Recurring concern
Unreliable recording of safety-critical mental health information
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Request correctionFirst reported 18 Aug 2014•Latest report 27 May 2026
What this concern includes
Includes failures in mental health or related care processes to accurately record, update or retain clinically or safety-relevant mental health information, including risk history, significant concerns, care-relevant objections and other information needed by staff making later decisions.
Not included
- Excludes generic clinical or care record deficiencies where the information is not specifically mental health or mental-health-risk information.
- Excludes failures to communicate or share accurately recorded information where the recording process itself was reliable.
- Excludes failures in mental health assessment, treatment, referral or follow-up where no deficiency in recording safety-critical mental health information is identified.
- Excludes routine administrative information and non-safety-relevant mental health notes.
- Reports
- 51
- Individual concerns
- 54
- Date range
- 2014–2026
- Stated actions
- 61
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
Failure to record the timing and rationale for returning usual clothing after ligature risk
This report raised 18 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
Review and document MDT decisions on anti-ligature clothing and bedding through regular MDT and ward-review processes.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised2
Failure to accurately record changes in mental health diagnosis in discharge summaries
Failure to record changes in mental health diagnosis in Psychology records
This report raised 6 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 document risk assessments
This report raised 5 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
Incomplete mental health care records
This report raised 7 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
Take forward MDT learning on documenting and escalating inconsistencies between clozapine assays, adherence reports and clinical stability.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Continue the Record Keeping Safety Improvement Programme to improve documentation-related patient safety through learning and regular review.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Develop clinical record-keeping guidance defining the characteristics of a good clinical record.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Discuss case-related record-keeping requirements with service leads and task service managers with reinforcing their importance to staff.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to record the rationale for mental health assessment decisions
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 the rationale for decisions not to detain following mental health assessments
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
Transfer Mental Health Act assessment recording from RIO to Mosaic to enable inclusion in the audit programme.
Stated by Cornwall Council
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Concerns raised1
Failure to accurately record contact and suicidal ideation in mental health records
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
Deliver focused SystmOne training on recording suicidal ideation and review template completion fields with Mental Health Practitioners.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to record detailed information about detained persons’ mental health concerns
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.4
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Action
Provide custody staff with instruction and learning on recording detainees’ mental-health concerns through the Custody Newsletter, Custody Compendium and direct reminders to Custody Sergeants.
Stated by Northumbria Police -
Action
Review and update CJLD guidance for recording screening assessments, mental-health concerns, risks, clinical reasoning, referrals and handovers on electronic custody records.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust -
Action
Circulate the updated operating procedure and train CJLD staff on required electronic-record entries and verbal handover documentation.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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Action
Conduct monthly random audits of every CJLD staff member’s screening records and discuss audit outcomes in monthly clinical supervision to monitor implementation.
Stated by Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust
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Concerns raised1
Poor documentation of mental health assessment content
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
Provide paper copies of clinical templates for use when electronic templates are inaccessible.
Stated by gtd healthcare
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
Concerns about care and documentation should be addressed by the provider, rather than NHS England or the CQC.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to highlight recent mental-health and self-harm risk information in medical records for clinical assessment
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.3
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Action
Ensure TAG referrals and healthcare applications are added to and visible in SystmOne.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Reinforce reviewing recent electronic patient-record activity before assessment or intervention through incident-meeting messages, governance dissemination, management reminders and supervision.
Stated by Midlands Partnership University NHS Foundation Trust -
Action
Document patient concerns in SystmOne so subsequent staff can identify raised concerns and plan care and treatment to mitigate risk.
Stated by Midlands Partnership University NHS Foundation Trust
Data last updated 7 September 2026