Recurring concern

Insufficient workload capacity for timely clinical record completion

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First reported 3 Mar 2015•Latest report 17 May 2021

Definition

What this concern includes

Includes assertions from different reports identifying workload, interruptions, competing duties or insufficient allocated time as directly causing delayed or incomplete completion of clinical or care records.

Not included

  • Excludes inaccurate, incomplete or unavailable records where workload or time capacity is not the identified unsafe condition.
  • Excludes generic staffing shortages or workload pressure without a direct effect on timely completion of clinical or care records.
  • Excludes delays in non-record clinical tasks, such as assessment, treatment, referrals or investigations.
  • Excludes failures of record content, systems, access or handover that are not materially caused by insufficient time or workload capacity.
Reports
3

Distinct published reports

Individual concerns
4

A report can raise multiple concerns

Date range
2015–2021

First to latest report issue date

Stated actions
2

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.

Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Department of Health and Social Care1
Greater Manchester Mental Health NHS Foundation Trust1
NHS England1
Norfolk and Suffolk NHS Foundation Trust1

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.

  1. Manchester South

    AI-generated summary

    Stephen Thurm · 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

    Stephen Thurm died at the scene on 5 February 2020 after being found suspended by a rope from a tree, with the medical cause of death recorded as hanging. The concerns included family information about self-harm risk not being taken into account in care planning and risk assessments, no designated time for care coordinators to write detailed notes contemporaneously, and insufficient consideration of the mental health and care needs of his main carers.

    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

    Lack of designated time for care coordinators to record detailed notes contemporaneously

    Wider context from the report

    “2. The inquest heard that there is no designated gap between service user appointments to allow care coordinators to write up their detailed notes contemporaneously. ”

    Source location

    Stephen Thurm · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Norfolk

    AI-generated summary

    BRIAN STANNARD · 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

    Brian Stannard was a resident at Eversley Nursing Home and was found drowned on a beach at Great Yarmouth on 14 November 2016 after being seen asleep in his room earlier that morning. The report raised concerns about the nursing home’s capacity to manage his mental ill health and threats of self-harm or suicide, as well as incomplete staff records and limited use of the Lorenzo computer system.

    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 complete staff records fully during the same shift

    Wider context from the report

    “(2) Records of staff were not always completed or fully completed. Staff are now provided with laptops to aid flexibility with regard to record keeping. It is understood staff are now required to complete their records by the end of each shift. Due to the volume of work, it is not clear if members of staff are given sufficient time and space to see the service user and then to write up their records during the same shift. ”

    Source location

    BRIAN STANNARD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Workload-related delays in staff record completion

    Wider context from the report

    “(3) Due to volume of work, some staff may be completing their records in their own time. ”

    Source location

    BRIAN STANNARD · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve health-record completion through an organisation-wide programme with active monitoring.

    Verbatim wording from the response

    “Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a program to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way.”

    Source location

    2017-0394-Response
    Page 1 · response
    Published 15 February 2018

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Work with clinical teams to provide sufficient staffing and equipment for consistent, balanced work allocation.

    Verbatim wording from the response

    “Your report confirmed the findings of the RCA report that aspects of Mr Stannard’s health record had not been maintained to the expected standard, notably risk assessment and care plans. The Trust are engaged in a program to improve its performance in this area with active monitoring at all levels of the organisation. The Trust recognises there are many influencing factors affecting this and are working with clinical teams to ensure they have the right number of staff and equipment to ensure work can be allocated in a consistent and balanced way.”

    Source location

    2017-0394-Response
    Page 1 · response
    Published 15 February 2018

    Open published response

  3. Sunderland

    AI-generated summary

    Paige Louise Bell · 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

    Paige Louise Bell, aged 20, died at Sunderland Royal Hospital on 14 August 2014 after applying a ligature to her neck following an episode of self-harm. The inquest identified contradictions in the observation policy as a contributing factor. Concerns included case notes not being held together or fully transferred with the patient, and the need for consistent observation policies and updated guidance on managing patients with Borderline Personality Disorder.

    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

    Insufficient time for staff to complete records promptly

    Wider context from the report

    “Although a new Engagement and Observation Policy is to be implemented in April 2015 it may be that you would wish to review matters arising from the Inquest to enhance this further (if appropriate) so that there are no contradictions that may create ambiguity in its application. I appreciate that a lot of work has gone into the new policy. However, I note the following (and this is not an exhaustive list): - • The new Observation record does not allow sufficient space for commentary. • The front sheet does not appear to have the RIO reference. • On the face of the document it is not clear that staff must complete all parts of the record. • If the rationale for observations were to change then the form needs to provide for that. • It may be possible in the fullness of time for the record to be completed electronically (perhaps with a tablet) with a drop down box and a freehand note facility? This would also allow for mandatory completion of certain parts of a form. • If electronic, the engagement/observation record could be readily accessible possibly via hyperlink. The same could be done for incident report forms rather than being manually filed. No doubt there will be full training undertaken with regard to the new Policy. I was concerned that not all relevant information was readily available and although I appreciate events can be fast moving it can then become even more important for staff to have access to up to date and accurate information from the notes. All staff need time to be able to complete such records in a more timely way. That takes me to my final concern and that relates to the difficulty with navigation around the records. Whilst this may be easier via a screen it was extremely difficult (even with time to do it) to be able to have a clear chronology of events and to understand the rationale for decisions. That has the potential to compromise patient management and safety. I also enclose a copy of my report to the Secretary of State. ”

    Source location

    Paige Louise Bell · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing national guidance and statutory frameworks provide guidance on patient observation, with local policies expected to align with them.

    Verbatim wording from the response

    “You ask if there is a national policy on patient engagement and observation. NHS England is planning to update its Suicide Prevention Audit Tool for Emergency Care, in light of learning from suicides in acute care settings. This stresses the importance of engagement with the patient, the recording of observations and timeliness of mental health assessment.”

    Source location

    2015-0075-Response-by-Department-of-Health
    Page 2 · response
    Published 3 March 2015

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Immediate recording of every decision or action is impracticable in a busy mental health ward, so entries are made as soon as practically possible.

    Verbatim wording from the response

    “In respect to the stated over the presentation of written copies of RiO records, ████████ explained that this is something which was identified in the Serious Incident Review. He explained that the RiO records are used by staff electronically, and a printed version does not properly reflect how they would be seen or used by staff. In particular the date and time of a meeting or incident is recorded in addition to when the record was made. This allows the entries to be recorded chronologically in relation to the date and time of the meeting or incident. As you heard in evidence, in a very busy and demanding mental health ward”

    Source location

    2015-0075-Response-by-Northumberland-Tyne-Wear-NHS-Trust
    Page 2 · response
    Published 3 March 2015

    Open published response
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Data last updated 7 September 2026