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.

6 Sep2013
Sunderland
Concerns raised1
1. Failure to paginate daily statements sequentially
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 1
1. Action
  Number all documentation pages for daily statements to prevent pages being mislaid and ensure sequential pagination.
  Stated by European CareStated completed
AI-generated summary

Peter Pattinson · 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

Peter Pattinson, who had complex medical needs, was readmitted to hospital after falling from his bed at Cedar Court Care Centre and died on 19 March 2013. Concerns included family requests for raised bed rails not being acted on or documented or subject to risk assessment, delayed repair of the bed rails, and missing or non-sequentially paginated daily statements.

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 paginate daily statements sequentially
Wider context from the report
“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”
Source location
Peter Pattinson · 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
Number all documentation pages for daily statements to prevent pages being mislaid and ensure sequential pagination.

Verbatim wording from the response
“All documentation relating to daily statements used are now numbered so pages cannot be mislaid.”

Source location
2013-0250-Response-by-European-Care-Group
Page 2 · response
Published 6 September 2013
Open published response
20 Aug2013
South London
Concerns raised1
1. Incomplete documentation of important clinical decisions
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

Nicola Matthews · 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

Nicola Matthews took an overdose of medication after leaving hospital on 15 October 2010 and was found unrousable at her partner’s home in the early hours of 16 October, later being pronounced dead in hospital. The principal concern was that decisions about her discharge, including follow-up arrangements and the nature and quantity of medication supplied, were unclear and inadequately documented or communicated.

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
Incomplete documentation of important clinical decisions
Wider context from the report
“My concern is about the way in which the outcome of decisions taken by the consultant on the ward round on 15 October 2010 were documented and implemented. The contemporaneous note in the EPJS was conceded to be an incomplete record of everything that was decided on the ward round. Nicola had a long-standing history of borderline personality disorder and was constantly at risk of self-harm. Her acts were frequently impulsive. Whilst she had been sectioned on 12 October, the Section 5 order was rescinded on 15 October at the ward round. Nicola was then insistent on being allowed to leave the hospital. The follow-up arrangements made for her continuing care were not clear and were not documented. Evidence at my inquest suggested that there was no clarity as to what the follow-up arrangements were and whether or not they were made clear either to Nicola or to her partner. In the event, Nicola went home and later that evening took an overdose of medication which resulted in her death. Whilst it is not possible to state that better arrangements for follow-up would probably have made a difference to the outcome, I am concerned to ensure that in future patients who are discharged have a clear understanding of follow-up arrangements. It is important that staff members on the ward who have to handle the departure of the patient from the ward have clarity as to what is to happen. In the case of Nicola, with the period of time between the decision being made and her actually leaving, staff had changed and the contemporaneous documents did not allow the member of staff who escorted Nicola off the ward to have a clear understanding of follow-up arrangements or indeed of the nature of and quantity of medication with which she was being discharged. I suggest that consideration should be given to formulating better advice and ensuring that important decisions are better documented and that follow-up arrangements are made clear and adequately documented. ”
Source location
Nicola Matthews · Prevention of Future Deaths report
Page 3 · concerns
Open source report
7 Aug2013
Manchester (West)
Concerns raised1
1. Poor record keeping by district nursing teams
This report raised 4 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

Jean Miller · 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 Miller was admitted for incisional hernia repair, discharged home under district nursing care, and later readmitted with a purulent wound discharge before dying in hospital on 24 January 2013. The report identified concerns about the district nursing team’s lack of baseline wound assessments, failure to involve tissue viability specialists, absence of thermometers, poor record keeping, and poor communication with the GP.

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 by district nursing teams
Wider context from the report
“3. Poor record keeping by the District Nursing Team ”
Source location
Jean Miller · Prevention of Future Deaths report
Page 2 · concerns
Open source report
13 Dec2008
Buckinghamshire
Concerns raised1
1. Failure to record mobile-phone medication instructions and changes in patient 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.

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

Heather Beatrice Planner · 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

Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent investigation.

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 mobile-phone medication instructions and changes in patient records
Wider context from the report
“(4) There does not appear to be a system for recording on a patient’s records specific medication instructions or changes to medication which might have been given or taken by mobile phone. ”
Source location
Heather Beatrice Planner · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to paginate daily statements sequentially

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 raised1

Incomplete documentation of important clinical decisions

Concerns raised1

Poor record keeping by district nursing teams

Concerns raised1

Failure to record mobile-phone medication instructions and changes in patient records

Actions described in response 1