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 preserve old care plans in their contemporaneous format
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.
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 retain hospital blood samples in suspected anaphylaxis cases
This report raised 11 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.
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
Establishing the systems identified by the Coroner falls outside UKHSA’s remit.
Stated by UK Health Security Agency
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Position
Pathology policy responsibility lies with DHSC and the Royal College of Pathologists, rather than the respondent.
Stated by Food Standards Agency
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Concerns raised2
Failure to retain and preserve evidence relevant to learning from deaths in custody
Insufficient robustness of the local system for retaining and preserving material relevant to deaths
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
Finalise and roll out the updated Death in Custody procedure and checklist across English Serco prisons, with guidance for staff collating relevant documentation.
Stated by Serco Limited -
Action
Add the Oscar Journal to the Death in Custody checklist so it is preserved when relevant in Serco prisons using an Oscar journal.
Stated by Serco Limited
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Concerns raised1
Failure to retain placentas when required for death investigation
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.5
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Action
Store all placentas for 48 hours after birth using designated fridges and automated temperature monitoring.
Stated by RBFT -
Action
Ratify and implement the placenta-retention Standard Operating Procedure, including histology guidance and 48-hour storage requirements.
Stated by RBFT -
Action
Train Band 7 midwives and Unit Coordinators on the placenta-retention Standard Operating Procedure.
Stated by RBFT
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Action
Coordinate with Waste Management so midwifery staff attend placenta disposal and correct procedures are followed.
Stated by RBFT -
Action
Update electronic safety-huddle templates to identify recent neonatal deterioration or admissions and prevent erroneous placenta disposal.
Stated by RBFT
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
Retention of placentas beyond 48 hours would not provide reliable histology findings, so longer storage is not undertaken.
Stated by RBFT
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Concerns raised1
Failure to retain medical records after sudden unexpected deaths
This report raised 12 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
Carry out a comprehensive review of the Report’s concerns at the Children’s Trust through South East regional representatives.
Stated by NHS England -
Action
Develop clear protocols and training for unexpected child deaths using relevant national and local guidance.
Stated by The Children's Trust
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Concerns raised1
Failure to preserve handover records
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 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
Preserve handover records through electronic monthly files, printed management-office copies, archiving and monthly completeness checks.
Stated by Exemplar Health 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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Position
Electronic storage, printed copies and monthly checks ensure handovers cannot be overwritten and remain accessible.
Stated by Exemplar Health Care
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Position
Existing management oversight, quality assurance and governance processes are considered sufficient to ensure records are kept, retained and reviewed for trends.
Stated by Exemplar Health Care
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Concerns raised1
Failure to retain the placenta for full paediatric post mortem examination before coronial reporting
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.2
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Action
Maintain a 96-hour stop on dissecting placentas sent to Pathology, allowing fixation during the period without dissection.
Stated by Nottingham University Hospitals NHS Trust -
Action
Review whether placental examination processes need adaptation after receiving further information about the examination.
Stated by Nottingham University Hospitals 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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Position
The Trust considers a process to identify very unwell neonates for pre-death Coroner discussions impractical and unreliable because deaths are not predictable.
Stated by Nottingham University Hospitals NHS Trust
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Concerns raised1
Failure to preserve key evidence
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
Create and implement a local operating policy requiring retention of essential documents, including cell bell records, CCTV and body-worn video footage.
Stated by HM Prison and Probation Service -
Action
Install a new CCTV system providing a more reliable source of incident footage.
Stated by HM Prison and Probation Service -
Action
Conduct a rapid learning review of every death in custody within 72 hours, ensuring pertinent information is made available and reviewed.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure of private laboratories to retain Listeria isolates
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.
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
PHE has no legislative power to implement actions in NHS organisations or impose food safety measures.
Stated by Public Health England
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Position
The Food Standards Agency is responsible for implementing food safety measures.
Stated by Public Health England
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Concerns raised1
Delays in seizing key digital evidence
This report raised 14 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.
Data last updated 7 September 2026