Recurring concern

Failure to review relevant clinical records before care decisions

First to latest report 23 Aug 2013 — 8 Jun 2026

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.

Reports and published responses 54 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Brighton and Hove

    AI-generated summary

    Kalma RAM-HENMAN · 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

    Kalma RAM-HENMAN died on 7 June 2018 after presenting to A&E in a precarious state and later being found to have a perforated gastric ulcer. The report identified concerns about incomplete fluid monitoring, failure to administer prescribed potassium and sufficient intravenous fluids, missed ECG abnormalities, inadequate repeat blood testing, and delays in responding to her deterioration and providing planned treatment.

    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 clinical notes during ward transfer and overnight review

    Wider context from the report

    “(3) Opportunities to realise that sodium and fluids had not been administered were missed overnight when Mrs RAM-HENMAN was transferred from A&E to Bristol Ward and was seen in the early hours of the 7th. It seems her notes were not read so the failure to give fluids and potassium was missed. ”

    Source location

    Kalma RAM-HENMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Keith Dransfield · 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

    Keith Dransfield died in Northern General Hospital on 30 September 2017 from cerebral hypoxia due to hanging, with psychiatric depression also recorded. The inquest identified concerns about an inappropriate observation regime, inadequate risk assessment, failure to routinely consult patient records, and insufficient staff training.

    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 consult patients' records

    Wider context from the report

    “During the inquest, evidence showed:- Mr Dransfield was on an inappropriate observation regime with no written record of why he was moved from 10 minute observations to routine observations. There was not a clear risk assessment of Mr Dransfield. Staff did not routinely consult patients records. There was a lack of appropriate training. ”

    Source location

    Keith Dransfield · Prevention of Future Deaths report
    Page 1 · 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

    Inform staff of named- and associate-nurse responsibilities for knowing service-user care plans and current circumstances.

    Verbatim wording from the response

    “that are in place for them. The Trust found no evidence that notes were looked at nor did the two staff know they were the named nurses for Mr Dransfield on this shift. Staff have been informed of their responsibilities when undertaking the named and associate nurse role and the Ward Manager is responsible for ensuring all Ward staff fulfil their responsibilities effectively.”

    Source location

    2018-0273-Response-by-Sheffield-Health-and-Social-Care-NHS-Trust
    Page 4 · response
    Published 30 October 2018

    Open published response

  3. South London

    AI-generated summary

    Julia Jane MacPherson · 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

    Julia Jane MacPherson, an informal patient of Oxleas NHS Foundation Trust, suffered swallowing difficulties and collapsed in the community with food bolus and vomitus in her throat; resuscitation was unsuccessful. Concerns included failure to arrange or undertake a timely medical review, failure to assess her mental capacity after concerns about confusion, incomplete clinical records, and prescribing and consent processes for off-licence medication. The inquest recorded the medical cause of death as upper airway obstruction associated with swallowing difficulties secondary to medication-related extrapyramidal symptoms.

    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 hospital staff to regularly read clinical and nursing entries in patient medical records

    Wider context from the report

    “(1) It was agreed that Julia usually had a comprehensive understanding of her mental health and medications and was an informal patient consenting to her care and treatment. Quetiapine had been stopped due to concerns about seizures. A trial of Clozapine was commenced on 18 January 2016, prescribed off licence and Julia and her family raised concerns with her clinicians who had made adjustments to her dose but she continued to have experience side effects that she found difficult to tolerate. She had a home visit with her mother on Sunday 15th May and despite usually being self-caring, she needed full assistance in her care and she spent most of the visit in bed. Significant concerns were raised by her mother that Julia was not well enough to be taken out, that she had no comprehension of her medication, that she appeared confused and that her memory and speech appeared to be affected. Her mother left a note with nursing staff requesting an immediate medical review by her Responsible Clinician as she had no other way of contacting him, however: (a) This review did not take place and her Responsible Clinician did not see this note until the inquest. (b) Julia was not reviewed on 16th May. (c) A formal review of her mental capacity to consent to her treatment did not take place following concerns raised by her mother on 15th May or when Hospital staff noted that Julia was very confused on 17th May. (2) Evidence at the inquest was that hospital staff did not regularly read clinical and nursing entries in patient medical records. (3) Medical records concerning discussions about her consent to prescription off licence medication for her mental health were missing or incomplete even though numerous concerns about her Clozapine and polypharmacy, over sedation and confusion were raised. (4) NICE guidelines for the prescription of off licenced medicines was not followed. (5) Adult patients sectioned under the Mental Health Act have statutory forms that lists all psychiatric medication that can be administered either on T2 (patient consents) or on T3 (patient does not consent) which requires the approval of a Second Opinion Appointed Doctor. There is no statutory process for recording consent to medication for informal patients. ”

    Source location

    Julia Jane MacPherson · Prevention of Future Deaths report
    Page 1 · 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

    Write to all consultants reiterating expectations to read clinical and nursing notes written by trainees and other staff.

    Verbatim wording from the response

    “In addition, our Medical Director, Dr Okocha will write to all consultants in the Trust reiterating the expectations that they check and read notes which are written by their trainees and other staff.”

    Source location

    2018-0298-Oxleas-NHS-Foundation-Trust
    Page 2 · response
    Published 19 January 2019

    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

    Conducted a follow-up inspection of Oxleas NHS Foundation Trust’s acute wards to assess whether specific improvements had been made.

    Verbatim wording from the response

    “Since Julia Jane MacPherson's death in May 2016, we have inspected Oxleas NHS Foundation Trust once. This was a follow up inspection of the acute wards in the Trust, including Norman Ward, in February 2017 to see if some specific improvements had taken place since the comprehensive inspection in April 2016. We also carried out regular visits by our Mental Health Act reviewers, and the last one took place on Norman Ward in March 2017.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    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

    Return to inspect Oxleas NHS Foundation Trust and follow up the identified concerns to check that necessary improvements have been made.

    Verbatim wording from the response

    “We will be returning to inspect Oxleas NHS Foundation Trust later in the year. We intend to follow through some of the areas of concern in more detail. This will be to ensure the trust has learnt from this and made the necessary improvements.”

    Source location

    2018-0298-Response-by-CQC
    Page 2 · response
    Published 19 January 2019

    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

    Specific circumstances of Julia MacPherson’s individual care and treatment fall outside the regulator’s remit for comment.

    Verbatim wording from the response

    “We note our legal responsibility to submit a written response to you, however some of the matters of concern relate to the very specific circumstances of Julia MacPherson's individual care and treatment, so we are unable as a regulator to comment on this.”

    Source location

    2018-0298-Response-by-CQC
    Page 1 · response
    Published 19 January 2019

    Open published response

  4. Warwickshire

    AI-generated summary

    Mr Anderton · 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

    The supplied text does not describe the circumstances of Mr Anderton’s death, but states that an inquest concluded with a Narrative Verdict. The principal concern was that medical staff failed to attempt CPR after consulting the wrong set of medical notes.

    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 consult the correct set of medical notes

    Wider context from the report

    “(1) the failure of the medical staff to attempt CPR having consulted the wrong set of medical notes ”

    Source location

    Mr Anderton · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Inner North London

    AI-generated summary

    Siân Louise WITHERIDGE · 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

    Siân Louise Witheridge died by suicide after hanging herself at home on 30 May 2017, following admission to Highbury Grove Crisis House. Concerns included staff not having or fully reviewing her mental health records, inadequate or unenforceable risk-assessment arrangements, misunderstanding of responses about suicide plans, and disjointed care between the crisis house and crisis team.

    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 historical mental health records

    Wider context from the report

    “3. The crisis team staff (as opposed to the crisis house staff) did have access to Ms Witheridge’s mental health records, but they did not read them any further back than the first call to crisis house during that last episode, i.e. 25 May 2017, despite her very extensive past medical history. There seemed a lack of recognition of the importance of the notes, particularly the older notes. ”

    Source location

    Siân Louise WITHERIDGE · Prevention of Future Deaths report
    Page 3 · 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

    Reinforce comprehensive clinical-record review, including the risk assessment, before staff see patients.

    Verbatim wording from the response

    “The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did. To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking a comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient. The practice of reading the history will be checked in regular supervisions.”

    Source location

    2017-0305-Response
    Page 2 · response
    Published 27 November 2017

    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

    Check clinical-history review practice during regular staff supervision.

    Verbatim wording from the response

    “The Assistant Practitioner acknowledged at the inquest that she should have read further back in the clinical records than she did. To ensure that the learning from this case is embedded within the teams, the operational manager and team manager of the crisis team have reinforced the importance of undertaking a comprehensive review of the clinical records, including reading the risk assessment, before seeing a patient. The practice of reading the history will be checked in regular supervisions.”

    Source location

    2017-0305-Response
    Page 2 · response
    Published 27 November 2017

    Open published response

  6. Manchester West

    AI-generated summary

    Carol Buchanan · 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

    Carol Buchanan was admitted to hospital after a fall and later deteriorated following the combined prescription of Itraconazole and Simvastatin, which led to rhabdomyolysis and muscle necrosis. She died on 26 May 2017 despite treatment. Concerns included inadequate prescription record checking and documentation, failure to recognise the serious drug interaction, missed opportunities to act on relevant history, and delays in monitoring and diagnosis.

    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 consult or cross-reference the Summary Care Record when prescribing

    Wider context from the report

    “1. The prescription of Itraconazole was undertaken at the Royal Bolton Hospital’s Respiratory Clinic’s without the consultation or cross referencing information with the Summary Care Record. ”

    Source location

    Carol Buchanan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. Blackpool and the Fylde

    AI-generated summary

    Bernard Cosgrove · 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

    Bernard Cosgrove was admitted to hospital on 28 February 2017 after being observed unresponsive and was discharged to his nursing home on 10 March 2017 with a dislocated right hip joint that had started to become infected. He died at the nursing home on 21 March 2017 from bronchopneumonia, with significant heart disease and hip joint infection contributing to his death. The principal concerns were that the dislocation was not recognised for seven days, that relevant medical-record information was not incorporated into his care, and that patient monitoring and consideration of medical records were insufficient.

    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 consider relevant previous medical record entries in subsequent patient care

    Wider context from the report

    “The concerns are: • Despite an entry in the clinical records made by a doctor on 3rd March 2017 which refers to a rotating right leg, neither the issue he identifies nor his entry in the notes appear to have been appreciated by nursing staff who cared for Mr Cosgrove thereafter. A Sister who was a clear and helpful witness acknowledged in court that the issue identified by the doctor on 3rd March 2017 was not considered as part of his plan of care subsequently. This is despite the fact that between 3rd March 2017 and discharge from hospital he was seen regularly by staff with responsibility for physically rolling him with a view to providing pressure relief. • Although from the evidence it is not known how the dislocation occurred the fact it does not appear to have been recognised over a period of 7 days is concerning and strongly suggests that staff paid insufficient regard to the patient's previous medical record entries. Patients such as Mr Cosgrove should not find themselves being discharged from hospital in such circumstances and at a time when the medical professionals looking after his welfare are unaware of such an issue. • But for the fact he was discharged from hospital on 10th March 2017 and that this resulted in the dislocation problem being identified, had he spent a lengthier period in hospital the dislocation and developing infection may well have continued to go unrecognised which raises a concern about how effectively patients are being monitored and their medical records are being considered by staff who are subsequently involved in that patient's care. On this occasion once the dislocation issue was identified this did not substantially alter his care and he was treated conservatively, but in other circumstances not recognising the problem may have directly caused a death. ”

    Source location

    Bernard Cosgrove · 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

    Provide ward-based education, updates and reminders supporting professional responsibility for patient care and contemporaneous recordkeeping.

    Verbatim wording from the response

    “The Trust notes your concern in terms of other potential circumstances where not recognising issues or recording specific history within patient notes could lead to future problems and we are working hard to eradicate such problems. We work closely with our staff in terms of practice development and continued professional development through Ward based education, updates and reminders of their professional responsibility in terms of patient care and contemporaneous recording of observations and notes.”

    Source location

    2017-0285-Response-by-Blackpool-Teaching-Hospital-NHS-Trust
    Page 2 · response
    Published 27 November 2017

    Open published response

  8. Preston and East Lancashire

    AI-generated summary

    Robert Cardwell · 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

    Robert Cardwell was under the care of a Home Treatment Team but was discharged after information about his missed appointment and request for a further appointment was not passed to the multidisciplinary team. He later expressed suicidal thoughts, described a plan to hang himself using a football scarf, and was found deceased at home on 29 September 2016 after hanging himself. Concerns included failures in communication, failure to discuss or follow up his request for an appointment, and inadequate record keeping during multidisciplinary team meetings.

    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 clinical records during MDT meetings

    Wider context from the report

    “On the 6th July 2016 a nurse at the Trust contacted Mr Cardwell to find out why he had not attended his appointment with the Psychiatrist that day. Mr Cardwell told the nurse that he had been unable to attend the appointment because he had no petrol. He also advised that he had no phone credit and had therefore been unable to contact them. Mr Cardwell reported that his ex-partner had stolen his bankcard and that all the money had gone from his account. The nurse advised that this information would be passed to the MDT for their consideration the following day. Mr Cardwell wanted another appointment but he said it would have to be a home visit. Whilst Mr Cardwell was discussed at the MDT meeting on the 7th July and discharged, I found on the evidence that the message explaining his non-attendance and requesting a further appointment was not relayed to the MDT. Had that message been relayed to the MDT, I found that Mr Cardwell would have been offered a further appointment and would not have been discharged at that time. This failure in communication is a matter of concern. I am concerned about the process by which messages are relayed from service users to the MDT team. The nurse explained that the information was passed on to be taken up by the Duty Worker and it should then have been reported to the team. The nurse also recorded the contact in Mr Cardwell’s clinical record but these were not looked at during the course of the MDT meeting. ”

    Source location

    Robert Cardwell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  9. Preston and West Lancashire

    AI-generated summary

    Stephen McDermott · 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

    Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.

    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 available records fully during assessment

    Wider context from the report

    “2) In addition to the problems highlighted above of not having all records on one system, there was evidence of poor use of the records that were available resulting in liaison nurses who were assessing Mr McDermott having an incomplete picture: a) During the GP’s telephone call to ████████ at the Single Point of Access team on 16 March 2015, ████████ did not check the full records to learn the background of Mr McDermott’s recent admission following an overdose; b) During her assessment of Mr McDermott on 27 March 2015, ████████ mental health liaison nurse, was only aware that Mr McDermott had taken an overdose of drugs and alcohol. She was unaware that Mr McDermott had been brought to Accident and Emergency whilst intoxicated having been located near the train station by police and having reported to them that he was having thoughts of jumping in front of a train, a fact that was readily available in the records; c) Following his assessment of Mr McDermott on 6 April 2015, ████████ mental health liaison nurse, discharged Mr McDermott without a plan for referral into the crisis team for assessment. Part of his rationale for this was that Mr McDermott told him he had an appointment with Mindsmatter on 9 April. This was incorrect (this date was in fact due to be the first face-to-face appointment with the SPOA, which was subsequently cancelled) and demonstrates that ████████ either did not have access to or did not properly check relevant records; ”

    Source location

    Stephen McDermott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. West Yorkshire (Western)

    AI-generated summary

    Kirsty Childs · 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

    Kirsty Childs, aged 20, developed severe abdominal symptoms and repeatedly sought advice from NHS Direct and other services between 31 December 2012 and 2 January 2013. She was not admitted to hospital and was later found dead at home; the inquest recorded septic shock caused by an undiagnosed and untreated mesenteric venous thrombosis. The principal concerns included incorrect telephone triage, failure to review earlier calls, medically unqualified staff selecting questionnaires, the ability to override recommended outcomes, and poor information-sharing between agencies.

    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 details of earlier calls when assessing subsequent calls

    Wider context from the report

    “4.Within NHS direct there was a complete consistency of treating each call separately, there was no attempt to review details of earlier calls made. ”

    Source location

    Kirsty Childs · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026