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.

21 Aug2014
Central and South East Kent
Concerns raised1
1. Confusing medical-record format preventing sequential recording of entries
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

Herbert Chandler · 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

Herbert Chandler was admitted to William Harvey Hospital with chronic obstructive pulmonary disease and a left pneumothorax. On 22 January 2013, an attempt to aspirate the left pneumothorax mistakenly aspirated the right lung first, after which the left lung was aspirated and he died soon afterwards. The concerns included the conservative management of the pneumothorax, medication prescribing, failures in clinical review and communication, the aspiration procedure, medical record format, and respiratory consultant cover.

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
Confusing medical-record format preventing sequential recording of entries
Wider context from the report
“A series of failings by the Trust have caused or contributed to the cause of death, namely:- • A conservative approach to managing the left pneumothorax with antibiotics, • Inappropriate prescribing of medication, namely gentamicin and aminophylline, • A failure to put in a chest drain when the patient was reviewed on 22nd January by a Consultant Respiratory Physician, • A failure to communicate findings after a Consultant’s review on 22nd January to the medical on-call team, • The Medical Registrar’s failure to request a chest x ray before attempting the aspiration procedure given that more than 48 hours had elapsed since the previous x ray, • The Medical Registrar’s failure to check the radiology immediately prior to aspirating the right lung, The Medical Registrar’s failure to examine Mr Chandler immediately prior to aspirating the right lung to confirm her findings concurred with the radiology, • A confusing format of medical records which prevented sequential recording of entries by health care professionals, • A failure to provide Consultant on call respiratory cover. ”
Source location
Herbert Chandler · Prevention of Future Deaths report
Page 2 · concerns
Open source report
25 Jul2014
Surrey
Concerns raised1
1. Poor GP documentation
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.
  Stated by Woodlands SurgeryStated planned
2. Action
  Submit anonymised consultation notes for assessment during doctors’ next appraisals.
  Stated by Woodlands SurgeryStated planned
AI-generated summary

Clare Serena Anke COOPER · 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

Clare Serena Anke Cooper, a young adult, developed weight loss, lassitude, dizziness, nausea, difficulty eating and an intermittently low blood sodium level before dying after a cardiorespiratory arrest and hospital admission. The inquest concluded that she died from the consequences of undiagnosed Addison’s disease and an Addisonian crisis. Principal concerns included inadequate assessment and documentation in primary care, failure to investigate the low sodium and possible physical causes, insufficient eating-disorder service triage processes, and inadequate information available for the post-mortem examination.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor GP documentation
Wider context from the report
“1. Poor GP documentation ”
Source location
Clare Serena Anke COOPER · 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
Fully document consultations, including relevant histories, examinations and clinically relevant routine vital signs.

Verbatim wording from the response
“We have all agreed that all consultations should be fully documented in the patients’ notes. All patients should have a proper assessment of their history and a full examination should be done and routine vital signs should be recorded if they are clinically relevant.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 2 · response
Published 25 July 2014
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
Submit anonymised consultation notes for assessment during doctors’ next appraisals.

Verbatim wording from the response
“We have all agreed that the notes keeping in this case should have been better and may have compounded the issue relating to lack of continuity of care. In order to improve patient care and ensure that an episode like this is not repeated, doctors at the practice have agreed that as part of their ongoing personal development plan to submit anonymised consultation notes for their next appraisals. This will give a chance for each individual doctor’s appraiser to assess the quality of note keeping.”

Source location
2014-0345-Response-by-Woodlands-Surgery
Page 2 · response
Published 25 July 2014
Open published response
18 Jul2014
Blackburn, Hyndburn and Ribble Valley
Concerns raised1
1. Failure of drug charts to indicate the precise dispensed tramadol dose
This report raised 3 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

Kathleen Cornthwaite · 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

Kathleen Cornthwaite, aged 76, was an inpatient at Pendle Community Hospital when her tramadol prescription was increased after a fall causing a rib injury. The inquest concluded that she died of cardiorespiratory failure due to combined tramadol and fluoxetine toxicity. Concerns included the imprecise tramadol dose recorded, failure to account for her age, size and frailty, and failure to consider interactions with other prescribed medicines.

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 of drug charts to indicate the precise dispensed tramadol dose
Wider context from the report
“1. That the drug chart failed to indicate the precise dose of tramadol dispensed. ”
Source location
Kathleen Cornthwaite · Prevention of Future Deaths report
Page 2 · concerns
Open source report
16 Jul2014
Essex
Concerns raised1
1. Poor record keeping
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

Julie Ann Robertson · 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

Julie Ann Robertson died on 11 May 2013 from complications following an operation for an elective total abdominal hysterectomy and bilateral salpingo-oophorectomy. The inquest narrative described delays in escalation, obtaining blood and starting surgery, as well as poor record keeping and unclear timings. The report raised concerns that matched blood was not immediately available on the ward and that there was insufficient formal training in record keeping.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Poor record keeping
Wider context from the report
“2) Record keeping was poor and this was acknowledged in the Root Cause Analysis report. Although I heard evidence that there had been some training instigated there is no formal training and indeed witnesses at the inquest still seemed unaware of good practice as to record keeping. ”
Source location
Julie Ann Robertson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
7 Jul2014
Inner North London
Concerns raised1
1. Inconsistent recording between assessments and correspondence
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

Harold George de Mello · 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

Harold George de Mello, who had multiple co-morbidities, limited mobility and incontinence, died in hospital on 13 April 2014 after collapsing at home and being treated for bronchopneumonia. The principal concerns were that social-care assessments did not adequately investigate or record the reported incontinence, hygiene problems, care arrangements and differing information, and lacked sufficiently comprehensive guidance and senior review.

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
Inconsistent recording between assessments and correspondence
Wider context from the report
“(5) that there was a difference in the actions recorded in the assessment (apparently the ordering of urine bottles) and the letter written to Mr de Mello stating that a commode had been ordered and no consideration of whether he could use a commode ”
Source location
Harold George de Mello · Prevention of Future Deaths report
Page 2 · concerns
Open source report
4 Jul2014
West Sussex
Concerns raised1
1. Failure to properly complete Cardex 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.
Actions described in response 1
1. Action
  Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.
  Stated by The Salvation ArmyStated completed
AI-generated summary

Stanley Bere · 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

Stanley Bere, a resident of a nursing home, fell on 31 October 2011 and sustained a fractured ankle that was not identified until 8 November 2011. He later developed an infection and died on 4 June 2012; the inquest recorded congestive cardiac failure and bronchopneumonia, with the fractured ankle and subsequent infection contributing to his death. Concerns included incomplete Cardex records, inadequate follow-up of incident reports, and insufficient cross-referencing or monitoring of records, which meant his injuries were not identified promptly.

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 complete Cardex records
Wider context from the report
“(1) There was evidence provided at the Inquest that showed that the Cardex system used at the home was not being properly completed. Dates, on occasions, appeared to be out of order and important information such where a patient had fallen was not being recorded. Family concerns also did not appear to always be recorded. ”
Source location
Stanley Bere · 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
Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.

Verbatim wording from the response
“We have tightened up our reporting systems, particularly ensuring all falls, accidents and "near misses" are recorded, and updating on any accident or incident. A more secure system of archiving has been introduced. We have also found a copy of a receipt we asked the coroner's officer to sign when taking the records, as she had no letter with her. I have enclosed a copy for your records. The home manager regularly checks that issues are recorded and followed up in his regular auditing of documents. Staff are aware of the consequences if they do not follow correct procedures. These improvements were put in place immediately following the inquest.”

Source location
2014-0339-Response-by-Older-Peoples-Services
Page 1 · response
Published 4 July 2014
Open published response
1 Jul2014
Brighton and Hove
Concerns raised2
1. Inaccurate terminology about the cause of procedural injury
2. Failure to record suspected trial-related causes in hospital notes
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these 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

John Henry ADAMS · 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

John Henry Adams died following multiple complications of an appropriate cardiac intervention after being recruited to a cardiac trial just before the procedure. Concerns included whether there was sufficient time for informed consent, the suitability and preparedness of the trial operator, and the recording and communication of the trial’s possible relevance to the cardiac tamponade and subsequent death.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Inaccurate terminology about the cause of procedural injury
Wider context from the report
“(7) The hospital notes in Brighton, the letter of referral to Kings College Hospital and the report to the Coroner all gave the impression, because of the wording used, that what had happened at the PCI was that the diagonal artery had dissected and this is what is believed to have caused the pericardial effusion and tamponade. The Consultant Cardiologist is the only person to have used the expression "dissection" to describe the damage to the diagonal artery which occurred during the PCI. Should more care be taken in terminology? In this case it seems to have lead to a great deal of confusion. ”
Source location
John Henry ADAMS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to record suspected trial-related causes in hospital notes
Wider context from the report
“(6) The Hospital notes for Mr. Adams admission on the 30th do not mention the view (apparently formed within an hour or so of surgery), that it was the pacing wires; which was the extra requirement of the Trial; which caused the cardiac tamponade. Why not? Why was this information effectively concealed? ”
Source location
John Henry ADAMS · Prevention of Future Deaths report
Page 2 · concerns
Open source report
9 Jun2014
Manchester West
Concerns raised1
1. Inadequate clinical record keeping
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.
Respondent positions 1
1. Position
  Concerns about the practice’s record keeping, prescribing and response should be addressed by the GMC and CQC, which can take action where warranted.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Daniel Joseph McCallum Keane · 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

Daniel Keane was found dead at home after a period in which he had difficulty managing his Type 1 diabetes and was left without active support apart from his family. The cause of death was recorded as ketoacidosis. The reported concerns included a lack of leadership and coordination, no clear post-discharge care plan, ineffective multidisciplinary meetings, and uncertainty about the GP’s role, including the prescribing of citalopram and failure to respond to concerns about Daniel’s wellbeing.

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 clinical record keeping
Wider context from the report
“████████ was called to give evidence at the Inquest. He accepted in the course of his evidence that his record keeping was inadequate. He could not say from either his records or his recollection who had arranged for diabetic medication or citalopram to be prescribed on 29th September 2010. ████████ had no recollection or contemporaneous record of a telephone conversation with a neuropsychologist called ████████ on 8th November 2010 in which she said she alerted ████████ to Daniel Keane’s situation, which she described to him and indicated it was very worrying. ████████ asked him to make an urgent referral to the district nurses as she was concerned he was not reliable in managing his insulin himself. ████████ said he could not refer to the district nurses. Despite having been put on alert in this telephone conversation ████████ took no action. At this time ████████ was in possession of various reports including a Multi-Disciplinary Team Discharge Summary dated 2nd September 2010 that concluded Daniel Keane was at extreme risk to himself and was not a safe option to live by himself without supervision. 2. An investigation of the circumstances in which citalopram was prescribed on 29th September 2010 to establish who deemed this medication necessary, what features of his presentation justified this medication and the follow up action envisaged. 3. An investigation into ████████'s lack of response to the telephone conversation with ████████ on 8th November 2010. 4. Consideration of the role of GP’s generally in relation to the management of Type 1 diabetic patients in the community. ”
Source location
Daniel Joseph McCallum Keane · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Concerns about the practice’s record keeping, prescribing and response should be addressed by the GMC and CQC, which can take action where warranted.

Verbatim wording from the response
“I consider that the first three concerns, relating to ████████ should be raised with the General Medical Council (GMC) and the Care Quality Commission (CQC). To this end, my officials contacted your office on 12 June to advise that these actions would be most appropriately addressed by the GMC and CQC. We suggested that you write to both of these organisations for their separate responses to these issues. These organisations have the power to take action where warranted.”

Source location
2014-0260-Response-by-Department-of-Health
Page 2 · response
Published 9 June 2014
Open published response
5 Jun2014
Manchester South
Concerns raised1
1. Unavailability of nursing notes, observation charts and pressure ulcer charts
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Scan records for deceased patients and patients involved in high-level incidents into the electronic patient record as a priority.
  Stated by Manchester University NHS Foundation TrustStated completed
2. Action
  Implement the Patientrack electronic observation and early-warning-score monitoring system across Trafford Hospital.
  Stated by Manchester University NHS Foundation TrustStated planned
3. Action
  Develop and roll out the Chameleon electronic patient-record system across the Trust in stages.
  Stated by Manchester University NHS Foundation TrustStated in progress
1. Action
  Run the Health Records Improvement Programme to address patient-record management risks.
  Stated by Manchester University NHS Foundation TrustStated in progress
AI-generated summary

THOMAS PATRICK MAHER · 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 Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

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
Unavailability of nursing notes, observation charts and pressure ulcer charts
Wider context from the report
“1. All the nursing notes, observation charts and pressure ulcer charts for the period 20th December 2013 to 29th January 2014 are missing, and despite a widespread search by the hospital, it has proved impossible to locate them. This had the effect of hampering the High Level Investigation and potentially the inquest itself. ”
Source location
THOMAS PATRICK MAHER · 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
Scan records for deceased patients and patients involved in high-level incidents into the electronic patient record as a priority.

Verbatim wording from the response
“Trafford Hospital acknowledges that the loss of these nursing records is unacceptable. In order to minimise the risk of this issue arising again, a new process has been implemented by the Trafford Medical Records Manager that all records, including nursing charts, for any patient who has died and for any patient involved in a high level incident will be scanned into the electronic patient records (EPR) system as a priority.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 1 · response
Published 5 June 2014
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 the Patientrack electronic observation and early-warning-score monitoring system across Trafford Hospital.

Verbatim wording from the response
“In the future, the recording of observations will be electronic with the implementation of the Patientrack early warning score monitoring system. The implementation of this new system is planned to commence across Trafford Hospital from the end of October 2014. Once fully installed, observation charts will always be available electronically.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 1 · response
Published 5 June 2014
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 and roll out the Chameleon electronic patient-record system across the Trust in stages.

Verbatim wording from the response
“There is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust using a system called Chameleon. This will minimise the risks that documentation will be lost. The timeframe for this to be complete across the entire Trust is 2018. However, this is being developed and implemented in stages so it is likely that Trafford will be fully electronic before then.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 1 · response
Published 5 June 2014
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
Run the Health Records Improvement Programme to address patient-record management risks.

Verbatim wording from the response
“The Trust acknowledges that the management of patient records is a significant risk. The risk is included on the Trust Risk Register and a Health Records Improvement Programme is underway to address the issues. As explained earlier, there is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust.”

Source location
2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
Page 5 · response
Published 5 June 2014
Open published response
2 Jun2014
West Sussex
Concerns raised1
1. Inadequate record-keeping of oxygen levels and prescriptions
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 8
1. Action
  Apply the Trust oxygen-prescribing and monitoring policy in all settings.
  Stated by University Hospitals Sussex NHS Foundation TrustStated completed
2. Action
  Re-audit oxygen-policy use and redistribute the updated Rapid Response report.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
3. Action
  Audit compliance with the current drug chart and present outcomes to clinical governance groups.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
1. Action
  Obtain an online F1 training package containing oxygen-prescribing content and make completion mandatory during doctors’ first year.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
2. Action
  Obtain online medical-gases training for nurses and establish a method for completing it.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
3. Action
  Move inspired-oxygen recording from the electronic observation chart to the electronic prescribing screen.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
4. Action
  Upgrade PatientTrack to record the oxygen device delivered to patients.
  Stated by University Hospitals Sussex NHS Foundation TrustStated in progress
5. Action
  Share the upgraded oxygen-device recording facility with other UK hospitals using PatientTrack.
  Stated by University Hospitals Sussex NHS Foundation TrustStated planned
Respondent positions 4
1. Position
  PatientTrack appears accessible via desktop computers; intermittency was attributed to uncharged Android handheld devices rather than system unavailability.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
1. Position
  PatientTrack is intended as the normal record, with paper charts reserved for significant information-technology problems.
  Stated by University Hospitals Sussex NHS Foundation TrustExisting arrangements considered sufficient
2. Position
  The current Trust policy robustly governs oxygen prescribing and monitoring, with requirements to be followed in all settings.
  Stated by University Hospitals Sussex NHS Foundation TrustExisting arrangements considered sufficient
3. Position
  PatientTrack already has, and the Trust uses, a facility to record inspired oxygen concentration delivered to patients.
  Stated by University Hospitals Sussex NHS Foundation TrustDisputes the concern
AI-generated summary

Denise PRIOR · 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

Denise Prior died on 6 November 2013 following a cardiac arrest after a fall caused by her underlying medical condition. The report raised serious concerns about record-keeping at St Richards Hospital, including recording and prescribing oxygen and applying the National Early Warning Score system, with a stated risk of future deaths.

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 record-keeping of oxygen levels and prescriptions
Wider context from the report
“That there is a risk of other deaths occurring in the future from the inadequacy of record-keeping practices at St Richards Hospital in the recording of oxygen levels and its prescription, and in the application or departure from the ‘NEWS’ system. ”
Source location
Denise PRIOR · 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
Apply the Trust oxygen-prescribing and monitoring policy in all settings.

Verbatim wording from the response
“Action taken There is a current and very robust Trust policy regarding prescribing and monitoring of oxygen – all requirements to be followed in all settings.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 4 · response
Published 2 June 2014
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
Re-audit oxygen-policy use and redistribute the updated Rapid Response report.

Verbatim wording from the response
“There was Rapid Response alert issued by NPSA in 2009. This alerted all NHS organisations to assess and self-implement the issues identified but there is a case for refreshing the message after five years on.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 4 · response
Published 2 June 2014
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
Audit compliance with the current drug chart and present outcomes to clinical governance groups.

Verbatim wording from the response
“Compliance with the current drug chart, which was developed in line with oxygen prescribing policy and directs towards the identification of device and O2 saturation target.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 5 · response
Published 2 June 2014
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
Obtain an online F1 training package containing oxygen-prescribing content and make completion mandatory during doctors’ first year.

Verbatim wording from the response
“We are going to have access to an online training package (via HEKSS) for F1s – which a respiratory section of which should be included in oxygen prescribing. This should become mandatory training for doctors for completion during the first year.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 5 · response
Published 2 June 2014
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
Obtain online medical-gases training for nurses and establish a method for completing it.

Verbatim wording from the response
“We are going to have access to online training packages for nurses in relation to medical gases including oxygen and should ensure that they understand their usefulness and a method to implement their completion.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 5 · response
Published 2 June 2014
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
Move inspired-oxygen recording from the electronic observation chart to the electronic prescribing screen.

Verbatim wording from the response
“In contradiction to the evidence given to the Assistant Coroner at the inquest, PatientTrack does have the facility to record inspired oxygen concentration (FiO2) delivered to the patient and this is used within the Trust. The screenshot below is currently taken place on the electronic observation chart, but will move onto the electronic prescribing screen where it is a realtime facility for recording and not describing, hence the opposite gives a realtime assessment of the inspired oxygen.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 8 · response
Published 2 June 2014
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
Upgrade PatientTrack to record the oxygen device delivered to patients.

Verbatim wording from the response
“Oxygen concentration for mechanically ventilated patient monitored”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 9 · response
Published 2 June 2014
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 the upgraded oxygen-device recording facility with other UK hospitals using PatientTrack.

Verbatim wording from the response
“The team at WSHT are also in the process of upgrading this facility so that the actual oxygen device (e.g. nasal prongs, Venturi, non-invasive ventilation) can also be recorded in Patientrack, and this facility will also be shared with other hospitals in the UK using Patientrack.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 9 · response
Published 2 June 2014
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
PatientTrack appears accessible via desktop computers; intermittency was attributed to uncharged Android handheld devices rather than system unavailability.

Verbatim wording from the response
“(3) Problems with intermittency of working of patient track paper as an alternative.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 6 · response
Published 2 June 2014
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
PatientTrack is intended as the normal record, with paper charts reserved for significant information-technology problems.

Verbatim wording from the response
“The issue appears to be that the Android handheld devices were not charged, as PatientTrack can be accessed at all times by desktop computers at the nurses station.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 6 · response
Published 2 June 2014
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The current Trust policy robustly governs oxygen prescribing and monitoring, with requirements to be followed in all settings.

Verbatim wording from the response
“Matter of concern (2) Lack of recording of oxygen prescription and concentration and accountability on patient track.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 4 · response
Published 2 June 2014
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
PatientTrack already has, and the Trust uses, a facility to record inspired oxygen concentration delivered to patients.

Verbatim wording from the response
“(4) Record of inspired Oxygen concentration on PatientTrack.”

Source location
2014-0262-Response-by-Western-Sussex-Hospitals-NHS-Trust
Page 8 · response
Published 2 June 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Confusing medical-record format preventing sequential recording of entries

Concerns raised1

Poor GP documentation

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 of drug charts to indicate the precise dispensed tramadol dose

Concerns raised1

Poor record keeping

Concerns raised1

Inconsistent recording between assessments and correspondence

Concerns raised1

Failure to properly complete Cardex 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.1

Concerns raised2

Inaccurate terminology about the cause of procedural injury

Failure to record suspected trial-related causes in hospital notes

Concerns raised1

Inadequate clinical record keeping

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

Concerns raised1

Unavailability of nursing notes, observation charts and pressure ulcer charts

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.4

Concerns raised1

Inadequate record-keeping of oxygen levels and prescriptions

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.8

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4

Actions described in response 2

Actions described in response 1

Respondent positions 1

Actions described in response 4

Actions described in response 8

Respondent positions 4