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 raised2
Failure of nurses to read medical entries
Failure of medical staff to read nursing notes
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.
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
The decision to use particular patient records is a clinical decision for individual clinical staff.
Stated by Tameside and Glossop Integrated Care NHS Foundation Trust
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Concerns raised1
Failure to read or understand medical and nursing notes
This report raised 6 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 GP medical records during hospital admissions for young children
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.2
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Action
Introduce and implement a Trust-wide SOP requiring clinicians to obtain and review relevant patient, GP and other records during assessment and admission.
Stated by the Royal Wolverhampton NHS Trust -
Action
Audit compliance with the SOP six months after implementation and identify actions arising from the audit.
Stated by the Royal Wolverhampton NHS Trust
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Concerns raised1
Failure of clinicians to review patients’ historical medical records
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised2
Failure of subsequent medical teams to re-review previous medical history, historical imaging and medications after A&E transfer
Failure to consider previous radiology, medical history and medication before invasive procedures
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.3
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Action
Implement adult transfer and four-hour-plan checklists requiring handover teams to document medications and consider historical radiology.
Stated by Epsom and St Helier University Hospitals NHS Trust -
Action
Use an introduced medical proforma requiring clerking staff to record patients’ medical history and medication.
Stated by Epsom and St Helier University Hospitals NHS Trust -
Action
Deliver chest-drain training that reinforces reviewing historical radiology, medical history and medication and involving the respiratory team in patient care.
Stated by Epsom and St Helier University Hospitals NHS Trust
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Concerns raised1
Failure to communicate and review relevant clinical information before risk decisions
This report raised 7 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
Insufficient time to read all patient notes before assessment
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.
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 by mental health and general nursing staff to take account of system 1 entries
This report raised 11 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 all available risk information in the Person Escort Record
This report raised 6 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 access and read all relevant information across nursing and clinical records
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.
Data last updated 7 September 2026