First reported 7 Feb 2020•Latest report 23 Jun 2025
Definition
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.
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
4
Distinct published reports
Individual concerns
4
A report can raise multiple concerns
Date range
2020–2025
First to latest report issue date
Stated actions
16
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.
49 Marine Avenue Surgery1
Cegedim Healthcare Solutions1
Department of Health and Social Care1
Egton Medical Information Systems Limited1
EMIS Group1
Joint GP IT Committee1
Moorbridge1
NHS England1
NHS North East and North Cumbria Integrated Care Board1
Northumbria Healthcare NHS Foundation Trust1
Queen Elizabeth Hospital, Woolwich1
Stockport NHS Foundation Trust1
The Phoenix Partnership (Leeds) Ltd1
NHS trust2
Company1
Executive non-departmental public body1
Healthcare site1
Health professional committee1
Integrated care board1
Ministerial department1
Multi-service care provider1
Private limited company1
Pupil referral unit / alternative provision1
Sub-organisation1
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.
Northumberland
Concerns raised1
Lack of one accessible system for weights, heights and BMI
This report raised 9 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.5
Action
Develop improved information-sharing strategies across primary care, secondary care, schools, mental health services and social care, including exploring monthly multidisciplinary meetings.
Stated by 49 Marine Avenue GP Surgery (NPC SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
Action
Deliver a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 14 July 2025.
Action
Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.
Stated by Northumbria Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 14 July 2025.
Action
Continue reviewing clinical systems and digital platforms to streamline central reporting and interoperability of height and weight measurements.
Stated by Northumbria Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 July 2025.
West Yorkshire Eastern
Concerns raised1
Failure of general practice IT systems to validate or challenge potential data input errors at the point of entry
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.4
Action
Maintain point-of-entry validation restricting extreme height, weight and calculated BMI values in SystmOne.
Stated by The Phoenix Partnership (Leeds) LtdStated completedThe respondent said that this action was complete when they made their response on 29 April 2024.
Action
Contact NHS England separately about validation of calculated BMI data in GP IT systems.
Stated by The Phoenix Partnership (Leeds) LtdStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Action
Ask NHS England to consider coordinating funded clinical-safety workshops to document causes, identify controls and define professional requirements for safer system behaviour.
Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Action
Ask NHS England to report to the Joint GPIT Committee on addressing the concerns through changes to existing supplier-contract standards and capabilities.
Stated by Royal College of General PractitionersStated plannedThe respondent said that this action was planned when they made their response on 29 April 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.8
Position
Existing EMIS Web functionality is sufficient to mitigate the specific data-entry risk, so no further software development is required.
Stated by EMIS GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
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.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Cross-domain validation of automatically calculated BMI is not currently implementable, and implementation would present substantial challenges and further clinical risks requiring balanced assessment.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
SystmOne already validates height, weight and BMI ranges, and must permit unusually high BMI values when clinically accurate.
Stated by The Phoenix Partnership (Leeds) LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Any additional BMI validation requirements should be set nationally by NHS England to ensure consistency across GP systems.
Stated by The Phoenix Partnership (Leeds) LtdRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Age-sensitive BMI functionality has not been developed because it is not currently required under NHS framework agreements.
Stated by Cegedim Healthcare SolutionsUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Building validation of multiple GP-record data items was not feasible within the Covid-19 programme’s speed, safety and delivery constraints.
Stated by Royal College of General PractitionersUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Completely preventing entry of a BMI of 68.97 may not be appropriate, limiting use of exclusion thresholds as a data-entry control.
Stated by Royal College of General PractitionersUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Manchester South
Concerns raised1
Failure to calculate and identify inaccurate BMI measurements
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
Action
Provide mandatory MUST screening training at induction and every three years, and report compliance across the Trust.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Develop and cascade a standardised nutrition and MUST briefing covering malnutrition, assessments, food charts and protected mealtimes.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Conduct twice-weekly Matron quality assurance checks of nutrition assessments, fluid-balance charts and documentation standards.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Run Malnutrition Awareness Week activities including MUST audits, nutritional nurse drop-in sessions and speech and language therapy presentations.
Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Inner South London
Concerns raised1
Lack of a systematic process for recording weights
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
Action
Implement a trust-wide electronic patient record enabling staff to record and view patient weights electronically.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Action
Operate a systematic weekly weight assessment process after admission, with weights and heights visible to Trust staff.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
Action
Provide an electronic medicines-management order for recording patient weights at a specified frequency.
Stated by Lewisham and Greenwich NHS TrustStated completedThe respondent said that this action was complete when they made their response on 18 March 2020.
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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.
