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. Manchester City

    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

  2. Norfolk

    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

  3. Manchester North

    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

  4. West Yorkshire (East)

    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

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