Recurring concern
Failure to review relevant clinical records before care decisions
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Request correctionFirst reported 23 Aug 2013•Latest report 8 Jun 2026
What this concern includes
Includes failures to consult, check, cross-reference or review relevant existing clinical records as part of clinical assessment, prescribing, treatment, admission, transfer, escalation or other care decisions, including review of the correct record set and routine review requirements.
Not included
- Excludes failures to retrieve or make records available when the records were not accessible in the first place; those belong to access or record-availability concerns.
- Excludes deficiencies in the completeness, accuracy or maintenance of the records themselves unless the asserted unsafe condition is also failure to review them.
- Excludes generic failures to communicate or hand over clinical information where no record-review failure is identified.
- Excludes non-clinical record reviews, such as administrative, inspection or mortuary monitoring records.
- Reports
- 54
- Individual concerns
- 59
- Date range
- 2013–2026
- Stated actions
- 70
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 review and act on clinical records and recent investigation results
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.7
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Action
Flag all abnormal results within MEDITECH.
Stated by the Rotherham NHS Foundation Trust -
Action
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
Stated by the Rotherham NHS Foundation Trust -
Action
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
Stated by the Rotherham NHS Foundation Trust
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Action
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
Stated by the Rotherham NHS Foundation Trust -
Action
Develop a Power BI module to monitor acknowledgement of results.
Stated by the Rotherham NHS Foundation Trust -
Action
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
Stated by the Rotherham NHS Foundation Trust -
Action
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Stated by the Rotherham 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
Existing face-to-face handover arrangements require follow-up tasks to be transferred to the out-of-hours team.
Stated by the Rotherham NHS Foundation Trust
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Concerns raised1
Failure to review patient history and query inconsistencies in medical records
This report raised 18 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
Reinforce review of patient history and information gathering from consenting families through supervision and governance meetings.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Provide greater pharmacy input to inpatient MDTs and medication-history reviews through pharmacist participation.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to review medical records during mental health risk assessments
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.3
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Action
Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
Stated by Hywel Dda University LHB -
Action
Issue a professional practice reminder requiring relevant practitioners to review electronic patient records before assessments and consider historical risks and safeguarding concerns.
Stated by Hywel Dda University LHB -
Action
Discuss historical-record review and collateral-information requirements in Adult Mental Health Services operational team meetings to reinforce consistent practice.
Stated by Hywel Dda University LHB
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
Implemented, immediate and ongoing safety work collectively addresses the identified risk-assessment concerns.
Stated by Hywel Dda University LHB
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Concerns raised1
Failure of nurses to read notes before significant decisions
This report raised 10 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 review medical records before recovery-worker interactions
This report raised 8 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
Remind all Recovery Workers to check SystmOne records before visiting people accessing services.
Stated by Phoenix Futures -
Action
Reinforce SystmOne-record checking through team meetings, six-month communications and supervision.
Stated by Phoenix Futures
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
Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.
Stated by Practice Plus Group
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Position
Records cannot always be reviewed before consultations when requests are urgent or staff are redirected to support another person.
Stated by Phoenix Futures
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Concerns raised1
Failure to review preceding clinical records for relevant falls information
This report raised 8 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
Require ward rounds and multidisciplinary reviews to consider events from the preceding 24–72 hours, including weekends.
Stated by Barts Health 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
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of clinicians to identify Sickle Cell Disease from available clinical records
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.6
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Action
Require clinicians to review relevant previous patient encounters and expand the requirement to all patients.
Stated by Partnership of East London Co-operatives Ltd -
Action
Share organisational learning with staff about reviewing all relevant previous patient encounters, including regular dissemination to new and existing employees.
Stated by Partnership of East London Co-operatives Ltd -
Action
Include the requirement to review all relevant prior patient encounters in relevant clinical staff contracts.
Stated by Partnership of East London Co-operatives Ltd
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Action
Implement a clinical-record alert for children presenting with sickle cell disease, triggered by disclosure or clinician identification from summary care records with consent.
Stated by Partnership of East London Co-operatives Ltd -
Action
Add clear pop-up alerts and warnings identifying sickle cell disease in each clinical record.
Stated by Maylands Healthcare -
Action
Implement and jointly publish Jess’s Rule to encourage structured clinical re-evaluation after three unresolved or worsening consultations.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to obtain and consider relevant previous medical history
This report raised 4 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
Ensure clinicians assess whether available clinical information is sufficient without delaying appropriate patient assessment.
Stated by Marine Lake Medical Practice
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Concerns raised1
Failure to search clinicians’ records from previous prison stays during Reception Health Screens or mental health needs reviews
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
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Stated by HCRG Care Group -
Action
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Stated by HCRG Care Group -
Action
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Stated by HCRG Care Group
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Action
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Stated by HCRG Care Group
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Concerns raised1
Failure to review records and identify the need for urgent mental health assessment
This report raised 10 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
Require full biopsychosocial mental health assessments, with documented rationale for omissions.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.
Stated by Essex Partnership University NHS Foundation Trust
Data last updated 7 September 2026