Recurring concern

Unreliable recording and availability of patient weight, height and BMI information

First to latest report 7 Feb 2020 — 23 Jun 2025

Reports that mention this concern
4
Times this concern has been raised
4
Stated actions linked to this concern
16

What this concern includes

Includes failures in systems and processes for recording, calculating, validating, retrieving and making patient weight, height and BMI information available across healthcare settings, including fragmented records and undetected BMI errors.

What is not included
  • Excludes general electronic-record fragmentation or interoperability failures where weight, height or BMI information is not the material unsafe object.
  • Excludes broader nutrition, malnutrition or clinical-assessment failures where anthropometric information is not the deficient control.
  • Excludes failures to act on accurate and accessible weight, height and BMI information when the information process itself is reliable.
  • Excludes unrelated measurement, record-keeping or data-quality concerns involving other patient information.

Reports and published responses 4 reports

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

  1. Northumberland

    AI-generated summary

    REDACTED Deceased · 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 deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.

    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 one accessible system for weights, heights and BMI

    Wider context from the report

    “6.One records system - weights, heights and Body Mass Index (BMI) I heard that patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. I heard good examples of accessible records such as the Great North Care Record (GNCR) and SystmOne operated by some in Primary Care. I am concerned there is not one accessible system for weights, heights and BMI. ”

    Source location

    REDACTED Deceased · Prevention of Future Deaths report
    Page 5 · 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

    Develop improved information-sharing strategies across primary care, secondary care, schools, mental health services and social care, including exploring monthly multidisciplinary meetings.

    Verbatim wording from the response

    “3. Communication and Information Sharing: The report highlights concerns regarding the flow of information from other agencies, including the school and mental health services. We concur that a more robust system for sharing relevant clinical and safeguarding information is essential. We are committed to improving multidisciplinary communication, including liaising more proactively with schools, mental health services, and social care teams involved with patients at risk.”

    Source location

    2025-0314 - Response from 49 Marine Avenue Surgery
    Page 1 · response
    Published 14 July 2025

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    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

    Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.

    Verbatim wording from the response

    “It is recognised by NHS England that the joining up of records to achieve easy access to all the information by clinicians and 'patients/their guardians' remains a challenge and NHS England with the Department of Health and Social Care is currently executing a substantial programme of work to increase the interoperability and sharing of all patient records, including medical history, investigations and vital patient measurements (Blood pressure, Height and Weight etc) and would include centile charts in paediatric services. This has been outlined in the Governments 10 Year Plan and the ambition to develop a ‘Single Patient Record’.”

    Source location

    Response from Department for Health and Social Care
    Page 2 · response
    Published 14 July 2025

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    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

    Deliver a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.

    Verbatim wording from the response

    “The Government’s 10 Year Health Plan commits to the delivery of a SPR. This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place which will help prevent unfortunate incidents where fragmented and disjointed information prevents treatment from being provided on time.”

    Source location

    Response from Department for Health and Social Care
    Page 3 · response
    Published 14 July 2025

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    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

    Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.

    Verbatim wording from the response

    “3. Introduction of SystmOne as a clinical electronic records system for Nutrition and Dietetics outpatient consultations (Go Live of the Nutrition and Dietetics SystmOne unit was August 2024) provides:”

    Source location

    2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
    Page 2 · response
    Published 14 July 2025

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    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

    Continue reviewing clinical systems and digital platforms to streamline central reporting and interoperability of height and weight measurements.

    Verbatim wording from the response

    “12. The Trust are continuing to review all clinical systems and digital platforms to streamline, where possible, the reporting of weight and height and the interoperability of systems to provide assurance that measures are captured and reported centrally by all services.”

    Source location

    2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
    Page 3 · response
    Published 14 July 2025

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    ALEXANDER LEE REID · 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

    Alexander Lee Reid received the Oxford AstraZeneca Covid-19 vaccine after being invited early because an erroneous BMI in his GP records led him to be identified as vulnerable. He died on 29 June 2021, and the inquest concluded that his death was linked to the vaccination, with the medical cause recorded as cerebral venous sinus thrombosis and Covid-19 vaccine-induced immune thrombotic thrombocytopenia. The principal concern was whether general practice IT systems should validate or challenge potentially erroneous data at the point of entry to improve data reliability and patient safety.

    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 general practice IT systems to validate or challenge potential data input errors at the point of entry

    Wider context from the report

    “(2) The inquest heard expert evidence that the combined vaccination monitoring and recall specification designed to identify vulnerable people for the purposes of inviting them to receive their Covid vaccinations early had identified Alex as vulnerable from an incorrect BMI of 68.97 recorded in his GP records on 06/02/2004. The mistake was due to the relevant clinician recording Alex's height as 145cm and his weight as 145kg, giving a BMI of 68.97 for an 11 year old boy whose previously recorded BMI aged 9 had been 14.88. (3) The inquest heard expert evidence that to have built a system that would validate multiple data items in an individual's GP records for the purposes of ensuring that individuals were not incorrectly identified as vulnerable would not have been feasible within the constraints and context of the Covid-19 programme. (4) The inquest heard expert evidence that an easier and more appropriate option would be to embed validation rules in general practice IT systems that would check such information at the time of data entry. (5) If the obviously erroneous BMI had not been recorded or had been challenged at the point of entry by the relevant IT system, Alex would not have been classed as vulnerable, would not have been offered a vaccine before guidance was published that the under 30’s should not receive the Oxford Astra Zeneca vaccine, and would not have died when he did. (6) The consequences of the data input error in this case give rise to a concern that more might be done by way of specification design to allow for the correction of or challenge to potential data input errors at the point of entry, with consequential improvements in the reliability of such data and the safety of patients and reducing the risk of other deaths occurring in similar circumstances in the future. ”

    Source location

    ALEXANDER LEE REID · 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

    Maintain point-of-entry validation restricting extreme height, weight and calculated BMI values in SystmOne.

    Verbatim wording from the response

    “In SystmOne, there is already validation at the point of entry on height and weight measurements to prevent extreme values being entered. For example, a maximum height of 3 metres can be entered, with the maximum weight being 500 kilograms. Similarly, a calculated BMI is constrained to between 0 and 150. It is not impossible, however, for someone to have a BMI as high as the one that was calculated in this instance. Thus the system must allow such a BMI to be accurately recorded if this is the true calculated BMI.”

    Source location

    Response from TPP
    Page 1 · response
    Published 29 April 2024

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    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

    Contact NHS England separately about validation of calculated BMI data in GP IT systems.

    Verbatim wording from the response

    “To return to the specific concern that could be directed to GP system suppliers, should NHS England decide that it would be appropriate to include validation concerning the calculation of BMIs in GP IT systems, the requirements for this would be most appropriately set at a national level to ensure a consistent approach across all GPs. Of course, in the clinical environment there are already a number of alerts, flags, prompts and notifications directed at clinical staff, and consideration would need to be taken to the sensitivity of the validation to ensure this is not triggered so frequently as to cause ‘alert fatigue’.”

    Source location

    Response from TPP
    Page 2 · response
    Published 29 April 2024

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    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

    Ask NHS England to consider coordinating funded clinical-safety workshops to document causes, identify controls and define professional requirements for safer system behaviour.

    Verbatim wording from the response

    “We will ask NHS England to:”

    Source location

    Response from RCGP
    Page 4 · response
    Published 29 April 2024

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    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

    Ask NHS England to report to the Joint GPIT Committee on addressing the concerns through changes to existing supplier-contract standards and capabilities.

    Verbatim wording from the response

    “We will ask NHS England to:”

    Source location

    Response from RCGP
    Page 4 · response
    Published 29 April 2024

    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

    Existing EMIS Web functionality is sufficient to mitigate the specific data-entry risk, so no further software development is required.

    Verbatim wording from the response

    “As detailed above, the System has inbuilt safety principles and is compliant with NHS specifications. Nevertheless, we will continue to review our solutions to determine whether there are changes to be made which would improve their performance.”

    Source location

    Response from EMIS
    Page 3 · response
    Published 29 April 2024

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    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

    GP IT systems are centrally assured against the GP IT Futures Framework and statutory clinical safety standards require consideration of data-entry and transmission hazards.

    Verbatim wording from the response

    “Core GP IT records systems are developed - and centrally assured - against standards set out in the GP IT Futures Framework. More information about this can be found here.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 29 April 2024

    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

    Cross-domain validation of automatically calculated BMI is not currently implementable, and implementation would present substantial challenges and further clinical risks requiring balanced assessment.

    Verbatim wording from the response

    “Where there is an automated calculation using other data items (such as is the case for BMI), there is no currently implementable means to apply validation – or define normal – across domains. It should also be noted that the ranges of values that may be possible (or probable) for height, weight and BMI vary by age, gender, and may vary by ethnicity.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 29 April 2024

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    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

    SystmOne already validates height, weight and BMI ranges, and must permit unusually high BMI values when clinically accurate.

    Verbatim wording from the response

    “In SystmOne, there is already validation at the point of entry on height and weight measurements to prevent extreme values being entered. For example, a maximum height of 3 metres can be entered, with the maximum weight being 500 kilograms. Similarly, a calculated BMI is constrained to between 0 and 150. It is not impossible, however, for someone to have a BMI as high as the one that was calculated in this instance. Thus the system must allow such a BMI to be accurately recorded if this is the true calculated BMI.”

    Source location

    Response from TPP
    Page 1 · response
    Published 29 April 2024

    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

    Any additional BMI validation requirements should be set nationally by NHS England to ensure consistency across GP systems.

    Verbatim wording from the response

    “To return to the specific concern that could be directed to GP system suppliers, should NHS England decide that it would be appropriate to include validation concerning the calculation of BMIs in GP IT systems, the requirements for this would be most appropriately set at a national level to ensure a consistent approach across all GPs. Of course, in the clinical environment there are already a number of alerts, flags, prompts and notifications directed at clinical staff, and consideration would need to be taken to the sensitivity of the validation to ensure this is not triggered so frequently as to cause ‘alert fatigue’.”

    Source location

    Response from TPP
    Page 2 · response
    Published 29 April 2024

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    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

    Age-sensitive BMI functionality has not been developed because it is not currently required under NHS framework agreements.

    Verbatim wording from the response

    “It should be noted that, such enhanced functionality (to additionally take into account patient age when recording weight or height for calculation of BMI, including for patients who are under 16 years of age) is not currently among the NHS requirements in the Framework agreements and therefore has not been developed in our clinical solutions.”

    Source location

    Response from Cegedim
    Page 2 · response
    Published 29 April 2024

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    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

    Building validation of multiple GP-record data items was not feasible within the Covid-19 programme’s speed, safety and delivery constraints.

    Verbatim wording from the response

    “Issue 3 - The inquest heard expert evidence that to have built a system that would validate multiple data items in an individual’s GP records for the purposes of ensuring that individuals were not incorrectly identified as vulnerable would not have been feasible within the constraints and context of the Covid-19 programme”

    Source location

    Response from RCGP
    Page 3 · response
    Published 29 April 2024

    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

    Completely preventing entry of a BMI of 68.97 may not be appropriate, limiting use of exclusion thresholds as a data-entry control.

    Verbatim wording from the response

    “a) A warning at the point of entry would be one example of a control mechanism and we agree that it would have been likely that if such a mechanism were in place, those data would not have been recorded in Alex’s record.”

    Source location

    Response from RCGP
    Page 4 · response
    Published 29 April 2024

    Open published response

  3. Manchester South

    AI-generated summary

    Alan Harry Hunter · 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

    Alan Harry Hunter was admitted to hospital after a fall, with a urinary tract infection, confusion and delirium. He experienced incorrectly calculated BMI and MUST scores, rapid weight loss, increasing frailty, Covid-19 and a further urinary tract infection before dying at Fernlea Care Home; concerns focused on poor documentation and inadequate monitoring of his diet, weight and nutritional risk.

    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 calculate and identify inaccurate BMI measurements

    Wider context from the report

    “The inquest heard that the quality of the documentation relating to Mr Hunter was poor particularly in relation to monitoring his diet and weight. The BMI was incorrectly calculated on admission and this was not identified subsequently. As a consequence his MUST score was inaccurate and his level of risk due to his weight and poor nutritional status was not correctly understood. The NICE guidance relating to monitoring weight was not followed and this was not recognised by ward managers. ”

    Source location

    Alan Harry Hunter · 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 mandatory MUST screening training at induction and every three years, and report compliance across the Trust.

    Verbatim wording from the response

    “I would like to provide assurance that prior to Mr Hunter’s inquest, improvement work related to MUST, nutrition and hydration had already commenced with a number of actions undertaken to improve the care we provide to patients and the way in which we document and evidence that care. The Nutrition and Hydration Steering Group takes place on a monthly basis and is chaired by the Deputy Chief Nurse. This Group reports to the Patient Safety Group chaired by the Medical Director and has oversight of improvements to nutrition and hydration across the Trust. Reports received by the Group include the training compliance position for MUST screening training which is currently reported at 90.76% trust wide, the compliance position for quality metrics standards for nutrition and hydration and fluid balance monitoring undertaken by senior nurses.”

    Source location

    Response from NHS Stockport
    Page 1 · response
    Published 4 November 2021

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    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

    Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.

    Verbatim wording from the response

    “A seven minute briefing document has been developed related to nutrition and MUST assessment and cascaded to teams. The seven minute briefing format is a standardised method of communication used at Stockport NHS Trust to provide teams with key information to improve patient and staff safety. The Nutrition and MUST seven minute briefing provides an overview of malnutrition, MUST assessments and the use of food charts, and the importance of protected mealtimes.”

    Source location

    Response from NHS Stockport
    Page 2 · response
    Published 4 November 2021

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    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

    Conduct twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.

    Verbatim wording from the response

    “The action plan also describes the audit processes now in place to ensure oversight of the MUST assessment and the completion of food charts. The Quality Assurance Checks completed by Matron twice weekly include a patient care section which looks at completion of nutrition assessment, that the assessment is up to date, and that fluid balance charts are up to date. The documentation section of the Quality Assurance Check audits that the MUST assessments are completed to the required standard and that standards of documentation are upheld, for example that all nursing entries are legible, signed, dated and timed. Alongside regular audit, daily safety huddles with the matron and ward managers take place to review any concerns in regard to patients. This holistic review includes a review of any nutrition and hydration concerns.”

    Source location

    Response from NHS Stockport
    Page 2 · response
    Published 4 November 2021

    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

    Run Malnutrition Awareness Week activities including MUST audits, nutritional nurse drop-in sessions and speech and language therapy presentations.

    Verbatim wording from the response

    “Finally I would like to confirm that in October 2021, the Trust took part in Malnutrition Awareness Week, with a timetable of activities including MUST audit, drop in sessions with the nutritional nurses and a presentation from the speech and language therapy team.”

    Source location

    Response from NHS Stockport
    Page 3 · response
    Published 4 November 2021

    Open published response

  4. Inner South London

    AI-generated summary

    Mr Adrian Ashford · 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

    Mr Adrian Ashford died in Queen Elizabeth Hospital on 15 December 2018 after a massive upper gastrointestinal bleed, with the medical cause of death recorded as upper gastrointestinal bleeding due to chronic peptic ulcer. Concerns included the absence of a systematic process for recording weights and failures to identify or respond to risks of gastrointestinal bleeding, including consideration of gastroenterology referral.

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    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 a systematic process for recording weights

    Wider context from the report

    “1. ████████ GP and ████████ Divisional Medical Director, both gave evidence of the value of having some system for regular weighing, and that it might save lives. This would enable reported weight loss to be verified and quantified and highlight triggers for investigation in a timely manner. But there appears to be no systematic process of recording weights. ”

    Source location

    Mr Adrian Ashford · 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

    Implement a trust-wide electronic patient record enabling staff to record and view patient weights electronically.

    Verbatim wording from the response

    “- The Trust has now implemented a trust-wide electronic patient record system (since May-June 2019). The system enables weight to be consistently recorded electronically which can then be observed by all staff within the Trust”

    Source location

    2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
    Page 2 · response
    Published 18 March 2020

    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

    Operate a systematic weekly weight assessment process after admission, with weights and heights visible to Trust staff.

    Verbatim wording from the response

    “- The Trust also has a systematic process in place that covers weekly weights. On admission, there is a nursing task called safety assessment. The safety assessment is a set of assessments bundled into one task. One of the assessments within the safety assessment is the Nutritional Assessment, which includes patient weight/ height/ BMI. This task is then presented automatically on a weekly basis following admission. Weights and heights are then viewable in iView for all staff within the Trust”

    Source location

    2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
    Page 2 · response
    Published 18 March 2020

    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

    Provide an electronic medicines-management order for recording patient weights at a specified frequency.

    Verbatim wording from the response

    “- Additionally, the electronic medicines management system has recently implemented a new way in which to get weights onto the system. There is now an order on the system that can be ordered to any desired frequency. This needs to be completed from the drug chart. Once completed in the drug chart the weights are viewable in iView as well.”

    Source location

    2020-0054-Response-from-Lewisham-and-Greenwich-NHS-Trust.-Redacted
    Page 2 · response
    Published 18 March 2020

    Open published response

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