Recurring concern
Incomplete clinical history-taking
- Reports that mention this concern
- 55
- Times this concern has been raised
- 58
- Stated actions linked to this concern
- 96
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.
What is 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.
Trends
Reports over time
Reports mentioning this concern, 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.
Reports and published responses 55 reports
See individual reports that have raised this concern, and the actions taken in response
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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.
Linked response
- North East London NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
North East London NHS Foundation Trust
Communicate to inpatient staff how to access external shared-link records for collateral information.
-
North East London NHS Foundation Trust
Amend the electronic admission checklist to prompt staff to identify other Trust involvement and obtain collateral information.
-
North East London NHS Foundation Trust
Send a further reminder to medical and nursing staff to obtain collateral information at the earliest opportunity.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked response
- Medway NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
-
Medway NHS Foundation Trust
Deliver staff teaching and simulated training on evidence-based trauma care for elderly patients.
-
Medway NHS Foundation Trust
Resume the suspended staff teaching and simulated training programme on elderly trauma care.
-
Medway NHS Foundation Trust
Implement ED silver trauma screening for frail patients with low-energy trauma, including senior-clinician assessment where red flags require escalation.
-
Medway NHS Foundation Trust
Adopt the London Major Trauma System elderly-trauma screening and triage pathway prompting immediate senior-doctor assessment.
-
Medway NHS Foundation Trust
Provide a specialist-nurse front-door team to assess frail elderly patients arriving in ED and expedite transfer, escalation or discharge.
-
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.
Linked response
- NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
NHS England
Replicating NHS 111’s standard questions for subsequent clinicians is considered unnecessary because the existing assessment and information-sharing process is sufficient.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
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.
Linked responses
- Department of Health and Social Care
- NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
-
NHS England
Request community medical records for newly arrived prisoners within one week.
-
NHS England
Audit healthcare-record requests to verify that the records-request process is effective.
-
NHS England
Run regular SystmOne reports checking whether newly arrived prisoners’ healthcare records have been requested.
-
Department of Health and Social Care
Improve prison healthcare data and intelligence collection and enable information-sharing before, during and after incarceration to support continuity of care.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Department of Health and Social Care
Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.
-
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.
Linked response
- West Timperley Medical Centre
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
West Timperley Medical Centre
Search the clinical system regularly for patients receiving regular opiate analgesia or Pregabalin who have a history of drug misuse.
-
West Timperley Medical Centre
Contact identified patients to update records of their current illicit drug use.
-
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.
Linked response
- Herefordshire and Worcestershire Health and Care NHS Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Herefordshire and Worcestershire Health and Care NHS Trust
The actions taken regarding partial disclosure were considered reasonable and proportionate, so no further action was identified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026