Recurring concern
Failure to retain safety-critical source records and evidence
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Request correctionFirst reported 21 May 2014•Latest report 20 May 2026
What this concern includes
Includes failures to retain, preserve or protect original or contemporaneous records and other safety-critical evidence whose later availability is needed for patient care, safeguarding, formal review, inquest, investigation or organisational learning, including patient or family registration forms, supervision records, engagement notes, primary-source data and material evidence relevant to deaths.
Not included
- Excludes records that were never created or are merely incomplete, inaccurate or inaccessible when no failure to retain or preserve the source material is identified.
- Excludes ordinary record-transfer, filing, retrieval or information-sharing failures where the source record was reliably retained and the deficiency arose later.
- Excludes routine destruction under an adequate and applicable retention schedule where no safety-critical record or evidence is lost.
- Excludes non-safety-related administrative records and generic document-management failures without a material care, safeguarding, investigation or safety-learning consequence.
- Reports
- 32
- Individual concerns
- 36
- Date range
- 2014–2026
- Stated actions
- 36
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to retain evidence pertinent to deaths
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 concernsEach 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
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Action
Implement an electronic central repository for prisoner records with controlled access, document tracking, retrieval and secure sharing.
Stated by HM Prison and Probation Service and Lowdham Grange Prison -
Action
Manage, download and securely retain death-in-custody CCTV footage under a local protocol to prevent overwriting.
Stated by HM Prison and Probation Service and Lowdham Grange Prison
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Concerns raised1
Failure to retain and prevent destruction of supervision records
Responses linked to these concernsEach 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
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Action
Strengthen the Clinical Supervision Policy to prohibit disposal or destruction of records before three years and link to the national Records Management Code of Practice.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust -
Action
Issue a Trust-wide Policy Alert highlighting the coroner’s concern and the Clinical Supervision Policy amendment.
Stated by Cumbria, Northumberland, Tyne and Wear 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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Position
The existing policy already required clinical supervision records to be retained for at least three years; the destruction occurred outside expected policy guidance.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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Concerns raised1
Failure to retain infusion equipment and supplies for forensic investigation
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised3
Failure to seize and retain relevant scene samples and evidence for later investigation
Failure to retain hospital blood samples for testing
Failure to collect and retain tissue samples in suspected anaphylaxis
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 concernsEach 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
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Action
Establish SOCO liaison and incorporate assessment and seizure of potentially evidential biological samples into child-death forensic strategies.
Stated by Cambridgeshire Constabulary -
Action
Amend, reissue and widely circulate procedural guidance and aide-memoires for child-death investigations, covering evidence preservation, medical liaison and anaphylaxis considerations.
Stated by Cambridgeshire Constabulary -
Action
Include revised child-death investigation processes in ongoing training cycles for frontline and investigative staff.
Stated by Cambridgeshire Constabulary
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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Position
Sample retention is determined by the requesting Coroner and subsequently by parental or next-of-kin consent under the Human Tissue Act 2004.
Stated by Royal College of Pathologists
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Concerns raised1
Failure to preserve potentially important service email evidence
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 concernsEach 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
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Action
Implement a process to retain, where appropriate, deceased service personnel’s email accounts for potential inquest evidence retrieval.
Stated by Ministry of Defence
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Concerns raised2
Failure to give orders securing evidence for domestic explosion investigations
Lack of understanding of evidence requiring preservation during domestic explosion investigations
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 concernsEach 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
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Action
Raise the identified investigation concerns with the National Liaison Committee for consideration in the Protocol review.
Stated by South Wales Police -
Action
Prepare national training material on work-related aspects of investigations, including advice for first responders.
Stated by Health and Safety Executive -
Action
Develop a proposed Suspected Gas Explosion checklist for consideration alongside the existing Carbon Monoxide checklist.
Stated by Health and Safety Executive
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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Position
The National Liaison Committee is responsible for deciding and implementing any appropriate amendments to the Protocols.
Stated by South Wales Police
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Position
The existing Work Related Death Protocol is considered fit for purpose and addresses evidence preservation, investigation coordination and information-sharing concerns.
Stated by Health and Safety Executive
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Concerns raised1
Destruction of contemporaneous handwritten notes following neonatal deaths
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to preserve fire scenes until all instructed investigations are completed
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 concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
The Welsh Government has no control over operational scene and inter-service matters and cannot take action addressing them.
Stated by Welsh Government
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Position
Operational matters concerning scene items and inter-service working are for South Wales Police and Mid and West Wales Fire and Rescue Service.
Stated by Welsh Government -
Position
Police retain responsibility for scene management and decisions to remove or seize items in fatality or suspected-criminality fire investigations.
Stated by Mid and West Wales Fire and Rescue Service
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Concerns raised1
Failure to secure and retain accurate documentary evidence following a death in custody
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 concernsEach 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
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Action
Keep ACCT books on the wing during quality assurance checks so staff can make contemporaneous entries.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to maintain and retain complete contemporaneous records and documents
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 concernsEach 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
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Action
Establish and maintain MS Teams folders to retain death-in-custody information and provide required documents.
Stated by Thameside Prison -
Action
Complete an independent audit of document retention in death-in-custody cases.
Stated by Thameside Prison -
Action
Conduct an independent review of a wider selection of PNOMIS files.
Stated by Thameside Prison
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Action
Implement written security guidance governing body-scanner use and recording of scans.
Stated by Thameside Prison
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
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Position
Existing contractual monitoring, record-retention requirements and death-in-custody plans provide sufficient oversight of records and data retention.
Stated by HM Prison and Probation Service
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Position
Issues beyond the inspection process fall outside the inspectorate’s remit, which is distinct from the prison service’s role.
Stated by His Majesty’s Inspectorate of Prisons (HMI Prisons -
Position
Existing MS Teams, SharePoint, PNOMIS, QA audits and management safeguards are considered sufficient for retaining and recording death-in-custody information.
Stated by Thameside Prison
Data last updated 7 September 2026