Recurring concern
Failure to reliably record information and advice given to patients
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Request correctionFirst reported 13 Dec 2008•Latest report 2 Apr 2026
What this concern includes
Includes failures to record, preserve or accurately represent information, advice or safety-relevant instructions given directly to patients during clinical care, including the anchor's unavailable evidence of information given and failures to document advice allegedly given to a patient.
Not included
- Excludes general clinical or care-record deficiencies where the missing or inaccurate information is not information or advice given directly to a patient.
- Excludes failures in the content, appropriateness or accessibility of patient advice where the advice was reliably recorded.
- Excludes failures to communicate information to professionals, families or other third parties unless the assertion also concerns recording information or advice given directly to the patient.
- Excludes generic documentation, staffing or communication deficiencies that do not specifically concern recording patient-facing information or advice.
- Reports
- 12
- Individual concerns
- 12
- Date range
- 2008–2026
- Stated actions
- 16
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Inadequate recording of important discharge advice
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 concernsEach 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
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Action
Use a standardised discharge-summary process with pre-approved #tag advice to reduce variation and inaccurate instructions.
Stated by West Suffolk NHS Foundation Trust -
Action
Train junior doctors during induction to use standardised discharge-summary #tags.
Stated by West Suffolk NHS Foundation Trust -
Action
Assign consultants ownership of discharge processes and require checking and challenging draft discharge letters.
Stated by West Suffolk NHS Foundation Trust
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Action
Rectify digital barriers and implement digital enablers for producing discharge letters.
Stated by West Suffolk NHS Foundation Trust -
Action
Monitor discharge-letter compliance through Clinical Directors and Clinical Leads and discuss the data in governance meetings.
Stated by West Suffolk NHS Foundation Trust
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Concerns raised1
Failure to maintain records providing a full and verifiable account of information and assistance provided
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 concernsEach 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
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Action
Review assessment and documentation practices regularly to support continuous improvement.
Stated by Waythrough Charity (Waythrough
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Position
Records documented signposting to emergency services, the GP, the CRISIS Team and Samaritans at the initial assessment.
Stated by Waythrough Charity (Waythrough
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Position
Initial assessment procedures, including risk assessment, recovery planning and follow-up arrangements, were considered robust and appropriate.
Stated by Waythrough Charity (Waythrough
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Concerns raised1
Failure to record the assessment, discussion and advice about the appropriate telecare package
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 concernsEach 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
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Action
Record all assessments within the main body of the client record system.
Stated by Croydon
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Records contained the Careline risk assessment, signed agreement and installation information documenting advice about the service and its cost.
Stated by Croydon
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Concerns raised1
Failure to record prescribed-drug counselling and safety advice
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 concernsEach 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
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Action
Update the medication counselling SOP to require documentation of every counselling episode and community-support referral on eScript.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Incorporate this case into statutory senior-doctor safe-prescribing training, covering medication counselling, documentation and support for patients who do not understand.
Stated by the Shrewsbury and Telford Hospital NHS Trust -
Action
Take concerns about medication counselling and written records to an appropriate forum for discussion and consideration of necessary actions.
Stated by NHS England
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Concerns raised1
Failure to record information given to patients
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record hospital advice and the person's understanding of that advice
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 concernsEach 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
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Action
Complete refresher training for crew members on documentation standards, checking EPR entries and obtaining signatures for non-conveyance cases.
Stated by West Midlands Ambulance Service University NHS Foundation Trust
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Concerns raised1
Failure of EPR records to accurately reflect information given to patients
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 concernsEach 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
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Action
Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.
Stated by Yorkshire Ambulance Service NHS Trust -
Action
Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.
Stated by Yorkshire Ambulance Service NHS Trust -
Action
Re-audit care-plan documentation after the intervention.
Stated by Yorkshire Ambulance Service NHS Trust
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Action
Develop EPR tick-box indicators to record information left with patients.
Stated by Yorkshire Ambulance Service NHS Trust
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Concerns raised1
Failure to document advice given to patients
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 concernsEach 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
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Action
Put relevant safe-sleeping documentation in place.
Stated by Bolton NHS Foundation Trust
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Concerns raised1
Failure to record changes to medication-taking instructions
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to record advice about inoculation and life-long antibiotic prophylaxis
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026