Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

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First reported 13 Dec 2008•Latest report 26 Jun 2026

Definition

What this concern includes

Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.

Not included

Information-transfer failures where the underlying records are reliable
Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
Non-care administrative records

Reports: 474
Individual concerns: 568
Date range: 2008–2026
Stated actions: 780

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care64

NHS England38

Care Quality Commission30

NHS Greater Manchester Integrated Care Board12

University Hospitals Sussex NHS Foundation Trust11

Essex Partnership University NHS Foundation Trust10

Greater Manchester Mental Health NHS Foundation Trust10

Stockport NHS Foundation Trust10

Tameside and Glossop Integrated Care NHS Foundation Trust10

Office of the Chief Coroner9

Recipient name withheld9

Sussex Partnership NHS Foundation Trust9

Barts Health NHS Trust8

East London NHS Foundation Trust8

Manchester University NHS Foundation Trust8

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

1 Sep2025
Inner North London
Concerns raised1
1. Failure to complete allocated clinical tasks within the responsible shift
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Train qualified nursing staff in nurse-in-charge responsibilities, including allocation and monitoring of outstanding tasks.
  Stated by East London NHS Foundation TrustStated in progress
2. Action
  Develop a longer electronic training package for the nurse-in-charge role.
  Stated by East London NHS Foundation TrustStated in progress
3. Action
  Use a standardised handover template to identify and allocate outstanding nursing and medical tasks, with senior nursing oversight.
  Stated by East London NHS Foundation TrustStated completed
AI-generated summary

Name not published · 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

████████ was detained under the Mental Health Act and admitted to psychiatric wards at the Tower Hamlets Centre for Mental Health before being found unresponsive in a patient room on 7 June 2022; her death was verified later that day. The jury identified several contributing factors, including a non-functioning door-locking system and shortcomings in patient observations. Further concerns included risk assessment, staff understanding and attitudes towards risk, auditing, and clinical oversight.

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 allocated clinical tasks within the responsible shift
Wider context from the report
“7) Attitudinal concerns There was a recurrent theme in the evidence provided by nursing and support staff that certain clinical tasks (including, but not limited to, the completion of risk assessment documentation) could simply be left for the next shift to complete. The net result of this was that such tasks were not completed, allowing the risks associated with non-completion to be perpetuated. The court was told that all shifts (on Rosebank Ward in particular) were busy and staff often did not have time to complete the tasks allocated to them. However, CCTV footage showed, for example, a member of staff (allocated to complete observations and not on a designated break at the material times) checking their mobile telephone and sitting in the lounge reading the newspaper instead of undertaking their clinical role. ”
Source location
Name not published · Prevention of Future Deaths report
Page 4 · 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
Train qualified nursing staff in nurse-in-charge responsibilities, including allocation and monitoring of outstanding tasks.

Verbatim wording from the response
“All qualified nursing staff are undergoing brief initial training around the role of the nurse in charge which includes allocation of outstanding tasks (assessments, care plans etc) and monitoring the completion of these. A longer electronic training package is being developed. This has already been completed in Tower Hamlets.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 2 December 2025
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
Develop a longer electronic training package for the nurse-in-charge role.

Verbatim wording from the response
“All qualified nursing staff are undergoing brief initial training around the role of the nurse in charge which includes allocation of outstanding tasks (assessments, care plans etc) and monitoring the completion of these. A longer electronic training package is being developed. This has already been completed in Tower Hamlets.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 2 December 2025
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
Use a standardised handover template to identify and allocate outstanding nursing and medical tasks, with senior nursing oversight.

Verbatim wording from the response
“A standardised handover template has been introduced which facilitates the identification of outstanding nursing and medical tasks to be allocated. The lead nurse and matrons are attending nursing handovers to monitor and embed this practice.”

Source location
Response from East London NHS Foundation Trust
Page 4 · response
Published 2 December 2025
Open published response
21 Aug2025
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Use of ‘advice given’ outcomes producing misleading impressions of events
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Nicholas Paul MURPHY · 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

Nicholas Paul MURPHY reported taking an overdose on 29 December 2023, declined further assessment and hospital transfer, and was later found deceased at home on 9 January 2024 after a further welfare concern. The principal concerns were that ambulance outcome codes did not record refusal of treatment or transfer, and that recording the outcome as “Advice only” or “advice given” could mislead staff and result in critical safeguarding information being missed.

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
Use of ‘advice given’ outcomes producing misleading impressions of events
Wider context from the report
“From the evidence I heard I am concerned that information critical to safeguarding and proper decision making may be missed, as it was in this case, given that the outcome codes do not include one that reveals the patient refused treatment. I am also concerned that the outcome of ‘advice given’ can give a very misleading impression of events when used in these type of circumstances. ”
Source location
Nicholas Paul MURPHY · Prevention of Future Deaths report
Page 2 · concerns
Open source report
6 Aug2025
Surrey
Concerns raised1
1. Deficient recording of key events following unwitnessed falls in nursing home records
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Stephen LAWRENCE · 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

Stephen Lawrence, a resident at Eastcroft Nursing Home, sustained an unwitnessed fall on 21 December 2022 and multiple rib fractures, which led to a haemopneumothorax and pneumonia. He died in hospital on 5 January 2023; concerns included unexplained injuries, deficient nursing home records, delayed medical advice, and conflicting evidence from the nursing home manager, with an ongoing risk to current residents.

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 recording of key events following unwitnessed falls in nursing home records
Wider context from the report
“- Mr Lawrence sustained significant unexplained injuries whilst he was a resident at Eastcroft Nursing Home; - Nursing Home records were deficient in their recording of key events following his unwitnessed fall on 21 December 2022; - There was a delay in seeking medical advice following the unwitnessed fall on 21 December 2022; - The Nursing Home Manager providing conflicting evidence about efforts to obtain medical advice and did not accept that the acute fractures leading to Mr Lawrence’s death occurred whilst he was at the nursing home. - In view of all of the above, the Coroner is concerned that there is an ongoing risk to current residents. ”
Source location
Stephen LAWRENCE · Prevention of Future Deaths report
Page 3 · concerns
Open source report
1 Aug2025
Milton Keynes
Concerns raised1
1. Reliance on delayed written clinical documentation in emergency settings
This report raised 21 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Implement joint clinical entries, mandatory immediate verbal handovers and contemporaneous electronic documentation after assessments, with random quality audits.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Continue anonymised learning events using Brian’s case in the Emergency Department to improve documentation and communication of risk.
  Stated by The TrustStated in progress
3. Action
  Share learning from Brian’s case across the Emergency Department to raise awareness of unclear documentation and communication risks.
  Stated by The TrustStated completed
AI-generated summary

Brian Thomas RINGROSE · 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

Brian Thomas Ringrose died on 2 February 2021 after being taken to hospital following an overdose and then subjected to prolonged prone restraint by police. The report identifies concerns about police restraint practices and welfare monitoring, communication and handover, prioritisation of transport over welfare, and the hospital and mental health teams’ assessment, communication and discharge processes.

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
Reliance on delayed written clinical documentation in emergency settings
Wider context from the report
“Thames Valley Police Inadequate application of police restraint training The evidence demonstrated that the officers who initially restrained Mr. Ringrose failed to follow their training in multiple critical respects: a) Officers maintained Mr. Ringrose in a prone position for a prolonged period (over 20 minutes with only a brief interruption) despite training that warns of the dangers of positional asphyxia in a restrained prone position. b) Officers positioned Mr. Ringrose's arms in extreme and abnormal positions (between 90-180 degrees) while handcuffed behind his back, causing severe shoulder injuries including torn ligaments, muscles, and deep internal bruising. c) Officers failed to place Mr. Ringrose on his side as soon as practicable after handcuffing and applying leg restraints, contrary to their training. There were opportunities when this could have been done. d) One officer inappropriately dragged Mr. Ringrose by his arms across the floor without informing the other officer or Mr. Ringrose he was about to do so despite being within a few feet only of both, causing significant pain to Brian. Failure to apply the National Decision Model Officers failed to apply the National Decision Model to reassess their actions during the restraint, particularly: a) When Mr. Ringrose was briefly on his side or back at around 15:31 and had become calmer, officers returned him to the prone position without reasonable justification. b) When hospital security staff arrived at approximately 15:35, providing an opportunity to reassess the situation, appoint a safety officer, and move Mr. Ringrose to his side, the officers failed to do so. Ineffective welfare monitoring The officers failed to adequately monitor Mr. Ringrose's welfare during restraint: a) Officers did not appropriately listen to, interpret, or react to Mr. Ringrose's breathing despite their close proximity, instead attributing his deteriorating condition to purposeful actions. b) Officers failed to check that Mr. Ringrose's airways were clear or monitor his breathing rate, despite their training to monitor the welfare of anyone in police custody without relying on medical professionals. c) Officers failed to voice concerns about Mr. Ringrose's changing pallor, which progressed from extremely pale to blue, red, and even purple. Failure of officers to "speak up and speak out" The officers failed to challenge inappropriate restraint techniques: a) None of the officers present, including those who arrived later, questioned the circumstances, duration, or manner of the restraint, despite police training requiring officers to "speak up and speak out." b) No officer raised concerns about the extreme position of Mr. Ringrose's arms or the prolonged prone restraint, despite this clearly contravening their training on positional asphyxia risks. c) No officer sought advice on Mr Ringrose’s clinical condition from the many clinical staff who were stood around watching the event. Inadequate communication and handover There were significant failures in communication between officers: a) When additional officers arrived to transport Mr. Ringrose, the initial restraining officers did not inform them of how long Mr. Ringrose had been restrained in the prone position or that his arms had been elevated and the arriving officers were passive in not making any enquiry as to that. b) Officers relied on the passive inaction of hospital staff who were stood about watching, rather than actively requesting them to assess Mr. Ringrose's condition. Inappropriate prioritisation of transport over welfare After the arrival of additional officers at approximately 15:45: a) All officers became primarily focused on applying the Flexible Lift and Carry System (FLACS) and transporting Mr. Ringrose to police custody rather than monitoring his welfare. b) During the ongoing restraint and application of the FLACS, none of the officers monitored Mr. Ringrose's welfare instead focussing on how to apply a device none had adequate experience of. Central and Northwest London NHS Foundation Trust a) Delay in Assessment: There was a significant delay in the mental health team attending to Brian in the Emergency Department (ED), despite the urgency of his condition. b) Inadequate Assessment: When the mental health team did attend, they felt unable to assess Brian due to his unresponsiveness but did not escalate their concerns or communicate effectively with medical staff or police. They did not plan to return to follow up on Brian Ringrose. c) Failure to Escalate Concerns: A member of the mental health team believed Brian was not medically fit for discharge but failed to voice this to medical staff or police. d) Unsafe Communication Practices: Reliance on verbal communication and delayed written notes (within a maximum 24 hours) is inherently risky in emergency settings, as contemporaneous notes are essential for critical information to be promptly shared with other clinical and nursing staff dealing with patients. e) Inappropriate Discharge Recommendation: The mental health team suggested reassessment in police custody, despite Brian’s ongoing medical instability. In my view this represented a very high risk to Brian’s safety. Milton Keynes University Hospital NHS Foundation Trust a) Non-existent Documentation Referenced in Policy: The hospital policy makes reference to a "discharge for police custody form" that does not actually exist. This suggests the policy was hastily created, possibly for the purposes of satisfying the inquest requirements, without appropriate consideration of its content or implementation. b) Misleading Discharge Documentation: The discharge form generated by hospital staff was interpreted by police officers as a formal discharge notice, as the jury found. The current system allows for the generation of forms that may be misinterpreted by third parties as official discharge documents when they may not be. c) Unsafe Form Design: The process of generating discharge forms and additional notes requires staff to advance through a structure that may include boxes not meant to be ticked but none the less resulting in production of a document purporting to be a “Discharge Notice” which the police then understandably but erroneously rely on. This poses a risk to patient safety through potential misunderstanding of care requirements. d) Inadequate Discharge Review Process: The decision on whether patients should have a final review by doctors before formal medical discharge is reportedly scheduled to be made by a committee by June 2025. Given that four years had already passed since Brian's death at the time of Inquest, this timeline for implementing such a critical safety measure is unreasonably prolonged, and, in my view, cannot be supported. An immediate decision by the clinical director should have been made to institute final medical reviews before discharge. e) Ambiguous discharge process: The ED doctor’s plan for discharge was vague (“more awake”), not aligned with ToxBase guidance, and not clearly documented and not clearly communicated. The ED doctor told the jury that he did not assess or intend that Brian was fit for discharge at the time he was removed from the ED. I note however that when Brian was being removed he did not intervene or seek to prevent it. f) Unsafe supervision: There were a number of senior clinicians and nursing staff present and seen to be watching the restraint of Brian. None of those senior individuals asserted their authority and made enquiry or intervened. g) Premature Discharge: Brian was not medically fit for discharge (still symptomatic, GCS still not recovered, ECG not done as required, Toxbase recommendations not followed) ”
Source location
Brian Thomas RINGROSE · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement joint clinical entries, mandatory immediate verbal handovers and contemporaneous electronic documentation after assessments, with random quality audits.

Verbatim wording from the response
“d. Unsafe Communication Practices To enhance the robustness and integrity of our documentation process, we have implemented a joint entry protocol. Under this approach, both assessors will contribute directly: the second assessor will either formally approve the initial entry or provide a complementary entry to ensure a more comprehensive and balanced record. Verbal handovers to the treating medic, or to the Nurse in Charge if the medic is unavailable, are now mandatory immediately post-assessment, followed by contemporaneous entries in ECare summarising the handover with a more detailed entry to follow based on the SystmOne entry. These changes aim to improve the”

Source location
Response from Central and North West London NHS Foundation Trust
Page 2 · response
Published 4 August 2025
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
Continue anonymised learning events using Brian’s case in the Emergency Department to improve documentation and communication of risk.

Verbatim wording from the response
“This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.”

Source location
Response from Milton Keynes University Hospitals
Page 10 · response
Published 4 August 2025
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
Share learning from Brian’s case across the Emergency Department to raise awareness of unclear documentation and communication risks.

Verbatim wording from the response
“This is addressed in the Emergency Department SOP for the discharge of adult patients described above and appended at Appendix 2. The individuals involved in this case have reflected at great length about their actions and inactions. Brian’s death was a seminal event for the Trust and learning from it has been widely shared within the Emergency Department. Further learning events using Brian’s case (anonymised) will continue in the Emergency Department, both to raise awareness of risk of unclear documentation and communication, and to ensure that there is an enduring legacy of improvement following Brian’s death.”

Source location
Response from Milton Keynes University Hospitals
Page 10 · response
Published 4 August 2025
Open published response
7 Jul2025
Berkshire
Concerns raised1
1. Failure to properly record patient repositioning
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Maintain system-driven EPR prompts that automatically trigger repositioning tasks at defined intervals and support ward- and patient-level auditing.
  Stated by Frimley Health NHS Foundation TrustStated completed
2. Action
  Disseminate EPR bulletins and targeted communications reinforcing timely, accurate repositioning documentation.
  Stated by Frimley Health NHS Foundation TrustStated completed
3. Action
  Expand the Digital Ambassadors Network to provide peer training and EPR support for clinical staff.
  Stated by Frimley Health NHS Foundation TrustStated completed
1. Action
  Deliver education sessions and ward-based support on repositioning documentation, risk assessment and effective EPIC use.
  Stated by Frimley Health NHS Foundation TrustStated completed
2. Action
  Operate the Harm Free Care Audit Programme to test timely assessments and implementation of pressure-injury interventions.
  Stated by Frimley Health NHS Foundation TrustStated completed
AI-generated summary

Patrick Anthony COFFEY · 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 Anthony Coffey fell at home, fractured multiple ribs, remained on the floor for about 17 hours, developed a chest infection and subsequently deteriorated in hospital. The report identified concerns that his pain was not always effectively controlled and that he was probably not repositioned every 2–4 hours as required, with gaps of up to 27 hours in the records; it stated that this posed a risk of future deaths in people with chest infections or at risk of pressure damage.

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 properly record patient repositioning
Wider context from the report
“I heard evidence that it was important that Mr Coffey spent most of his time in a seated position rather than lying down. This was to assist with his ability to breathe more deeply and cough more effectively; both of which are of importance when treating chest infections especially in the context of a patient with rib fractures. The nursing witness for the trust confirmed that Mr Coffey should have been repositioned every 2-4 hours. It had been identified by the hospital during random monthly audits that this was either not being done or not being properly recorded. Frimley Trust, after the inquest concluded, provided confirmation of when Mr Coffey’s position was recorded during his stay. These reveal that on certain days almost no information is recorded and on other days it is possible to know his position on a 2-4 hourly basis. Of particular note is the following: 1. There is no record of his position from 16.39 on the 15/9/2024 to 06.51 on the 16/09/24, 2. The only record between 19.11 on the 16/9/24 and 04.18 on the 18/9/24 is one entry at 06.23 on the 17/9/24 3. The only record between 22.26 on the 18/9/24 and 01.51 on the 20/9/24 is one entry at 10.34 on the 19/9/24 4. There are only 2 entries for the 22/9/24 at 06.06 & 22.11 5. The entries for the 24/9/24 cease at 14.08 and they do not restart until 12.24 on the 25/9/24 6. The last entry on the 25/9/24 is at 14.35 and the next entry is not until 17.59 on the 26/9/24 7. The final entry on the 26/9/24 is at 20.54 and the first entry on the 27/9/24 is at 10.03. These records therefore have gaps of up to 27 hours. In addition the vast majority of records that do exist do not reveal whether Mr Coffey was actually repositioned as only one position is recorded. It is only on about 7 or 8 occasions that a repositioning has been recorded. The medical records from the hospital do not show repositioning every 2-4 hours and I found that Mr Coffey was probably not repositioned as required. In the particular circumstances of Mr Coffey this did not contribute to his death lack of repositioning does give rise to a risk of future deaths of those suffering from chest infections or, indeed, those particularly at risk of pressure damage. ”
Source location
Patrick Anthony COFFEY · 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
Maintain system-driven EPR prompts that automatically trigger repositioning tasks at defined intervals and support ward- and patient-level auditing.

Verbatim wording from the response
“• While Purpose T recommends repositioning, it does not prompt it directly. Accordingly, we have worked with our electronic patient record (“EPR”) supplier EPIC to introduce task prompts at defined intervals, visible on the care plan interface to support compliance (as below). This work forms part of a broader pressure ulcer improvement programme aligned with the National Wound Care Strategy.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 2 · response
Published 16 July 2025
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 EPR bulletins and targeted communications reinforcing timely, accurate repositioning documentation.

Verbatim wording from the response
“The Trust has also launched a targeted staff communication campaign, including the distribution of an EPR Bulletin to all relevant clinical teams, these are regularly shared to highlight key educational messages to staff. I understand that the Bulletin reinforcing the importance of timely and accurate documentation of patient repositioning was shared with your office in early July. To further support staff, the Trust has expanded our Digital Ambassadors Network, providing peer-to-peer training and access to ‘training buddies’ who can assist with EPR-related queries and reinforce best practice.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 2 · response
Published 16 July 2025
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
Expand the Digital Ambassadors Network to provide peer training and EPR support for clinical staff.

Verbatim wording from the response
“The Trust has also launched a targeted staff communication campaign, including the distribution of an EPR Bulletin to all relevant clinical teams, these are regularly shared to highlight key educational messages to staff. I understand that the Bulletin reinforcing the importance of timely and accurate documentation of patient repositioning was shared with your office in early July. To further support staff, the Trust has expanded our Digital Ambassadors Network, providing peer-to-peer training and access to ‘training buddies’ who can assist with EPR-related queries and reinforce best practice.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 2 · response
Published 16 July 2025
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
Deliver education sessions and ward-based support on repositioning documentation, risk assessment and effective EPIC use.

Verbatim wording from the response
“Education sessions have also been delivered, and in addition the Trust Clinical Education and Practice Development Teams have been visited wards to support staff in practice with documentation of repositioning, risk assessments and using EPIC effectively.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 3 · response
Published 16 July 2025
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
Operate the Harm Free Care Audit Programme to test timely assessments and implementation of pressure-injury interventions.

Verbatim wording from the response
“A formal Harm Free Care Audit Programme is in place (commenced July 2025). The pressure injury prevention sections test out whether assessments have been done in a timely manner and whether the appropriate care interventions such as repositioning have been put in place. The audit in July 25 showed a 20% improvement in the documentation of the interventions from a previous audit (60% to 80%) compliance.”

Source location
Response from Frimley Health NHS Foundation Trust
Page 3 · response
Published 16 July 2025
Open published response
23 Jun2025
Inner North London
Concerns raised1
1. Failure to ensure that staff make records using their own identification and accurately identify the author
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Streamline Smart Card access and require bank staff to hold cards and complete Rio training before booking shifts.
  Stated by North London NHS Foundation TrustStated completed
2. Action
  Review ward staff access daily and reinforce requirements against sharing Smart Cards or misattributing electronic records.
  Stated by North London NHS Foundation TrustStated completed
AI-generated summary

Louise Elizabeth Amy Crane · 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

Louise Elizabeth Amy Crane, who had a history of mental health diagnoses and was detained in hospital under the Mental Health Act, was found suspended by a ligature at Highgate Mental Health Centre on 19 September 2024. The jury found that factors contributing to her death included chronic suicide risk, unsatisfactory information sharing and recording, inadequate risk management, staffing, and insufficient care and treatment on Topaz Ward. The report also raised concerns about record keeping, therapeutic engagement and professional curiosity, ward observations, communication, transitions between wards, and outstanding actions in the Trust’s action 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
Failure to ensure that staff make records using their own identification and accurately identify the author
Wider context from the report
“1) Record Keeping / Professional Standards There was evidence that staff on Topaz Ward would sometimes use the ID card of another member of staff to makes notes on the records system, without making it clear who the entry was actually made by. In this case there were two entries that appeared to have been made by a support worker, that were actually made by a nurse. Such misleading and inaccurate record keeping risks significant confusion in the provision of care and potentially creates significant risk in relation to the continuity of care. ”
Source location
Louise Elizabeth Amy Crane · 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
Streamline Smart Card access and require bank staff to hold cards and complete Rio training before booking shifts.

Verbatim wording from the response
“Record Keeping / Professional Standards The Trust recognises the vital importance of accurate record keeping in supporting safe patient care. It is acknowledged that access to Smart Cards to support the use of Rio (the Trust’s Electronic Patient Record system) has been an issue, particularly for staff working via our bank staff provider NHS Professionals (NHSP). As part of the EMS program, this was investigated and processes streamlined so that all existing and new staff are now able to apply for a Smart Card and complete RIO training. Going forward, in order to be booked onto a bank shift, NHSP staff must have a Smart Card. As a result, all staff (substantive and NHSP) can now make their own records on the RIO System thereby reducing any reliance on using other colleagues’ accounts.”

Source location
Response from North London NHS Foundation Trust
Page 4 · response
Published 14 July 2025
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 ward staff access daily and reinforce requirements against sharing Smart Cards or misattributing electronic records.

Verbatim wording from the response
“Ward managers are expected to complete a daily review of staff attending their wards to check access and ability to record accurately.”

Source location
Response from North London NHS Foundation Trust
Page 4 · response
Published 14 July 2025
Open published response
19 Jun2025
Worcestershire
Concerns raised1
1. Failure to record significant incidents contemporaneously in residents’ records
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
  Stated by Green Range LimitedStated completed
2. Action
  Provided carers and the Home Manager with training on the Care Docs Portal’s core functionality.
  Stated by Green Range LimitedStated completed
AI-generated summary

Vera Fortey · 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

Vera Fortey suffered an unwitnessed fall at her care home, after which her mobility and condition deteriorated. Her fractured hip was not medically identified for approximately two and a half days, and she later underwent surgery, declined despite treatment, and died in hospital. The principal concerns were inadequate recording of the fall, missed opportunities to obtain medical assessment, insufficient auditing of residents’ records, and inadequate staff familiarity with the care home’s records system.

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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 record significant incidents contemporaneously in residents’ records
Wider context from the report
“1) Mrs. Fortey suffered an unwitnessed fall in her room at The Willows Care Home, Worcester shortly after midnight on 25.9.24. The carers who came and assisted her felt that she had not injured herself, and did not seek any medical attention for her. In fact, no medical attention was sought until shortly before midday on 27.9.24, when she was recorded as not being able to support her own body weight. The disclosure provided by the care home for the inquest did not contain: - any contemporaneous account of this fall written by either of the two carers who dealt with her at the time; - any entry made in Mrs. Fortey’s Daily Notes of this fall. Furthermore, although there was a document which the then manager of the care home had written, which was said to summarize the accounts of the fall given to her by the carers concerned, this document made no reference to the date of the fall; I was forced to conclude that no contemporaneous account of the fall on 25.9.24 ever made its way to Mrs. Fortey’s file. ”
Source location
Vera Fortey · 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
Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.

Verbatim wording from the response
“To address the specific items raised in the Regulation 28 Report we drew up an action plan that covered:”

Source location
Response from The Willows Care Home
Page 1 · response
Published 3 July 2025
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
Provided carers and the Home Manager with training on the Care Docs Portal’s core functionality.

Verbatim wording from the response
“In addition, further training was provided to the carers and Home Manager on the core functionality of the Care Docs Portal. An outline of the training provided by Care Docs is contained at Appendix 3. I trust that this provides you and Mrs Fortey's family reassurance that the home has taken onboard the concerns raised and made requisite changes.”

Source location
Response from The Willows Care Home
Page 1 · response
Published 3 July 2025
Open published response
18 Jun2025
Suffolk
Concerns raised1
1. Failure to record key detail about observations and the rationale for clinical decision making
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Deliver recurring documentation lectures and training to departments and aspiring Band 6 leaders, incorporating learning from real-life cases.
  Stated by West Suffolk NHS Foundation TrustStated completed
2. Action
  Disseminate documentation-learning content nationally through professional conference teaching.
  Stated by West Suffolk NHS Foundation TrustStated completed
3. Action
  Create and issue a deteriorating-patient safety-alert bulletin emphasising clear documentation.
  Stated by West Suffolk NHS Foundation TrustStated completed
1. Action
  Carry out a safety walkabout addressing documentation standards and related safety issues.
  Stated by West Suffolk NHS Foundation TrustStated completed
2. Action
  Continue working with system partners to monitor and review record-keeping performance while developing further safety improvements.
  Stated by West Suffolk NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  There is no universally right or wrong clinical record, and existing guidance is general rather than specifying one required level of detail.
  Stated by West Suffolk NHS Foundation TrustDisputes the concern
AI-generated summary

Pamela Christine BRAND · 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

Pamela Christine BRAND suffered a fall at her residence on 19 March 2024, sustaining a left hip fracture that was surgically treated. She suffered a cardiac arrest and died in hospital on 2 April 2024; the medical cause of death was pulmonary embolism due to deep vein thrombosis following the recent fall and hip fracture. The report raised concern that hospital records lacked key detail about observations and the rationale for clinical decision-making, potentially affecting future patient care.

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 key detail about observations and the rationale for clinical decision making
Wider context from the report
“During the course of the Inquest evidence received by the Court indicated that the hospital records for Mrs. BRAND lacked key detail relating to observations undertaken and the rationale for clinical decision making. This impacted on the Inquest’s ability to build a complete picture concerning Mrs. BRAND’s presentation, care and treatment during her last admission to hospital. Although not identified as having made a contribution to Mrs. BRAND’s death, I am concerned that such poor record keeping may adversely impact on the care and treatment provided to other patients in the future if not addressed. ”
Source location
Pamela Christine BRAND · 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
Deliver recurring documentation lectures and training to departments and aspiring Band 6 leaders, incorporating learning from real-life cases.

Verbatim wording from the response
“Summary of Learning At WSFT we have reflected on the national guidance above and incorporated that into the specific teaching we have provided staff at all levels. Drawing all this together, please find listed below details of the action/projects/teaching undertaken with a focus on improving record keeping for future patients at WSFT. We sincerely hope this work goes some way to addressing this important national and local issue you have highlighted:”

Source location
Response from West Suffolk Hospital NHS Trust
Page 3 · response
Published 28 October 2025
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 documentation-learning content nationally through professional conference teaching.

Verbatim wording from the response
“2. The Trust Solicitor delivers a mixture of bespoke lectures on documentation to departments throughout the year, in addition to having a regular teaching slot delivering training to aspiring leaders as part of the Band 6 study programme x3 times per year. This lecture focuses on sharing learning from real life cases and experiences to put “flesh on the bones of the general guidance above” about documentation. It includes feedback from previous Coroner’s cases such as this one and explains a different perspective of how records are reviewed and used. A variation of this lecture has also been delivered nationally in November 2023 at the National Rheumatology conference.”

Source location
Response from West Suffolk Hospital NHS Trust
Page 3 · response
Published 28 October 2025
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
Create and issue a deteriorating-patient safety-alert bulletin emphasising clear documentation.

Verbatim wording from the response
“4. The deteriorating patient team have created a safety alert learning bulletin, a copy is at appendix 2, and carried out a safety walkabout with the aim of driving up standards in documentation and other areas. Point 5 of the bulletin emphasises the need for clear documentation.”

Source location
Response from West Suffolk Hospital NHS Trust
Page 4 · response
Published 28 October 2025
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
Carry out a safety walkabout addressing documentation standards and related safety issues.

Verbatim wording from the response
“4. The deteriorating patient team have created a safety alert learning bulletin, a copy is at appendix 2, and carried out a safety walkabout with the aim of driving up standards in documentation and other areas. Point 5 of the bulletin emphasises the need for clear documentation.”

Source location
Response from West Suffolk Hospital NHS Trust
Page 4 · response
Published 28 October 2025
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
Continue working with system partners to monitor and review record-keeping performance while developing further safety improvements.

Verbatim wording from the response
“In addition to all of the above, in order to minimise harm and prevent documentation becoming a barrier to effective communication in future, WSFT will continue to work with all system partners, both to monitor and review performance as we look for new ways to address the difficulties of maintaining and achieving accurate record keeping.”

Source location
Response from West Suffolk Hospital NHS Trust
Page 4 · response
Published 28 October 2025
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
There is no universally right or wrong clinical record, and existing guidance is general rather than specifying one required level of detail.

Verbatim wording from the response
“Record Keeping Record keeping has evolved over time and continues to do so. The single biggest change in recent times was when WSFT moved to a fully digitalised medical record in 2016. Since that time, we have continued to evolve the systems with clinical colleagues and other healthcare partners. However, record keeping is also a clinical skill that all our staff continue to refine and develop through their careers personally. There is no right or wrong clinical record. That is reflected in the absence of advice nationally on what makes a good record. What guidance exists is often general, non-specific and high level.”

Source location
Response from West Suffolk Hospital NHS Trust
Page 2 · response
Published 28 October 2025
Open published response
17 Jun2025
South Yorkshire (Eastern)
Concerns raised1
1. Failure to time the request for medical review
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Hazel Gambles · 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

Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.

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 time the request for medical review
Wider context from the report
“There are several areas of concern around failures in documentation and failures to follow Trust policy, namely: 1. Lying and standing Blood Pressure was not recorded on admission. 2. There was no documentation of any falls prevention measures at the time of the first falls assessment. 3. There is no evidence of falls prevention measures being put in place following the first falls assessment. 4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen. 5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed. 6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain. 7. No Datix report was done following the in-patient fall leading to a delay in investigation. 8. The in-patient fall is not mentioned on the Discharge letter. I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping. ”
Source location
Hazel Gambles · Prevention of Future Deaths report
Page 2 · concerns
Open source report
17 Jun2025
North East Kent
Concerns raised1
1. Failure to document clinical events and observations
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 10
1. Action
  Complete a trust-wide audit of clinical documentation across representative care settings.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
2. Action
  Plan ongoing documentation audits within Care Groups to monitor quality and improvement progress.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
3. Action
  Conduct Gemba walks in emergency and inpatient settings to identify documentation and point-of-care process improvements.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
1. Action
  Undertake IT and Clinical IT team walks to review hardware provision, accessibility and reliability for real-time documentation.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
2. Action
  Install improved electronic medical record trend charting to show observation-parameter trends over time.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
3. Action
  Implement a communication plan highlighting accurate, timely clinical documentation, discharge documentation and appropriate use of copying and pasting.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
4. Action
  Introduce the improved Electronic Discharge Notification for clearer clinical documentation.
  Stated by East Kent Hospitals University NHS Foundation TrustStated completed
5. Action
  Begin a Surgical Teams trial of the Sunrise Mobile application on tablet devices to assess point-of-care documentation.
  Stated by East Kent Hospitals University NHS Foundation TrustStated planned
6. Action
  Plan digitisation of surgical care plans and review Local Safety Standards for Invasive Procedures to support digital documentation and compliance.
  Stated by East Kent Hospitals University NHS Foundation TrustStated in progress
7. Action
  Continue reviewing documentation improvement plans and re-audit to assess whether improvements are being made.
  Stated by East Kent Hospitals University NHS Foundation TrustStated in progress
AI-generated summary

Upali Meththanananda · 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

Upali Meththanananda underwent coronary artery bypass surgery and was later admitted with a large left-sided pleural effusion. He died after a chest drain inserted on 20 October 2023 was followed by hypovolaemia, bleeding and cardiorespiratory arrest; concerns were raised about inadequate documentation of observations, procedures and discussions between clinicians.

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 clinical events and observations
Wider context from the report
“(1) I was concerned about the documentation as the inquest process had been hampered by the poor documentation and whilst I accepted that clinicians may have been providing care and not always documenting the care provided during this time the importance of documentation cannot be understated. However it was not just in the emergency setting where the clinical notes were lacking the clinical notes did not record key events and observations taken even in the period prior to his collapse. Clinical observations were not documented, meaning that trends were not available to treating clinicians and they would not have a full picture upon which to base any clinical decisions. Discussions between clinicians at other organisations were also not documented and forms used by the hospital for procedures were not used as required even by experienced clinicians. Whilst I heard some improvements had been made by the witness who presented the Trust's action plan I remained concerned that the failure to document procedures and observations as well as advice given from third parties could lead to clinicians who take over care for a patient not having a full picture and leading to risks to patients in the future. ”
Source location
Upali Meththanananda · 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 a trust-wide audit of clinical documentation across representative care settings.

Verbatim wording from the response
“As part of our commitment to continually review and improve quality we recently undertook a trust wide audit supported by our Clinical Audit and Improvement Team of documentation across the organisation in all representative care settings. This highlighted a number of areas for improvement of both digital and written documentation which will be presented to our Operational Quality Governance Committee for support and communication across Care Groups. Following this ongoing documentation audits will be planned within Care Groups to monitor quality and progress in improvement.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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
Plan ongoing documentation audits within Care Groups to monitor quality and improvement progress.

Verbatim wording from the response
“As part of our commitment to continually review and improve quality we recently undertook a trust wide audit supported by our Clinical Audit and Improvement Team of documentation across the organisation in all representative care settings. This highlighted a number of areas for improvement of both digital and written documentation which will be presented to our Operational Quality Governance Committee for support and communication across Care Groups. Following this ongoing documentation audits will be planned within Care Groups to monitor quality and progress in improvement.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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 Gemba walks in emergency and inpatient settings to identify documentation and point-of-care process improvements.

Verbatim wording from the response
“○ Gemba walks were conducted across the emergency and inpatient settings on the 3rd July and 1st August at Queen Elizabeth the Queen Mother (QEQM) Hospital in Margate. A Gemba walk is a walk through of the clinical environment for senior leaders to review how processes are working in real time at the point of care to see for themselves where issues are arising. Actions are then set to follow up on these issues and improve the interface between patient care and note taking.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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 IT and Clinical IT team walks to review hardware provision, accessibility and reliability for real-time documentation.

Verbatim wording from the response
“○ Following feedback from the Gemba walks, additional IT Technical Team walks of the emergency and inpatient settings along with the Clinical IT Team will be undertaken in August to review the current IT hardware across settings. We will review provision, accessibility and reliability of hardware to ensure clinical teams have access to the right technology at the point of care to facilitate and encourage real-time documentation and recording of clinical parameters and observations.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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
Install improved electronic medical record trend charting to show observation-parameter trends over time.

Verbatim wording from the response
“○ We are waiting for our Electronic Medical Record (EMR) supplier to install an improved trend charting which will allow clearer visibility of trends in specific observation parameters over time (i.e. 24 hours/12 hours). This should be installed by the end of September 2025.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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
Implement a communication plan highlighting accurate, timely clinical documentation, discharge documentation and appropriate use of copying and pasting.

Verbatim wording from the response
“○ A communication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting' within the digital clinical notes.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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
Introduce the improved Electronic Discharge Notification for clearer clinical documentation.

Verbatim wording from the response
“○ A communication plan will be actioned in August (importantly coinciding with the new intake of Resident Doctors in August as part of their training) to continue to highlight the importance of accurate and timely clinical documentation both in the inpatient and emergency settings but also in the discharge of patients to our clinical colleagues in the community through the Electronic Discharge Notification (EDN). A new EDN went live in April with significant improvements in clarity of documentation. The communications plan specifically addresses the use of 'copy and pasting' within the digital clinical notes.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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
Begin a Surgical Teams trial of the Sunrise Mobile application on tablet devices to assess point-of-care documentation.

Verbatim wording from the response
“○ A trial will begin in the Surgical Teams at QEQM in August with the use of the 'Sunrise Mobile' (Sunrise™ - EKHUFT Electronic Medical Record (EMR)) application on a tablet device to assess whether this can facilitate more real-time documentation at the point of care to improve the quality of documentation in an acute setting by providing an easier and more portable hardware device over a computer on wheels.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 2 · response
Published 3 July 2025
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
Plan digitisation of surgical care plans and review Local Safety Standards for Invasive Procedures to support digital documentation and compliance.

Verbatim wording from the response
“○ The digitisation of the surgical care plan documentation is being planned and along with this a review of Local Safety Standards for Invasive Procedures (“LocSSIPs”) to plan for digitisation. This will ensure they are always visible in the medical record and drive compliance with documentation through mandating where appropriate data entry.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 3 · response
Published 3 July 2025
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
Continue reviewing documentation improvement plans and re-audit to assess whether improvements are being made.

Verbatim wording from the response
“We will continue to review these plans and re-audit to ensure that improvements are being made.”

Source location
2025-0308 Response from East Kent Hospitals NHS Trust
Page 3 · response
Published 3 July 2025
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to complete allocated clinical tasks within the responsible shift

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Use of ‘advice given’ outcomes producing misleading impressions of events

Concerns raised1

Deficient recording of key events following unwitnessed falls in nursing home records

Concerns raised1

Reliance on delayed written clinical documentation in emergency settings

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to properly record patient repositioning

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.5

Concerns raised1

Failure to ensure that staff make records using their own identification and accurately identify the author

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to record significant incidents contemporaneously in residents’ records

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to record key detail about observations and the rationale for clinical decision making

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 3

Actions described in response 3

Actions described in response 5

Actions described in response 2

Actions described in response 2

Actions described in response 5

Respondent positions 1