Recurring concern

Failure to retain safety-critical source records and evidence

First to latest report 21 May 2014 — 20 May 2026

Reports that mention this concern
32
Times this concern has been raised
36
Stated actions linked to this concern
36

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.

What is 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 and published responses 32 reports

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

  1. Surrey

    AI-generated summary

    Chrylin Angela Maria Norrell-Goldsmith · 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

    Chrylin Angela Maria Norrell-Goldsmith was found shortly before midnight on 26 July 2013, partially suspended by a ligature in her cell at HMP Downview. CPR and subsequent paramedic efforts were unsuccessful, and the jury concluded that she took her own life. The principal concerns included exposed pipework in the cell, multidisciplinary input at ACCT reviews, retention of primary source data in the Phoenix Programme, and recording significant medical events in records accessible to prison discipline staff.

    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 retain complete primary source data within the Phoenix Programme

    Wider context from the report

    “3. Retention of Primary Source Data within the Phoenix Programme Consideration should be given to ensuring that all primary source data (ie data provided by the prisoner to the therapist), should be kept either in hard copy format or by way of faithfully recoding all the detail contained therein on the prisoner’s System One record. ”

    Source location

    Chrylin Angela Maria Norrell-Goldsmith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Manchester North

    AI-generated summary

    Mark Darren Bartholomew · 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

    Mark Darren Bartholomew, who had a longstanding diagnosis of paranoid schizophrenia and was detained in hospital after transfer from prison, died by hanging on 25 July 2013 during a routine observation check. Concerns included an inadequate response to emergency services, the absence of the ligature cutter needed to release him promptly, and insufficient detail in observation 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

    Failure to retain and make essential observation documentation available

    Wider context from the report

    “1. Notwithstanding the Trust’s policy entitled ’2999 Procedure’ the purpose of which is to advise staff of process during a psychiatric emergency, it was clear that the response to external emergency services was inadequate. More particularly:- • The informant was unable to provide the emergency controller with either the name or age of the patient; whether he was still breathing; and whether a defibrillator was available. • Essential documentation (the observation record for the relevant 24 hour period) was mislaid and not available for the Inquest. • Originally, a joint visit by both Police and Trust staff was arranged for the purpose of relaying news of the deceased’s death to the family. By reason of a lack of communication, the family were notified following an attendance by uniformed officers whereupon the deceased’s Mother telephoned the Trust. ”

    Source location

    Mark Darren Bartholomew · Prevention of Future Deaths report
    Page 1 · 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