Recurring concern
Failure to review relevant clinical records before care decisions
- Reports that mention this concern
- 54
- Times this concern has been raised
- 59
- Stated actions linked to this concern
- 70
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 54 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- the Rotherham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.7
-
the Rotherham NHS Foundation Trust
Flag all abnormal results within MEDITECH.
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the Rotherham NHS Foundation Trust
Introduce and communicate a Trust-wide standard operating procedure for managing investigation results.
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the Rotherham NHS Foundation Trust
Review and update the standard operating procedure for critically abnormal pathology results in clinical areas.
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the Rotherham NHS Foundation Trust
Conduct an additional 50-result audit of documentation and appropriate action for time-critical results.
-
the Rotherham NHS Foundation Trust
Develop a Power BI module to monitor acknowledgement of results.
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the Rotherham NHS Foundation Trust
Launch an Urgent and Emergency Care Centre pilot using the alertive bleep system to flag critical blood results.
-
the Rotherham NHS Foundation Trust
Include learning from the incident in the Quality Newsletter, focusing on acting upon time-critical blood results.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
the Rotherham NHS Foundation Trust
Existing face-to-face handover arrangements require follow-up tasks to be transferred to the out-of-hours team.
-
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.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Essex Partnership University NHS Foundation Trust
Reinforce review of patient history and information gathering from consenting families through supervision and governance meetings.
-
Essex Partnership University NHS Foundation Trust
Use ward-specific electronic dashboards and daily printed information to identify and address gaps in records, risk assessments, and care plans.
-
Essex Partnership University NHS Foundation Trust
Provide greater pharmacy input to inpatient MDTs and medication-history reviews through pharmacist participation.
-
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.
Linked response
- Hywel Dda University LHB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Hywel Dda University LHB
Use comprehensive assessment and referral-support tools to prompt multi-source information gathering, collateral enquiries and documentation of information sources.
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Hywel Dda University LHB
Issue a professional practice reminder requiring relevant practitioners to review electronic patient records before assessments and consider historical risks and safeguarding concerns.
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Hywel Dda University LHB
Discuss historical-record review and collateral-information requirements in Adult Mental Health Services operational team meetings to reinforce consistent practice.
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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Hywel Dda University LHB
Implemented, immediate and ongoing safety work collectively addresses the identified risk-assessment concerns.
-
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.
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.
Linked responses
- Phoenix Futures
- Practice Plus Group
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
Phoenix Futures
Remind all Recovery Workers to check SystmOne records before visiting people accessing services.
-
Phoenix Futures
Reinforce SystmOne-record checking through team meetings, six-month communications and supervision.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
-
Practice Plus Group
Responsibility for Phoenix Futures’ service and employees rests with Phoenix Futures, which is expected to respond separately.
-
Phoenix Futures
Records cannot always be reviewed before consultations when requests are urgent or staff are redirected to support another person.
-
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.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Barts Health NHS Trust
Require ward rounds and multidisciplinary reviews to consider events from the preceding 24–72 hours, including weekends.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
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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.
Linked responses
- Department of Health and Social Care
- Maylands Healthcare
- Partnership of East London Co-operatives Ltd
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6
-
Partnership of East London Co-operatives Ltd
Require clinicians to review relevant previous patient encounters and expand the requirement to all patients.
-
Partnership of East London Co-operatives Ltd
Share organisational learning with staff about reviewing all relevant previous patient encounters, including regular dissemination to new and existing employees.
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Partnership of East London Co-operatives Ltd
Include the requirement to review all relevant prior patient encounters in relevant clinical staff contracts.
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Partnership of East London Co-operatives Ltd
Implement a clinical-record alert for children presenting with sickle cell disease, triggered by disclosure or clinician identification from summary care records with consent.
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Maylands Healthcare
Add clear pop-up alerts and warnings identifying sickle cell disease in each clinical record.
-
Department of Health and Social Care
Implement and jointly publish Jess’s Rule to encourage structured clinical re-evaluation after three unresolved or worsening consultations.
-
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.
Linked response
- Marine Lake Medical Practice
Stated actions 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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Marine Lake Medical Practice
Ensure clinicians assess whether available clinical information is sufficient without delaying appropriate patient assessment.
-
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.
Linked response
- HCRG Care Group
Stated actions 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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HCRG Care Group
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
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HCRG Care Group
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
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HCRG Care Group
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
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HCRG Care Group
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
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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.
Linked response
- Essex Partnership University NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Essex Partnership University NHS Foundation Trust
Require full biopsychosocial mental health assessments, with documented rationale for omissions.
-
Essex Partnership University NHS Foundation Trust
Conduct monthly evidence-based assessment quality audits and provide feedback on findings.
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Essex Partnership University NHS Foundation Trust
Continue reviewing urgent-care learning, deadlines and impact through monthly quality and safety meetings.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026