Recurring concern

Failure to reliably record information and advice given to patients

First to latest report 13 Dec 2008 — 2 Apr 2026

Reports that mention this concern
12
Times this concern has been raised
12
Stated actions linked to this concern
16

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.

What is 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 and published responses 12 reports

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

  1. 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 record conclusions and advice from earlier calls

    Wider context from the report

    “5. It was not possible at the inquest to review what details were recorded. I was concerned that details of earlier calls may not contain the conclusion and advice given to the patient. This information may be of significant assistance to ensure that if the patient calls again, appropriate care and advice is given. ”

    Source location

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

    Open source report

  2. Buckinghamshire

    AI-generated summary

    Heather Beatrice Planner · 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

    Heather Beatrice Planner died at Wycombe Hospital on 1 April 2019 from a gastrointestinal bleed in the context of large bowel ischaemia. The report states that she had not received her prescribed apixaban anticoagulation at home for two days before admission, and identifies concerns about medication administration, communication and record-keeping processes for carers, as well as the subsequent 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

    Failure to record mobile-phone medication instructions and changes in patient records

    Wider context from the report

    “(4) There does not appear to be a system for recording on a patient’s records specific medication instructions or changes to medication which might have been given or taken by mobile phone. ”

    Source location

    Heather Beatrice Planner · 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