Recurring concern

Incomplete, inaccurate or unavailable clinical and care records

First to latest report 13 Dec 2008 — 26 Jun 2026

Reports that mention this concern
474
Times this concern has been raised
568
Stated actions linked to this concern
780

What this concern includes

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

What is not included
  • Information-transfer failures where the underlying records are reliable
  • Documentation dedicated to a separately named safety system when that system supplies the more faithful parent boundary
  • Non-care administrative records

Reports and published responses 474 reports

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

  1. County Durham and Darlington

    AI-generated summary

    Zeeyad Hamadi · 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

    Zeeyad Hamadi was a prisoner at HMP Frankland who became unwell, was diagnosed with Hodgkins Lymphoma, and deteriorated while arrangements were made to transfer him to a London hospital for private chemotherapy. Concerns included inadequate weighing and medical record keeping, limited communication between prison and hospital staff, unclear funding and transfer arrangements, and the absence of a system or responsible point of contact to manage the transfer, contributing to delay.

    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 medical records to clearly record information availability, entry timing and authorship

    Wider context from the report

    “(2) It was accepted in evidence that the standard of record keeping in the patient’s medical notes was not as good as it could or should have been. There was lack of clarity as to when certain medical information (for example blood tests results) were available for interpretation by a doctor, by paper or electronic means, there was lack of clarity as from the computer printouts of medical records when entries were inputted into the system and were available for view, who was the author of the entry (as opposed to who inputted the data). ”

    Source location

    Zeeyad Hamadi · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Record keeping, prison-hospital liaison, bed-watch security and prison ownership issues are not for the Department of Health to respond to.

    Verbatim wording from the response

    “I consider that several of the issues you have raised regarding record keeping, liaison between prison and hospital medical staff, security issues such as bed-watch and ownership of the situation at the prison, are not for my Department to respond.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 2 · response
    Published 13 January 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 National Offender Management Service is expected to address record keeping, liaison, bed-watch security and ownership issues.

    Verbatim wording from the response

    “I note that you have sent a copy of this Regulation 28 report to the National Offender Management Service (NOMS) and I would expect them to properly address these issues.”

    Source location

    2014-0014-Response-by-Department-of-Health
    Page 2 · response
    Published 13 January 2014

    Open published response

  2. Manchester South

    AI-generated summary

    James Hadfield Withers · 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

    James Hadfield Withers died on 27 January 2013 after surgery for invasive colonic adenocarcinoma, with the inquest recording congestive cardiac failure associated with diseased heart and the stress of the operation. Concerns included a five-day delay in cardiology review, missing medical and nursing notes, incorrect recording of DNAR status, and poor communication among staff and with the family.

    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

    Missing medical and nursing notes

    Wider context from the report

    “2. Various of the medical/nursing notes appear to have gone missing ”

    Source location

    James Hadfield Withers · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    Cynthia Fretwell · 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

    Cynthia Fretwell, aged 84, was admitted to hospital with abdominal pain, obstructive jaundice and suspected gallbladder inflammation, but was discharged after treatment with antibiotics. She later became unwell at home, was not admitted to hospital after GP contacts including a telephone consultation, and died that evening from peritonitis resulting from an infected gall bladder that had not responded to antibiotics. Concerns included telephone referral systems and responses, the threshold for telephone versus home consultations, assessment of mental capacity when refusing treatment or admission, and documentation of discussions.

    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 fully and properly document discussions with patients or their families

    Wider context from the report

    “(1) Telephone referrals and the lack of an effective system for conveying and responding to information between the caller and the doctor. Specifically, I had concerns about the following aspects: (a) The inability of reception staff to interrupt a GP during surgery for the purposes of alerting and informing the doctor of a change in the patient’s condition following a telephone referral. (b) Timely consultation and timely responses to telephone referrals from patients and their families. (c) The threshold for determining whether a telephone consultation is adequate or whether a home consultation should be undertaken. (2) A full assessment of the patient’s mental capacity in a situation where they are refusing medical treatment or admission to hospital. (3) Full and proper documentation of the discussions between the doctor and the patient/patient’s family in those circumstances. ”

    Source location

    Cynthia Fretwell · 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

    Document discussions with patients and families about treatment or hospital admission in the patient notes.

    Verbatim wording from the response

    “3. A full and proper documentation of the discussions that would take place between GP, the patient/patient’s family in these circumstances would be made in patient notes. Please refer to basic recording in the Mental Capacity Act 2005 Policy.”

    Source location

    2013-0366-Response-by-Hama-Medical-Centre
    Page 3 · response
    Published 16 December 2013

    Open published response

  4. South Yorkshire (Eastern)

    AI-generated summary

    ROSEMARY BRONWYN FERGUSON · 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

    ROSEMARY BRONWYN FERGUSON, who had a long-standing history of epilepsy, was admitted after a head injury from a fall and was assessed as unfit for discharge because of risks associated with further falls. Despite recommendations that she remain in hospital, she was discharged to the care of a friend and was found deceased alone at home on 11 March 2013; the medical cause of death was recorded as sudden unexpected death in epilepsy. The principal concerns were that Social Services were not notified of the discharge, the friend’s expected role was unclear, and hospital records did not adequately document key communications and the date of discharge.

    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 maintain complete and accurate records of discharge decisions and timing

    Wider context from the report

    “(3) The Hospital Notes were scanty and there appear to be material omissions to record important decisions such as a detailed note of the telephone call between ████████ and the clinician, properly timed and recording clearly what was intended. Further, it was difficult to trace from the Notes, the actual day of discharge, the clinician believing it to be the 8th March and ████████ believing it was the 9th March. Some computer records were presented to the Court suggestive of a discharge on the 8th March, but this information appears to be missing from the actual hand-written Notes. I am concerned that such problems with communication can lead to misunderstandings to the detriment of all concerns. ”

    Source location

    ROSEMARY BRONWYN FERGUSON · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Teesside

    AI-generated summary

    STUART ARRON COLLINS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Stuart Arron Collins was taken to hospital while intoxicated and fully conscious, but was discharged several hours later with a reduced level of consciousness. After arriving at an address, he became unconscious and suffered cardiorespiratory arrest before being returned to hospital, where he died later that day. Concerns included uncertainty about his assessment on arrival, the absence of required hourly nursing observations, incomplete nursing records, and the possible accessibility of alcohol hand sanitiser gel.

    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 keep A&E nursing notes complete and up to date

    Wider context from the report

    “4. Evidence was given that the nursing notes in A&E were not fully completed and were not kept up to date. There was no apparent recording about Mr Collins’s epilepsy or the need for the hand sanitiser gel to be moved out of his reach. ”

    Source location

    STUART ARRON COLLINS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Inner North London

    AI-generated summary

    John Frank Henry LANSDOWNE · 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 Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.

    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 complete retrieval of medical and nursing records

    Wider context from the report

    “2. There was confusion regarding the retrieval of the entirety of the medical/nursing records after Mr Lansdowne’s death, and one observation sheet was never recovered. ”

    Source location

    John Frank Henry LANSDOWNE · 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

    Lack of clarity in nursing observation records

    Wider context from the report

    “1. The jury found that the times observations of Mr Lansdowne took place in the 45 minutes preceding his discovery were unclear, despite a nursing observation record setting these out. ”

    Source location

    John Frank Henry LANSDOWNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Surrey

    AI-generated summary

    Frederick Davidson · 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

    Frederick Davidson was admitted to Epsom General Hospital with aspiration pneumonia after recurrent seizures and later died following a pneumothorax caused by an unnoticed and incorrectly placed nasogastric tube. Concerns included inadequate documentation and communication, the use and checking of the tube, delayed recognition and treatment of the pneumothorax, and delays in radiology reporting.

    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

    Unexplained gaps in clinical notes

    Wider context from the report

    “Staff’s note keeping practices, in relation to the placement of the nasogastric tube, were inadequate. • The inappropriateness of the use of a naso gastric tube given Mr Davidson’s known history of advanced dementia and seizures • Unexplained and important gaps in the clinical notes • Breakdown in communication between the junior doctor and consultant. • The lack of recognition of the pneumothorax on the x ray and the subsequent delayed medical treatment. • The junior Doctor authorised feeding by way of the naso gastric tube prior to full checks being made. There was no note of this authorisation. • Delay in the forwarding and receipt of x ray reports from radiology ”

    Source location

    Frederick Davidson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Cornwall

    AI-generated summary

    Jean James · 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

    Jean James was an 85-year-old woman who developed stomach pain on 5 November 2012, was admitted to hospital with suspected appendicitis at approximately 11:00 on 6 November, and was not seen by a doctor until 17:00. She was later diagnosed with a perforated appendix, underwent surgery, and died in hospital on 19 November 2012. The principal concern was that patients admitted via their GP had no defined timeframe for medical review, unlike patients admitted through the Emergency Department, and that records of review times were not kept.

    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 keep records of doctor review timeframes for GP-referred hospital admissions

    Wider context from the report

    “By contrast, where the patient is admitted to the Medical Admissions Unit or the Surgical Receiving Unit after referral by their GP there is no time threshold within which a doctor should review them. Furthermore, I was told that records in this regard are not kept. On this occasion the question was asked whether, had Mrs James been seen earlier, the outcome may have been different. ████████ felt this was unlikely but he could not exclude the possibility that more prompt treatment by antibiotics may have led to a different outcome. I do not understand the rationale why patients admitted to hospital via their GP should not be seen within the same timeframe as patients admitted via the Emergency Department. I anticipate one justification for this may be that the GP has already conducted some form of medical examination. While that was the case in this instance I can easily see that there may be circumstances where it would not happen. In that situation it cannot be acceptable for a patient to wait more than four hours before being seen and assessed. It is equally the case that patients seen by their GP could actually be more unwell than those who present themselves at the Emergency Department. ”

    Source location

    Jean James · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Milton Keynes

    AI-generated summary

    Yvonne Sydney Annie Perry · 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

    Yvonne Sydney Annie Perry fractured her left hip after a fall at home, and the possibility of the fracture identified on 19 December 2012 was not acted upon until early January 2013. She later developed a severe urinary tract infection and died of sepsis on 2 February 2013; concerns included the lack of a robust process for tracking radiology reports and the absence of GP access to electronic hospital notes and records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of access to electronic hospital notes and records for GPs attending the Windsor Intermediate Care Unit

    Wider context from the report

    “(2) The GPs who attend the Windsor Intermediate Care Unit do not have access to the electronic hospital notes and records and those witnesses from WICU who attended the inquest considered that such access would improve the care afforded to patients. Similarly without access to the patients notes further deaths may occur in the future. ”

    Source location

    Yvonne Sydney Annie Perry · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  10. London Eastern

    AI-generated summary

    Tripta Rani KUMAR · 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

    Tripta Rani KUMAR underwent planned hysterectomy and was discharged, but was readmitted the following day with abdominal pain and a perforated bowel. She developed sepsis, suffered a cardiac arrest on 25 August 2012, and died despite CPR. A principal concern was that penicillin-containing Tazocin was prescribed despite records and a wristband indicating a penicillin allergy, after an unsigned handwritten alteration changed the record to “nil allergies”.

    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 maintain accurate and attributable penicillin allergy records

    Wider context from the report

    “In the emergency department, during the course of treatment given on the 24th August 2012, the deceased was attended to by an ST4, doctor in Obstetrics and Gynaecology. The doctor documented the likely diagnosis, requested an urgent CT scan and prescribed intravenous antibiotics in the form of Tazocin. Tazocin contains two active ingredients, Piperacillin, which is a penicillin type antibiotic and Tazobactum which is a medicine that prevents bacteria from inactivating Piperacillin. Evidence from the family of the deceased, confirmed by ████████ (Consultant in Accident and Emergency), revealed that the notes clearly showed that the patient had a penicillin allergy. The family of the deceased also confirmed in court that their mother was wearing a band on her wrist which confirmed the penicillin allergy. ████████ further confirmed that the entry in the notes that said ‘penicillin allergy’ had been crossed out and the note ‘nil allergies’ had been entered instead. This was in handwriting but with no signature to confirm who had written the note. The grave danger is that, although not relevant in this particular case, giving someone penicillin who was allergic to that penicillin could easily have resulted in an anaphylactic shock which, in turn, could have resulted in death. ”

    Source location

    Tripta Rani KUMAR · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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

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Data last updated 7 September 2026