Recurring concern
Incomplete, inaccurate or unavailable clinical and care records
- Reports that mention this concern
- 474
- Times this concern has been raised
- 568
- Stated actions linked to this concern
- 780
What this concern includes
Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
What is not included
- Information-transfer failures where the underlying records are reliable
- Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
- Non-care administrative records
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 474 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to ensure availability of patient observation records
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Wirral University Teaching Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
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Wirral University Teaching Hospital NHS Foundation Trust
Implement the Cerner Millennium electronic patient record across the remainder of the hospital.
-
Concerns raised1
Gaps in medical notes
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Incomprehensive and inefficient hospital notes
Failure of the electronic system to reveal notes of a previous admission
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Stockport NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Stockport NHS Foundation Trust
The hospital record system links both hospital numbers, while searching with the NHS number displays all associated records.
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Concerns raised1
Failure to record respiratory and pulse rates
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Lack of adequate records of medication discussions
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Roundwell Medical Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Roundwell Medical Centre
Document the full clinical plan and management in records when starting patients on addictive medication.
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Roundwell Medical Centre
Conduct six-monthly reviews for patients receiving long-term benzodiazepines or opiates and document the clinical plan and management discussed.
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Roundwell Medical Centre
Design a bespoke Addictive Medication Review template to ensure reviews are documented and completed correctly.
-
Concerns raised1
Failure of liaison psychiatry to record pertinent clinical information for subsequent clinicians
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- South West London and St George'S Mental Health NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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South West London and St George'S Mental Health NHS Trust
A mental health assessor may reasonably reach a different conclusion from the GP because risk changes rapidly and requires current assessment.
-
Concerns raised1
Failure to maintain complete, accurate and timely clinical records
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to appropriately record post-fall checks in clinical records
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to appropriately record patients’ medical conditions and blood test readings in clinical notes
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- North West Boroughs Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
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North West Boroughs Healthcare NHS Foundation Trust
Address staff competency in accurate, timely clinical-note recording through supervision and additional training.
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North West Boroughs Healthcare NHS Foundation Trust
Introduce practitioner-level care-quality-record audits led by ward leadership teams.
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North West Boroughs Healthcare NHS Foundation Trust
Conduct records audits and re-audits, communicate identified improvements, and action them through team managers.
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North West Boroughs Healthcare NHS Foundation Trust
Circulate Trust-wide Managers Briefing Notes reinforcing clinical information-recording requirements.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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North West Boroughs Healthcare NHS Foundation Trust
Existing processes and systems ensure clinical records are maintained in accordance with Trust policies and procedures.
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Concerns raised1
Failure of contemporaneous record keeping to support clinical recollections
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Department of Health and Social Care
Concerns about the GP’s decisions and actions should be addressed by Pennine Care NHS Trust and York House Surgery.
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Department of Health and Social Care
NHS England’s Performers Screening Group will determine whether specific action is needed regarding the GP’s clinical behaviour.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026