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
Distinct published reports
Individual concerns
568
A report can raise multiple concerns
Date range
2008–2026
First to latest report issue date
Stated actions
780
Described in published responses
Reports over time
Reports 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.
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
NHS trust265
Healthcare site91
Ministerial department73
Executive non-departmental public body44
Private limited company32
Health and social care service regulator30
Integrated care board26
Type not available24
Local health board21
Residential care home17
Multi-service care provider15
Nursing home15
Health professional body14
Independent healthcare provider12
Coronial office9
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.
Essex
Concerns raised1
Lack of complete medical records containing pertinent and relevant information
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.
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
Action
Implement the EPIC electronic patient record system with centralised, legible records, mandatory clinical fields, structured endoscopy templates and alerts for required actions.
Stated by East Suffolk and North Essex NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 June 2025.
Essex
Concerns raised1
Poor clinical record keeping and documentation of decision-making rationale
This report raised 10 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Require full biopsychosocial mental health assessments, with documented rationale for omissions.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Issue a Trust-wide safety alert reinforcing completion of electronic assessment documentation.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Develop an electronic handover tool documenting follow-up actions and emerging risks.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Action
Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
Stated by Essex Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 June 2025.
Cumbria
Concerns raised1
Lack of documentation about the use of cot sides
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.
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
Action
Explore mandatory electronic fields for bed-rail status and call-bell placement, including with the replacement-record supplier.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Action
Revise the Nurse-in-Charge checklist to include bed rails, call bells and environmental safety.
Stated by North Cumbria Integrated Care NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 17 June 2025.
Inner North London
Concerns raised1
Failure to label retrospective care 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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Introduce EnabLE digital care planning, handheld devices and staff recording requirements to standardise care records and support auditing.
Stated by Barchester Healthcare LimitedStated plannedThe respondent said that this action was planned when they made their response on 21 May 2025.
Action
Provide refresher training on EnabLE functionality, record-keeping expectations, policy and accurate contemporaneous recording.
Stated by Barchester Healthcare LimitedStated completedThe respondent said that this action was complete when they made their response on 21 May 2025.
Action
Continue remotely reviewing Home documentation quality through the assurance audit programme.
Stated by Barchester Healthcare LimitedStated in progressThe respondent said that this action was in progress when they made their response on 21 May 2025.
Manchester South
Concerns raised1
Failure of documentation to capture key discussions and 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.
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
Action
Review Multi Agency Discharge Event governance, attendance, decision-making and data capture.
Stated by NHS Greater Manchester Integrated Care BoardStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Action
Implement documentation of inpatient-related discussions and enquiries with acute trust staff in the GMMH electronic patient record, supported by a Trust-wide MHLT procedure.
Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 20 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Issues specifically relating to the patient’s care will be addressed by Manchester University Hospitals and Greater Manchester Mental Health NHS Foundation Trusts.
Stated by NHS Greater Manchester Integrated Care BoardRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
South London
Concerns raised1
Failure to record the assessment, discussion and advice about the appropriate telecare package
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Record all assessments within the main body of the client record system.
Stated by CroydonStated completedThe respondent said that this action was complete when they made their response on 20 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Records contained the Careline risk assessment, signed agreement and installation information documenting advice about the service and its cost.
Stated by CroydonDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Birmingham and Solihull
Concerns raised1
Failure to properly complete patient records
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.
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
Action
Place visual notices reminding staff to record patient observations promptly and accurately.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Make additional observation machines available in relevant clinical areas.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Communicate observation-recording requirements through verbal briefings and written emails.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Complete a re-audit of outpatient observation recording.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Review systems and processes supporting accurate and timely clinical documentation.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Implement the Apollo electronic patient record system Trust-wide to support consistent, legible and auditable clinical documentation.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 19 May 2025.
Action
Develop and implement Vitals recording for outpatient observations.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Action
Implement a standard operating procedure requiring baseline and higher-risk pre- and post-procedure observations in outpatient clinics.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 19 May 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Implementation of outpatient observation recording on Vitals is restricted by the external digital company's development timeframe.
Stated by the Robert Jones and Agnes Hunt Orthopaedic Hospital NHS Foundation TrustUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Birmingham and Solihull
Concerns raised1
Failure to adequately record heel-skin inspections in electronic inpatient notes
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Require the nurse in charge on each shift to check that care assessments, including skin inspection charts, are fully completed.
Stated by University Hospitals Birmingham NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 24 April 2025.
Action
Conduct ward spot checks of care documentation to verify completion of required assessments and skin inspection charts.
Stated by University Hospitals Birmingham NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 24 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Reviews found no pressure damage before 15 October, when a blister was identified, documented, escalated and assessed.
Stated by University Hospitals Birmingham NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester West
Concerns raised1
Failure to record clinical task communications on the medical records system
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Reinforce use of auditable systems for all clinical communication and prohibit screen messages for clinical referrals.
Stated by Ashton Medical Centre and SSP HealthStated completedThe respondent said that this action was complete when they made their response on 11 April 2025.
Action
Share a GDPR record-keeping reminder through the NHS Greater Manchester Primary Care Newsletter.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Action
Ensure the practice carries out a Significant Event Analysis concerning the identified safety issues.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Action
Ensure key learning from the Significant Event Analysis is implemented within the provider and SSP Health.
Stated by NHS Greater Manchester Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 April 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The concerns did not contribute to the death, and delayed anaphylaxis was extremely unlikely more than two days after the final dose.
Stated by Ashton Medical Centre and SSP HealthDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Essex
Concerns raised2
Inadequacy of electronic clinical records
Failure to maintain accurate patient-specific clinical records
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Operate the Record Keeping Safety Improvement Programme to investigate copying and pasting and develop systems addressing documentation risks.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Implement the unified NOVA electronic patient record to integrate systems and carry forward risk information.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
Action
Develop and pilot standardised multidisciplinary-team communication, recording and documentation principles across four sites.
Stated by Essex Partnership University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 17 March 2025.
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Includes failures affecting the completeness, accuracy, consistency, availability, legibility or contemporaneous maintenance of patient, resident and clinical care records.
