First reported 31 Mar 2014•Latest report 31 Oct 2025
Definition
What this concern includes
Includes failures to obtain a sufficiently complete and relevant patient history during clinical assessment, consultation, admission, clerking or health checks, including failure to elicit relevant information from the patient or appropriate informants.
Not included
Excludes failures limited to recording or documenting information that was already obtained, unless the report also identifies incomplete history-taking.
Excludes failures limited to communicating or handing over an already established history, unless the underlying history was not adequately obtained.
Excludes deficiencies in treatment, referral, escalation or testing where incomplete history-taking is not itself the recurring unsafe condition.
Reports
55
Distinct published reports
Individual concerns
58
A report can raise multiple concerns
Date range
2014–2025
First to latest report issue date
Stated actions
96
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.
NHS England11
Department of Health and Social Care6
North East London NHS Foundation Trust4
Barts Health NHS Trust3
Care Quality Commission3
Hampshire and Isle of Wight Healthcare NHS Foundation Trust3
Manchester University NHS Foundation Trust3
General Medical Council2
Greater Manchester Mental Health NHS Foundation Trust2
Medway NHS Foundation Trust2
Ministry of Justice2
North London NHS Foundation Trust2
Royal College of Emergency Medicine2
Royal College of Paediatrics and Child Health2
Surrey and Borders Partnership NHS Foundation Trust2
NHS trust38
Executive non-departmental public body11
Healthcare site8
Ministerial department7
Multi-service care provider4
Prison or young offender institution4
Health and social care service regulator3
Integrated care board3
Local health board3
Health and care professional regulator2
Health professional body2
Police force2
Professional body2
Coronial office1
English county council1
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.
Inner North London
Concerns raised2
Failure to elicit smoking status and family history of ischaemic heart disease in the emergency department
Failure to elicit relevant family medical history
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
Update the NHS health-check template to record negative family history of ischaemic heart disease.
Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Action
Expand family-history updates to annual chronic-disease checks, medication reviews, ECG appointments and standardised templates.
Stated by Church Lane SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
Action
Begin updating ischaemic-heart-disease family histories for all patients aged over 25 and inform patients about voluntary updates at registration.
Stated by Church Lane SurgeryStated in progressThe respondent said that this action was in progress when they made their response on 6 November 2023.
Action
Train staff to collect and accurately record family-history information in the clinical system.
Stated by Church Lane SurgeryStated completedThe respondent said that this action was complete when they made their response on 6 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Additional smoking and family-history information would not have triggered rapid access chest pain clinic referral under the HEART scoring system.
Stated by London North West University Healthcare NHS TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The established HEART-based chest pain pathway and cardiology governance were considered sufficient to determine appropriate rapid access chest pain referrals.
Stated by London North West University Healthcare NHS TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
The acute chest symptoms were appropriately investigated and safety-netted regardless of recorded cardiovascular risk factors.
Stated by Church Lane SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The family history was not disclosed during prior consultations, so it was unavailable for consideration in risk assessment and prescribing.
Stated by Church Lane SurgeryDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Hampshire, Portsmouth and Southampton
Concerns raised1
Lack of structured arrival handover and risk-history enquiry for detained patients
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 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
Work with Portsmouth Hospitals University NHS Trust and continue supporting developments addressing emergency-department handover and shared patient care arrangements.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Review the standardised handover, triage and risk-assessment approach to ensure self-harm and absconding risks are considered at handover.
Stated by Portsmouth Hospitals University NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 13 November 2023.
Action
Meet with Solent NHS Trust to review transfer-of-care priorities, including clinician-to-clinician discussion before Emergency Department transfer.
Stated by Portsmouth Hospitals University NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 November 2023.
Action
Agree an implementation timeline with Solent NHS Trust for its electronic handover system.
Stated by Portsmouth Hospitals University NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 13 November 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Solent NHS Trust is developing the electronic handover system, with implementation timing to be agreed jointly.
Stated by Portsmouth Hospitals University NHS TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Hampshire, Portsmouth and Southampton
Concerns raised1
Failure to incorporate family concerns and available information into ongoing treatment and clinical assessment
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 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.6
Action
Progress Triangle of Care accreditation from Star 2 toward Star 3.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Action
Introduce Esther Improvement Coaches to reinforce person-centred carer and family engagement.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 11 December 2023.
Action
Employ carer leads, honorary carer leads and dedicated Carer Support Workers across the Trust.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Embed information-sharing principles through policies, protocols, annual information-governance training and carer materials.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Expand feedback routes through carer groups, forums, storytelling events, surveys and a funded BAME carers group.
Stated by Hampshire and Isle of Wight Healthcare NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 11 December 2023.
Action
Maintain an ongoing focus on improving engagement with families and carers using learning from this case.
Stated by NHS Hampshire and Isle of Wight Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 December 2023.
Swansea and Neath Port Talbot
Concerns raised1
Difficulty obtaining an accurate clinical picture from patients with learning disabilities
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
East London
Concerns raised1
Lack of thorough history taking and verification of baseline oxygen saturation
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.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Inner West London
Concerns raised1
Failure by SGH doctors to take a reasonable psychiatric history during clerking
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Surrey
Concerns raised1
Failure to undertake a detailed history and full neurological examination in general practice
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.2
Action
Ask colleagues from seven NHS regions to share learning and available guidance with Integrated Care Boards for cascading to relevant healthcare professionals.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 31 March 2023.
Action
Replace the epilepsy guideline with updated recommendations on referral and information and support after a first seizure.
Stated by National Institute for Health and Care ExcellenceStated completedThe respondent said that this action was complete when they made their response on 31 March 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
NICE is responsible for producing clinical guidance on the diagnosis, treatment and management of febrile seizures.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing national guidance is considered sufficient for managing febrile seizures.
Stated by NHS EnglandExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Existing national guidance and the Clinical Knowledge Summary are considered sufficient to support timely assessment, investigation and referral for febrile seizures.
Stated by National Institute for Health and Care ExcellenceExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
RCEM will not lead development of further guidance because the project would be a significant undertaking, but can contribute with other organisations.
Stated by Royal College of Emergency MedicineUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
County Durham and Darlington
Concerns raised1
Failure to ask about family history of sudden cardiac death during reception health screening
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 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.1
Action
Refresh the secondary health screening template to add a specific prompt about family history of sudden cardiac death.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 24 January 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
No specific read code for sudden death syndrome is provided because there is no evidence supporting screening for the condition.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East London
Concerns raised1
Failure to account for learning disability when taking a clear clinical history
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 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.8
Action
Require CQC-registered service providers to ensure employees receive role-appropriate learning disability and autism training.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Make the first e-learning component of Oliver McGowan Mandatory Training available.
Stated by Department of Health and Social CareStated completedThe respondent said that this action was complete when they made their response on 23 September 2022.
Action
Publish a Code of Practice covering mandatory training requirements, content, delivery, monitoring and evaluation.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Action
Carry out a public consultation on the Code of Practice for mandatory learning disability and autism training.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Action
Apply a vulnerable-patient flag to all emergency-department patients with a learning disability.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Action
Require senior-clinician discussion and early review for all emergency-department patients with a learning disability through the SOP and induction package.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Action
Provide learning-disability training for hospital specialties during governance days.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Action
Add a learning-disability section to statutory and mandatory training.
Stated by Barts Health NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 23 September 2022.
Leicester City and South Leicestershire
Concerns raised1
Inadequate questionnaire on the person's medical history
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 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
Establish high-level principles for safe remote consultations and online prescribing with healthcare organisations.
Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Launch a call for evidence on remote consultations and prescribing to assess whether existing guidance remained appropriate for changing practice and technology.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Action
Publish updated prescribing guidance covering remote consultation suitability, information sharing, patient dialogue, and safeguards for controlled or potentially addictive medicines.
Stated by General Medical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 November 2021.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Online consultations and prescribing without face-to-face assessment can be safe where appropriate safeguards, history-taking, GP engagement and monitoring exist.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
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Includes failures to obtain a sufficiently complete and relevant patient history during clinical assessment, consultation, admission, clerking or health checks, including failure to elicit relevant information from the patient or appropriate informants.
