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
Distinct published reports
Individual concerns
59
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
70
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.
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
NHS trust34
Ministerial department13
Healthcare site12
Health and social care service regulator5
Executive agency4
Executive non-departmental public body3
Type not available3
Integrated care board2
Local health board2
Multi-service care provider2
Nursing home2
Prison or young offender institution2
Sub-organisation2
Company1
Education sector body1
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.
South Yorkshire (Western)
Concerns raised1
Failure of treating clinicians to consider individualised care plans during admission
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 concerns
Each 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.9
Action
File updated individualised care plans at the front of paper records under a new standard operating procedure.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 March 2024.
Action
Hold daily multidisciplinary board rounds on Haematology wards and include Haemoglobinopathy Clinical Nurse Specialist attendance.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Create and place individualised care plans for sickle cell patients without an existing plan after board-round review.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Review individualised care plans at discharge, discuss amendments with patients, and update plans through the multidisciplinary team when required.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Notify the Haemoglobinopathy Clinical Nurse Specialist team of planned admissions and ensure receiving ward staff know about the individualised care plan.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Develop an action card covering sickle cell care, guidelines, individualised care plans, and pain assessment.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Deliver individualised care plan training through the sickle cell education programme, with further Haematology nursing training planned.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 21 March 2024.
Action
Deliver individualised care plan education to Emergency Department staff.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 21 March 2024.
Action
Configure the new Connect electronic patient record to record, flag, and link users to individualised care plans.
Stated by Sheffield Teaching Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 21 March 2024.
South Yorkshire (Western)
Concerns raised1
Failure to ensure consistent review of medical notes before appointments, assessments, and handovers
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.
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
Action
Develop a Standard Operating Procedure specifying how to prepare for clinical reviews, appointments and handovers, including required documentation review.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Disseminate the clinical-review preparation procedure to relevant clinical staff through governance, supervision, training and the intranet.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 12 December 2023.
Action
Implement a clinical record keeping standards policy guiding clinicians to prepare for appointments using current issues, risks and concerns.
Stated by Sheffield Health Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 12 December 2023.
East London
Concerns raised1
Failure of clinical staff to read essential parts of the clinical record when providing care
This report raised 5 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.
Leicester City and South Leicestershire
Concerns raised1
Failure to review patients’ records before CRISIS team MDT meetings
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 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.
East London
Concerns raised1
Lack of thorough history taking and verification of baseline oxygen saturation
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner North London
Concerns raised1
Failure to consult medical notes and records during leave risk 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 concerns
Each 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
Action
Remind Gardner Ward and City and Hackney inpatient staff to record clinical decisions, review RIO notes, and discuss leave-recording requirements at scheduled away days.
Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 22 June 2023.
Manchester South
Concerns raised1
Failure to review relevant clinical notes during assessment
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 concerns
Each 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
Action
Implement a Trust-wide sepsis improvement programme covering recognition, Sepsis Care Bundle use, antibiotics, blood cultures and deteriorating-patient assessment.
Stated by Tameside and Glossop Integrated Care NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 30 September 2022.
East London
Concerns raised1
Failure to review clinical records before accepting a surgical referral
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 concerns
Each 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
Action
Develop internal professional standards for specialty teams reviewing emergency-department patients, including training on locating relevant electronic records information.
Stated by Barts Health NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 23 September 2022.
West Yorkshire (Western)
Concerns raised2
Failure to review earlier clinical records
Failure of registrar to review medical notes and records
This report raised 12 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 A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The Trust considers the doctor’s changed practice, including proactive information review and communication training, sufficient to address handover and record-review concerns.
Stated by Calderdale and Huddersfield NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
East London
Concerns raised1
Failure to effectively review medical records before assessment
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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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.
