Recurring concern

Unreliable recording of designated doctor visits and review requests

First to latest report 26 Feb 2014 — 7 Mar 2022

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures in the dedicated recording process for designated or requested doctor visits, including recording visit timing, purpose, attending doctor, residents requested for review and other information needed to coordinate and follow up medical visits.

What is not included
  • Excludes general clinical-record deficiencies where the asserted problem is not specifically the recording of a designated or requested doctor visit.
  • Excludes failures to contact, attend or clinically review a patient when the visit-recording process itself is not deficient.
  • Excludes records of non-medical visits, routine appointments or unrelated clinical activities.
  • Excludes failures to act on accurate doctor-visit records after the relevant information has been reliably recorded.

Reports and published responses 2 reports

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

  1. Surrey

    AI-generated summary

    Joyce May DENNIS · 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

    Joyce May Dennis, a resident of Roseacre Care Home, became unwell on 9 September 2019 and deteriorated over the following days before being admitted to hospital with sepsis and the onset of a heart attack. She died at 15.30 on 13 September 2019. The principal concerns were inadequate monitoring and record-keeping, failure to investigate or escalate worsening symptoms, insufficient staff training about illness and sepsis in older people, poor liaison, and failure to record family concerns.

    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 maintain accurate records of designated doctor visits and requested patients

    Wider context from the report

    “5. There were no accurate notes of when the designated doctor was to visit or who the doctor was asked to see. ”

    Source location

    Joyce May DENNIS · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

  2. Brighton and Hove

    AI-generated summary

    Herta Edith Maria WOODS · 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

    Herta Edith Maria WOODS, a 94-year-old woman living alone with carer support, was found after falls at home and admitted to hospital with injuries, dehydration, rhabdomyolysis and renal impairment. She was found deceased in her hospital bed early on 8 August 2013 after being overloaded with fluid. The principal concerns included apparent abandonment in the Acute Medical Unit, inadequate documentation and fluid monitoring, failure to act on the NEWS score, failure to obtain timely senior review, and failure to replace an inappropriate cannula.

    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 the timing and reason for doctors' visits

    Wider context from the report

    “(2) The failure to record the timing and reason for the Doctor's visit (the reason was only illicitied from evidence). ”

    Source location

    Herta Edith Maria WOODS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Back to top

Data last updated 7 September 2026