Recurring concern

Failure to review relevant clinical records before care decisions

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First reported 23 Aug 2013•Latest report 8 Jun 2026

Definition

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

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care11

Barts Health NHS Trust5

Care Quality Commission5

HM Prison and Probation Service4

Essex Partnership University NHS Foundation Trust3

NHS England3

Tameside and Glossop Integrated Care NHS Foundation Trust3

East London NHS Foundation Trust2

Greater Manchester Mental Health NHS Foundation Trust2

HM Prison Service2

Lancashire & South Cumbria NHS Foundation Trust2

Sheffield Health Partnership University NHS Foundation Trust2

Association of Ambulance Chief Executives1

Beeston Health Centre1

Berkshire Healthcare 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.

13 Dec2013
Manchester City
Concerns raised2
1. Lack of nurse review of recent records during admission or transfer handover
2. Failure of junior medical staff to review clinical records and history before prescribing medication
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Carry out weekly checks of compliance with handover documentation requirements.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
2. Action
  Instruct registered nurses to review recent admission records and risk information for unfamiliar patients, with understanding checked through supervision.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
3. Action
  Inform trainees about the Rapid Tranquillisation protocol through induction and clarify consultants’ supervision responsibilities for junior-doctor prescribing.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

STEPHANIE DANIELS · 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

Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

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 nurse review of recent records during admission or transfer handover
Wider context from the report
“2. Handover All the evidence showed that the handover of information between nursing and clinical colleagues was a vital piece in the jigsaw of care. MHSC have introduced a new policy but I have a concern that simple issues may be overlooked. For new patients being admitted or transferred, there is no requirement for the nurse in charge to review their recent records. MHSC have produced new or updated policies/protocols but experience has shown that what may be delivered on paper is not being done in practice. Consequently, I am concerned that without appropriate audit and clinical/nursing leadership this may prove to be ineffective. ”
Source location
STEPHANIE DANIELS · Prevention of Future Deaths report
Page 10 · 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
Failure of junior medical staff to review clinical records and history before prescribing medication
Wider context from the report
“6. Prescribing of Medication by Junior Medical Staff I am concerned by the circumstances in this case where medication came to be prescribed. There is an overlap of my concerns about supervision and my observations at paragraph 5 above should be regarded as repeated here. Both junior doctors had no recollection of attending the ward, speaking to the staff or seeing the patient. They simply prescribed the medication. They had no recollection of reviewing the deceased’s records and understood that was essential when considering prescribing any medication, and in particular PRN rapid tranquillisation. In this case, the patient was already taking a number of drugs which had sedative effects. Two further medications were introduced that have similar properties and that also could potentially affect heart function. ”
Source location
STEPHANIE DANIELS · Prevention of Future Deaths report
Page 10 · 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
Carry out weekly checks of compliance with handover documentation requirements.

Verbatim wording from the response
“As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over. The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staff have received and understood the instruction, which will be monitored through management supervision.”

Source location
2013-0353-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 13 December 2013
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
Instruct registered nurses to review recent admission records and risk information for unfamiliar patients, with understanding checked through supervision.

Verbatim wording from the response
“As you are aware, the Trust has a handover of care policy, which sets out the arrangements for the handover of care, and the documentation of information handed over. The Matrons will carry out weekly checks on compliance with the quality of the documentation on the handover forms. To address your concern that issues may be overlooked, the Head of Nursing is writing to all Ward Managers to instruct all registered nursing staff that they must read the recent admission records and risk information relating to all patients who are not known to them or have not been known during the current period of admission. Ward Managers will be required to ensure their registered nursing staff have received and understood the instruction, which will be monitored through management supervision.”

Source location
2013-0353-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 13 December 2013
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
Inform trainees about the Rapid Tranquillisation protocol through induction and clarify consultants’ supervision responsibilities for junior-doctor prescribing.

Verbatim wording from the response
“████████ Interim Medical Director, will ensure that all trainees will be informed about the Rapid Tranquillisation protocol through the induction process. In addition, consultants will be made aware of their responsibilities in respect of supervision of junior doctors prescribing. The Trust has amended the prescription card to ensure that Rapid Tranquillisation is clearly identifiable and not confused with PRN (as necessary) medication. The Trust incident reporting system is being adapted to record whether Rapid Tranquillisation was administered intramuscularly or orally and whether physical / safe observations were maintained in line with Trust policy. This is monitored through induction attendance records, pharmacy daily monitoring of prescriptions and Datix incident reporting.”

Source location
2013-0353-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 13 December 2013
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
Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.

Verbatim wording from the response
“As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.”

Source location
2013-0353-Response-by-Department-of-Health
Page 1 · response
Published 13 December 2013
Open published response
4 Dec2013
Norfolk
Concerns raised1
1. Failure of practice nurses to reliably access and check attending patients' past medical history
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Review and reinforce clinicians’ checking of patients’ past clinical history at each appointment.
  Stated by St Stephens Gate Medical PracticeStated completed
Respondent positions 1
1. Position
  Consultation details from other organisations cannot be viewed when patients withhold consent or make events private.
  Stated by St Stephens Gate Medical PracticeUnable to act
AI-generated summary

YUKI NORMAN-KNIGHT · 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

Yuki was a very young child who had a persistent cough and was seen at a walk-in centre and twice by practice nurses, receiving diagnoses of chest infection and courses of antibiotics. She later became unresponsive while with her father and died despite resuscitation efforts. Concerns related to checking her past medical history, guidance for practice nurses to refer children to a doctor, and appointment systems for securing a doctor’s assessment.

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 of practice nurses to reliably access and check attending patients' past medical history
Wider context from the report
“(1) Evidence given at Inquest from the Timber Hill walk in centre was that a record of a patient's attendance, if not registered at that practice, would be sent either electronically or by fax to the surgery where the patient was registered. In their evidence to the Inquest the practice nurses who saw Yuki at St Stephens Gate Medical practice could not recall if they had access to this information. I am therefore concerned that the systems for practice nurses checking an attending patient's past medical history, especially where the patient is a very young child or baby may need review. ”
Source location
YUKI NORMAN-KNIGHT · Prevention of Future Deaths report
Page 2 · 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
Review and reinforce clinicians’ checking of patients’ past clinical history at each appointment.

Verbatim wording from the response
“In other words, our ability to see the consultation details at another venue is reliant on the patient's consent. However, in the instance where consent has been given, we confirm that the information can be seen and that all nursing staff check records accordingly. Whilst this would be standard procedure in any case, we have reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment.”

Source location
2013-0321-Response-by-St-Stephens-Gate
Page 1 · response
Published 23 February 2014
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
Consultation details from other organisations cannot be viewed when patients withhold consent or make events private.

Verbatim wording from the response
“However: we would not be able to see the detail of the consultation if SystmOne showed:”

Source location
2013-0321-Response-by-St-Stephens-Gate
Page 1 · response
Published 23 February 2014
Open published response
21 Nov2013
Manchester North
Concerns raised2
1. Failure to routinely check medical records for new neonatal admissions
2. Failure to make treatment decisions collaboratively and using all available information
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 concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jack William PARTINGTON · 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

Jack Partington was born by planned caesarean section on 25 November 2011 and developed breathing difficulties requiring neonatal ventilation. After developing a pneumothorax, he was treated with intubation and ventilation but deteriorated and died on 26 November 2011. Concerns included gaps in neonatal handover and care planning, treatment decisions made without multidisciplinary consultation, lack of routine use of exhaled carbon dioxide detectors, absence of national guidance on paralysing agents and neonatal ventilation, and inadequate monitoring of ventilatory pressure after intubation.

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 routinely check medical records for new neonatal admissions
Wider context from the report
“1) That there was no 1:1 neonatal nurse/cotside ‘handover’ at shift change, no individualised neonatal nursing care plan in use and no routine checks of medical records for new neonatal admissions. ”
Source location
Jack William PARTINGTON · Prevention of Future Deaths report
Page 2 · 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
Failure to make treatment decisions collaboratively and using all available information
Wider context from the report
“2) Nursing staff, rather than the multi-disciplinary team plus parents, took treatment/change of treatment decisions in isolation and without consulting all available information (such as medical records etc.) ”
Source location
Jack William PARTINGTON · Prevention of Future Deaths report
Page 2 · 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
Staffing, training, governance and clinical issues are local matters that should be addressed by the NHS Trust.

Verbatim wording from the response
“I note that you have sent a Regulation 28 report to the local NHS Trust for its response. I believe that the issues concerning staffing, staff training, governance and clinical issues are local issues that should properly be addressed by the Trust.”

Source location
2013-0308-Response-by-Department-of-Health
Page 2 · response
Published 21 February 2014
Open published response
23 Aug2013
West Yorkshire (East)
Concerns raised1
1. Failure to review relevant computerised medical records during clinical consultation
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 concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

JILL FELICITY SINSON · 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

Jill Felicity Sinson had schizophrenia, an anxiety-related disorder, non-epileptic seizures, and a history of self-harm and suicidal tendencies. She was last seen alive on 3 September 2012 and was found lifeless at her home on 10 September 2012; life was pronounced extinct by paramedics. The concerns included inadequate GP monitoring, failure to review or refer her after a GP surgery consultation, insufficient consideration of her medical history when prescribing medication unsupervised, and failure to act appropriately on correspondence from her Consultant Psychiatrist.

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 review relevant computerised medical records during clinical consultation
Wider context from the report
“(2) When the Deceased was seen at the GP surgery by a Staff Nurse on the 3rd July 2012 – (a) the Deceased’s presentation on that occasion was such as to necessitate a review by a GP and/or referral to the Deceased’s Consultant Psychiatrist, but no such review and/or referral was considered, and (b) due regard was not paid to the Deceased’s computerised medical records prior to and/or in the course of consulting with the Deceased on that occasion, as information provided by the Deceased to the said Staff Nurse was fundamentally incorrect which was apparent from earlier entries in the Deceased’s said records ”
Source location
JILL FELICITY SINSON · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Lack of nurse review of recent records during admission or transfer handover

Failure of junior medical staff to review clinical records and history before prescribing medication

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure of practice nurses to reliably access and check attending patients' past medical history

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Failure to routinely check medical records for new neonatal admissions

Failure to make treatment decisions collaboratively and using all available information

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to review relevant computerised medical records during clinical consultation

Actions described in response 3

Respondent positions 1

Actions described in response 1

Respondent positions 1

Respondent positions 1