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 record observations following changes in patient presentation
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
Develop and share a learning-from-experience poster with community nursing teams on observations, deterioration recognition and documentation.
Stated by Cornwall Partnership NHS Foundation Trust
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Concerns raised1
Failure to accurately record ACCT observation times
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
Implement an ACCT assurance procedure with supervising-officer allocation, daily observation checks and escalation of discrepancies.
Stated by HM Prison and Probation Service -
Action
Provide two ACCT safety Floorwalkers to deliver regular staff upskilling on accurate observation completion.
Stated by HM Prison and Probation Service -
Action
Display ACCT V6 observation posters in wing offices and produce staff guides.
Stated by HM Prison and Probation Service
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Concerns raised1
Failure to maintain accurate and reliable observation records
This report raised 14 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
Reinforce observation-record training, audit records and address compliance in supervision.
Stated by North East London NHS Foundation Trust -
Action
Review electronic-observation functionality.
Stated by North 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
Concerns about care provision and coordination are mainly for the NHS Trust to address.
Stated by Department of Health and Social Care
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Concerns raised1
Failure of 1:5 observation records to evidence five-minute checks
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.3
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Action
Adopt five-minute observation recording sheets and audit completion at least weekly.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Review observation policy and practices against best-practice standards, guidance and potential digital innovations.
Stated by Greater Manchester Mental Health NHS Foundation Trust -
Action
Develop a staff training package and competency assessment framework for therapeutic observations and engagement.
Stated by Greater Manchester 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
The current observation policy already requires signatures every five minutes, with completion audited weekly by the ward manager.
Stated by Greater Manchester Mental Health NHS Foundation Trust
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Concerns raised2
Disconnect between observation policy, staff instructions and pre-printed recording forms
Failure to record the patient’s actual presentation during observations
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
Replace hospital observation forms with two centralised forms used across all Inmind hospitals.
Stated by Inmind Healthcare Group -
Action
Update the Inmind Observations Policy to require centralised forms and compliance with national NHS standards.
Stated by Inmind Healthcare Group -
Action
Train HCAs and other staff to complete meaningful observation records, followed by competency assessment.
Stated by Inmind Healthcare Group
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Action
Carry out regular audits of observation-record quality across all Inmind hospitals, overseen by the Group Medical Director.
Stated by Inmind Healthcare Group
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Concerns raised1
Failure to record observations in accordance with policy
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.3
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Action
Deliver ward-specific Safety Day training on clinical risk, care planning, incident learning and therapeutic observations.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Refresh staff understanding of the therapeutic observations policy through competency reassessment.
Stated by Norfolk and Suffolk NHS Foundation Trust -
Action
Review the Therapeutic Observations Policy to consider strengthened training, documentation, ward controls, staff guidance and assurance processes.
Stated by Norfolk and Suffolk NHS Foundation Trust
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Concerns raised1
Failure to keep accurate records of patient observations
This report raised 13 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 accurately record residents’ deteriorating condition and observation results
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.4
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Action
Revise PCS software to remove emotionally charged dropdown terms, require manual presentation descriptions, and reduce reliance on visual icons.
Stated by Kingsley Care Homes Limited -
Action
Provide standardised PCS training through required staff training and centrally accessible induction videos covering recording, assessment, care planning, and changing needs.
Stated by Kingsley Care Homes Limited -
Action
Audit care records routinely at home and head-office levels, including monthly Downham Grange sampling, and feed findings back to relevant staff.
Stated by Kingsley Care Homes Limited
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Action
Provide rolling refresher training reinforcing the requirement to record all care and observations in individual service-user records.
Stated by Kingsley Care Homes Limited
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Concerns raised1
Incomplete recording of vital signs
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.3
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Action
Adopt and implement the Managing a Deteriorating Patient policy, including monitoring and escalation guidance and regular NEWS2 baseline collection.
Stated by Holy Cross Hospital -
Action
Train staff on the Managing a Deteriorating Patient policy after implementation.
Stated by Holy Cross Hospital -
Action
Implement an electronic patient record system requiring measured values instead of narrative descriptions.
Stated by Holy Cross Hospital
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Concerns raised1
Inadequate recording of individual five-minute observations
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.5
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Action
Issue urgent instructions on using and recording intermittent supportive observations.
Stated by Mersey Care NHS Foundation Trust -
Action
Standardize language and roll out recording observations at unpredictable times within five-, ten- or fifteen-minute windows.
Stated by Mersey Care NHS Foundation Trust -
Action
Conduct local audits, spot checks and additional dip audits to verify accurate, random-time recording of supportive observations.
Stated by Mersey Care NHS Foundation Trust
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Action
Revise the Ward Assurance Audit, operate interim recording changes and conduct weekly audits with findings shared through safety and clinical meetings.
Stated by Mersey Care NHS Foundation Trust -
Action
Introduce an electronic system supporting unpredictable-interval supportive observations.
Stated by Mersey Care NHS Foundation Trust
Data last updated 7 September 2026