A medical record keeping course for GPs on the 6 October 2015 with subsequent reflection on the course.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 2 · response
Published 25 November 2015
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 medical records to ensure relevant information is recorded clearly.

Verbatim wording from the response
“We will share this incident’s findings and learning with our local GP colleagues at the next local meeting, to help prevent further deaths of this nature occurring. We will also include an update of this incident in our next practice meeting. Our medical records will be reviewed to ensure that all of the relevant information is recorded clearly.”

Source location
2015-0469-Response-by-Haughton-Thornley-Medical-Centres
Page 3 · response
Published 25 November 2015
Open published response
16 Nov2015
East London
Concerns raised1
1. Failure to record emails from family members in patient notes
This report raised 16 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

North East London NHS Foundation Trust
Stated actions 1
1. North East London NHS Foundation Trust
  Improve record keeping standards in AABIT.
AI-generated summary

EMMA LOUISE BRAY · 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

Emma Louise Bray had a history of problems with mood and was assessed by mental health services in January 2015 after her mood deteriorated. Her family reported worsening symptoms, hopelessness, suicidal research and concerns about her medication, but several planned referrals, follow-up actions and communication of information did not occur. She hanged herself on 25 February 2015. Concerns included incomplete medication and treatment histories, failures in follow-up and referral, inadequate response to family information, failures to record emails, unclear medication-risk communication, and wider deficiencies in service guidance and monitoring.

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 emails from family members in patient notes
Wider context from the report
“During the evidence I was told that a number of things had not happened that ought to have done: (a) A proper medication history was not taken on assessment (b) EB’s treatment and medication history were not obtained from either public or private sector providers. (c) Had EB’s history been obtained she should have been referred to a psychiatrist following assessment, to be seen and assessed within 14 days. (d) ████████ felt that there was an underestimate of the level and complexity of EB’s condition. (e) EB remained with the Intake team for the whole period of her contact with the service. This appears to have occurred because of a failure to make a referral rather than because of any positive decision to retain her within the team. (f) EB should have been referred to an appropriate service, probably initially the BIT. This would have provided her with better support and regular monitoring. (g) Even within the IT there was a failure to follow EB up. Telephone contact should have been made with her by seven days after the initial assessment. (h) There should have been regular contact with EB thereafter, initiated by IT. (i) Important information was provided by EB’s family about the changes in her presentation, most notably on 19 January, 22 January and then from 19 February 2015 onwards. Nothing happened in response to these reports. The information should have been placed before the Intake Team MDT to discuss her care. (j) Had the information been provided EB should have been seen by the team and, in response to the information of 19 February 2015 at the latest, had a psychiatric assessment. (k) The emails sent by EB’s family were not placed on her notes; accordingly other members of staff looking at her care were not aware of the family’s concerns. (l) Risks associated with the drug Sertraline do not appear to have been communicated to EB and her family. Were the drug was recommended by a psychiatrist who had not seen or assessed EB it was unclear where responsibility for advising about risk lay. On a systemic level, the following issues are of concern: (a) Absence of guidelines about what information must be obtained on assessment, including the medication history. (b) Absence of guidance about where that information should be obtained from: the patient / primary sources. (c) A lack of clarity amongst staff about when to retain patients under the IT and when to refer out of it intake to other services. (d) Lack of clarity about who should be the person between patients and the IT. (e) Lack of guidance about what to do when patients are not engaging directly with the IT but there is reason for concern about them. (f) A lack of monitoring / auditing of the passage of patients through the service to see whether cases are being managed and progressed as they ought to be. (g) An absence of guidelines giving staff timescales within which referrals should take place. (h) A lack of appreciation of the need to create a plan with timescales for further treatment / referral to take place. (i) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without a full medical history. (j) A lack of clear information about the circumstances in which it is appropriate for a psychiatrist to make recommendations about the medication without seeing the patient in person. (k) A lack of clarity about whose responsibility it is to communicate risks about medication to the individual when the medication is recommended by the WFAAT psychiatrist but prescribed by the GP. This was particularly the case with the Sertraline prescribed to EB, which apparently does have specific associated risks that must be warned of. (l) The lack of apparent process or procedure to ensure that emails sent to staff directly are placed on an individual’s notes. (m) Any proper understanding by staff of risk assessment in the context of self-harm. The risk assessment tool in use appeared very basic and not one that provided any real assistance to staff. ”
Source location
EMMA LOUISE BRAY · 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
Improve record keeping standards in AABIT.

Verbatim wording from the response
“The plan has five broad objectives within which your specific concerns have been addressed. These are:”

Source location
2015-0438-Response-by-NELFT-NHS-Trust
Page 1 · response
Published 16 November 2015
Open published response
29 Oct2015
Gateshead and South Tyneside
Concerns raised1
1. Lack of a coordinating record of recurrent asthma presentations
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Tamara Mills · 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

Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.

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 a coordinating record of recurrent asthma presentations
Wider context from the report
“1. The care management and treatment of this child on the innumerable occasions she presented with an exacerbation of asthma, was centred solely on treating the immediate presentation as an isolated acute event seeking its stabilisation and returning her to the care of her family. 2. There was :- i) No co-ordinating record of these occasions ii) No analysis of the frequency or circumstances of the events iii) No analysis of the medication or level of medication prescribed iv) No determination of its effectiveness the frequency or regularity of its use v) No appreciation of the deteriorating nature of her respiratory condition ”
Source location
Tamara Mills · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Oct2015
Manchester South
Concerns raised1
1. Failure to ensure accurate recording of treatment site
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

William Gordon Tolen · 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

William Gordon Tolen was living at Shawe Lodge when he developed problems with his legs and left great toenail; a podiatrist removed the toenail, after which he developed cellulitis. The investigation concluded that the death was from natural causes, with septicaemia and cellulitis recorded as the medical cause of death. Concerns included inadequate record-keeping, delays in arranging podiatry care, insufficient staff training, and the inappropriate conditions in which the procedure was carried out.

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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 accurate recording of treatment site
Wider context from the report
“5. The notes at Shawe Lodge indicated that the nail had been removed from the “right” great toe when in fact it was the left. This was apparently due to a misinterpretation of an abbreviation in those notes. (Shawe Lodge) ”
Source location
William Gordon Tolen · Prevention of Future Deaths report
Page 1 · concerns
Open source report
9 Oct2015
Newcastle upon Tyne
Concerns raised1
1. Inadequate completion of nursing and medical notes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

Northumbria Healthcare NHS Foundation Trust
Stated actions 1
1. Northumbria Healthcare NHS Foundation Trust
  Conduct annual documentation audits across rotating clinical areas.
AI-generated summary

Patrick Joseph Carrick · 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

Patrick Joseph Carrick underwent laparoscopic high anterior resection for colorectal cancer on 23 January 2012 and subsequently deteriorated, later dying from a rare but recognised complication of the surgery. Concerns included a significant unexplained departure from his management plan during rapid deterioration, failure to action blood analysis results, inadequate monitoring, delays in administering antibiotics, and inadequate completion of nursing and medical notes.

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 completion of nursing and medical notes
Wider context from the report
“(1) There was a significant departure from a patients management plan without explanation (2) The above was compounded as it occurred in a period of rapid deterioration (3) Crucial blood analysis results were not actioned (4) Inadequate completion of nursing and medical notes ”
Source location
Patrick Joseph Carrick · 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
Conduct annual documentation audits across rotating clinical areas.

Verbatim wording from the response
“• Annual documentation audits: The clinical audit team perform annual documentation audits rotating through specific areas checking that documentation is complete.”

Source location
2015-0374-Response-by-Northumbria-Health-Care-NHS-Trust
Page 3 · response
Published 9 October 2015
Open published response

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

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Failure to document headache assessment and clinical reasoning

Inadequate and incomplete recording of clinical events

Concerns raised2

Failure to record family concerns, clinical attendances and observed symptoms in patient notes

Failure to document attendance, actions, assigned responsibility and timescales in Multi-Disciplinary Team Meeting notes

Linked response

Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Concerns raised1

Failure to record clinical history and examination

Concerns raised2

Inadequate medical record keeping

Inadequate nursing record keeping

Linked response

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

Concerns raised1

Lack of recording the type of issue in the notes

Concerns raised1

Failure to accurately record the professional identity of the clinician who assessed the patient

Linked response

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

Concerns raised1

Failure to record emails from family members in patient notes

Linked response

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

Concerns raised1

Lack of a coordinating record of recurrent asthma presentations

Concerns raised1

Failure to ensure accurate recording of treatment site

Stated actions 5

Stated actions 1

Stated actions 3

Stated actions 1