Recurring concern
Incomplete clinical history-taking
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Request correctionFirst reported 31 Mar 2014•Latest report 31 Oct 2025
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
- Individual concerns
- 58
- Date range
- 2014–2025
- Stated actions
- 96
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 obtain collateral healthcare information from other trusts on hospital admission
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
Communicate to inpatient staff how to access external shared-link records for collateral information.
Stated by North East London NHS Foundation Trust -
Action
Amend the electronic admission checklist to prompt staff to identify other Trust involvement and obtain collateral information.
Stated by North East London NHS Foundation Trust -
Action
Send a further reminder to medical and nursing staff to obtain collateral information at the earliest opportunity.
Stated by North East London NHS Foundation Trust
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Concerns raised1
Failure to enable relevant family input during emergency mental health assessment
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 consider the circumstances of a fall during clinical assessment
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.
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
Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
Stated by Medway NHS Foundation Trust -
Action
Resume the suspended staff teaching and simulated training programme on elderly trauma care.
Stated by Medway NHS Foundation Trust -
Action
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
Stated by Medway NHS Foundation Trust
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Action
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
Stated by Medway NHS Foundation Trust -
Action
Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
Stated by Medway NHS Foundation Trust
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Concerns raised1
Failure to use a standard set of initial questions during clinical triage
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.
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
Replicating NHS 111’s standard questions for subsequent clinicians is considered unnecessary because the existing assessment and information-sharing process is sufficient.
Stated by NHS England
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Concerns raised1
Failure to establish the timing, quantity and potency of drug consumption
This report raised 17 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 take and consider relevant patient history before discharge
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.
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 elicit relevant information from first responders during 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.
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 obtain previous medical history
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.4
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Action
Request community medical records for newly arrived prisoners within one week.
Stated by NHS England -
Action
Audit healthcare-record requests to verify that the records-request process is effective.
Stated by NHS England -
Action
Run regular SystmOne reports checking whether newly arrived prisoners’ healthcare records have been requested.
Stated by NHS England
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Action
Improve prison healthcare data and intelligence collection and enable information-sharing before, during and after incarceration to support continuity of care.
Stated by Department of Health and Social Care
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
Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.
Stated by Department of Health and Social Care
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Concerns raised1
Failure to enquire about patients’ current or continued illicit drug misuse
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.2
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Action
Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
Stated by West Timperley Medical Centre -
Action
Contact identified patients to update records of their current illicit drug use.
Stated by West Timperley Medical Centre
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Concerns raised1
Failure to account for partial disclosure of symptomology and 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 concernsEach statement is shown once, even when linked to more than one concern.
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
The actions taken regarding partial disclosure were considered reasonable and proportionate, so no further action was identified.
Stated by Herefordshire and Worcestershire Health and Care NHS Trust
Data last updated 7 September 2026