Recurring concern
Unreliable recording of required observations in care and custody
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Request correctionFirst reported 23 Oct 2013•Latest report 19 May 2026
What this concern includes
Includes failures in recording required patient or prisoner observations, including inaccurate, delayed, anticipatory, incomplete or falsified entries, where records do not reliably reflect the observations performed. Includes paper, electronic and ACCT-related observation records across care and custody settings.
Not included
- Excludes failures to perform or maintain the required observation itself where the recording process is not deficient.
- Excludes unclear observation requirements, observation-level decisions and generic observation assurance or auditing where inaccurate or delayed recording is not the shared unsafe condition.
- Excludes general clinical, care or custody record-keeping deficiencies unrelated to required observations.
- Excludes recording of non-observation activities, such as searches, movements, inspections or clinical decisions, unless the assertion specifically concerns a required observation record.
- Reports
- 83
- Individual concerns
- 90
- Date range
- 2013–2026
- Stated actions
- 181
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 accurately and contemporaneously record patient observations
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.2
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Action
Monitor observation practice and documentation through audits, quality visits, safety huddles, senior reviews, and governance reporting.
Stated by North London NHS Foundation Trust -
Action
Amend the supportive observations policy and observation form to require and record each patient’s exact observation time.
Stated by North London NHS Foundation Trust
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Concerns raised1
Failure to record therapeutic observations accurately and effectively
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
Survey ward Wi-Fi problems and explore and test clinically safe solutions for identified hotspots.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Provide ward desktops and laptops for observation recording and remind staff to document observations while Wi-Fi issues are addressed.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Conduct monthly audits of observation quality, address non-compliance, and report results to the Quality Assurance Group to identify and resolve systemic issues.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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
Moving ward Wi-Fi receivers above ceilings is not currently feasible because it would create a ligature risk.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Concerns raised1
Failure to ensure truthful observation 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.
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 15-minute observations contemporaneously and accurately
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.
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
Contemporaneous ACCT observation recording is not feasible because staff cannot carry the document confidentially or without restricting their response to incidents.
Stated by HM Prison and Probation Service
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Concerns raised3
Falsification of patient observation records
Falsification of observation logs
Failure to further investigate or monitor falsified observation records
This report raised 28 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
Further develop PSIIR support and quality-check tools, including detailed investigation checklists, care-team confirmation and organisational sign-off checks.
Stated by Essex Partnership University NHS Foundation Trust
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 concern is factually incorrect because the 2022 inquest concerned a Derwent Centre patient, not a St Aubyn’s Centre patient.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised2
Failure to record therapeutic engagement and interaction during observations
Failure to require completion of the electronic observation and engagement record field
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.
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
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Action
Shift observation practice toward therapeutic engagement through updated guidance and training.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Check all staff Observation and Engagement competencies and completion of Oxevision e-observation training.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Deliver focused face-to-face training on interpreting observations, recording therapeutic engagement and reflecting on learning.
Stated by Essex Partnership University NHS Foundation Trust
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Action
Share inquest learning with care-unit quality and safety forums and the Training team to strengthen Oxevision engagement and recording training.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Pursue making the electronic engagement field mandatory for level 2, 3 and 4 observations.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review Tendable audit templates within the wider Trust audit-assurance process.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to conduct and record patient observations accurately, sufficiently and therapeutically
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 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
Use board relays to improve observation practices and therapeutic engagement.
Stated by East London NHS Foundation Trust -
Action
Update mobile-phone policy requirements for staff working in clinical areas.
Stated by East London NHS Foundation Trust -
Action
Deliver shared learning to unit staff on mobile-phone use while on duty.
Stated by East London NHS Foundation Trust
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Action
Introduce CCTV auditing of recorded observations after completing staff training on footage access.
Stated by East London NHS Foundation Trust
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
No further action is considered necessary because considerable work has addressed the identified concerns.
Stated by East London NHS Foundation Trust
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Concerns raised1
Failure to carry out and record ACCT observations at unpredictable times
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 all new prison officers with a full day of suicide and self-harm prevention training, including ACCT procedures and observation recording requirements.
Stated by HM Prison and Probation Service -
Action
Provide role-specific ACCT training to staff undertaking key ACCT case-management roles, including assessors and case coordinators.
Stated by HM Prison and Probation Service -
Action
Maintain an online Safety Learning Reference Library with ACCT guidance, templates, training materials and observation-recording resources accessible to staff.
Stated by HM Prison and Probation Service
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Action
Promote the Safety Learning Reference Library to new staff during induction and signpost it to all staff during the next national safety focus initiative.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to record all post-fall observation scores
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.7
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Action
Implement the EnabLE digital care-planning system for scheduled post-fall observations, alerts and point-of-care recording.
Stated by Barchester Healthcare Limited -
Action
Deliver targeted training and supervision on post-fall documentation, escalation, observation recording and lessons learned from the incident.
Stated by Barchester Healthcare Limited -
Action
Provide documentation prompt sheets to support completion of post-fall records.
Stated by Barchester Healthcare Limited
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Action
Continue EnabLE drop-in support, documentation audits and remote monitoring for adherence and learning needs.
Stated by Barchester Healthcare Limited -
Action
Complete NEWS2, RESTORE and sepsis training and themed supervision for recognising deteriorating residents.
Stated by Barchester Healthcare Limited -
Action
Complete induction, including NEWS2 training, for three new bank nurses.
Stated by Barchester Healthcare Limited -
Action
Review the falls policy with clinical staff and reinforce procedures for responding and escalating after falls.
Stated by Barchester Healthcare Limited
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Concerns raised1
Lack of frequent recorded observations for deteriorating 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 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
Complete an urgent assurance check of falls documentation and current AMU patient monitoring.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Explore electronic-health-record dashboard options for real-time observation flagging and escalation alerts.
Stated by North Cumbria Integrated Care NHS Foundation Trust -
Action
Develop a cohort-based care model for admission-ward patients with elevated NEWS2 scores and assess it for wider rollout.
Stated by North Cumbria Integrated Care NHS Foundation Trust
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
Four-hourly observations initially complied with NEWS2 policy because the recorded scores did not trigger increased monitoring, despite later missed observations and escalation failures.
Stated by North Cumbria Integrated Care NHS Foundation Trust
Data last updated 7 September 2026