Recurring concern

Unreliable recording of required observations in care and custody

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First reported 23 Oct 2013•Latest report 19 May 2026

Definition

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

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care8

HM Prison and Probation Service8

Care Quality Commission7

NHS England6

East London NHS Foundation Trust4

Greater Manchester Mental Health NHS Foundation Trust4

Ministry of Justice4

NHS Greater Manchester Integrated Care Board4

University Hospitals Sussex NHS Foundation Trust4

Barts Health NHS Trust3

Essex Partnership University NHS Foundation Trust3

North London NHS Foundation Trust3

Central and North West London NHS Foundation Trust2

Coventry and Warwickshire Partnership NHS Trust2

General Medical Council2

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.

6 Jan2014
Manchester South
Concerns raised1
1. Failure to accurately document custody cell checks
This report raised 12 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 1
1. Action
  Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.
  Stated by Greater Manchester PoliceStated planned
AI-generated summary

Billy Paul Thomas Salton · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Billy Paul Thomas Salton, who had epilepsy and was intermittently non-compliant with his medication, was detained at Cheadle Police Station without initially receiving his medication. He experienced seizures in custody and was later found collapsed in a cell at Stockport Magistrates’ Court; he died after being taken to hospital. The report identified concerns about medication verification and administration, recording and handovers, observation levels and cell checks, custody delays, and the accuracy and communication of medical and escort information.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to accurately document custody cell checks
Wider context from the report
“1. During the course of the evidence I heard that Mr Salton had remained in custody overnight and was not progressed as quickly as he could have been whilst in custody as there was no-one available to interview him. This is as a result of GMP policy on how people are progressed through custody. The Prisoner Processing Unit is not staffed overnight which leads to people being in custody longer than they should be and bringing GMP “up against the requirements of the Police and Criminal Evidence Act”. GMP cannot indicate how many people may have been detained in custody longer than they should have been under their new policy. 2. There was a lack of understanding amongst the custody staff and staff from other agencies as to the level of observations Mr Salton was on and why he was on those observations. It is important that everyone who has care of someone in custody understands what the observations have been, what they should be, when they are to be carried out, whether rousing is required and why the observations are set as they are – i.e. what the medical condition/ concern is. 3. When the deceased is visited and checked all such visits should be accurately recorded on the custody record. 4. Risk assessments carried out whilst in police custody should be recorded when they are done. If there are no changes to a risk assessment then this should be recorded and any rationale noted. 5. Handovers between Custody Sergeants were ineffective and there was no handover between the Civilian Detention Staff. Important information was missed or lost in translation. Proper handovers should take place as to a detained person’s condition, risk assessment, any medical condition, level of visits and other important matters. 6. The Prisoner Escort Form was incorrectly completed. The final Custody Sergeant should ensure that the transferring documentation is accurate. 7. There were no specific instructions to monitor Mr Salton whilst he was in the CCTV cell. The CCTV screen is situated furthest away from the desk where someone in the back office is more likely to be seated (next to the security controls) meaning that there is less likelihood of them “glancing” at the CCTV screen. 1. MEDACS should ensure that all staff are fully aware of the content of any MEDACS policies or protocols, where these can be located in the police station and if necessary receive any required training on the same (the Court heard that ████████ was not aware of the MEDACS Epilepsy Policy). 2. MEDACS should receive a verbal report from Custody Staff and as much information as possible as to the detained person’s medical condition. Even if they are solely to administer medication MEDACS staff should read any previous medical notes from the same stay in custody. 3. All staff are reminded of the need to record information on the MEDACS Assessment Form including completing a Care Plan. Such a form should be completed accurately including any negative answers to questions asked. 4. If a doctor or nurse is unable to complete a medical assessment or is not assessing an individual then this should be explained and any potentially misleading information should not be recorded. 1. Staff should be reminded of the levels of observation (cell checks) required on detained persons whilst in their custody. 2. Staff should be reminded that all cell checks should be accurately documented. 3. GEO AMEY should ensure that their staff have knowledge of and fully read any documentation available when collecting a detained person. This is especially true of any medical information and if there is a medical reason why someone is on a certain level / type of observation that this is replicated whilst in the custody of GEO AMEY. ”
Source location
Billy Paul Thomas Salton · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Provide staff inputs using case studies to reinforce recording risk-assessment rationales and custody actions accurately.

Verbatim wording from the response
“I do agree with this but can see how this can degrade into quite significant events not being accurately recorded. We will, therefore, shortly be giving a series of inputs to staff which will”

Source location
2014-0002-Response-by-Greater-Manchester-Police
Page 2 · response
Published 6 January 2014
Open published response
13 Dec2013
Manchester City
Concerns raised1
1. Failure to complete and record patient observations
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Adapt incident reporting to record Rapid Tranquillisation route and whether required physical and safe observations were maintained.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated in progress
2. Action
  Require contemporaneous, gap-free observation records, countersigning, physical handover, and staff accountability for completion.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated completed
3. Action
  Require nurse-in-charge end-of-shift review of observation records, correction and incident reporting of gaps, with Matron monitoring and policy-compliance audits.
  Stated by Greater Manchester Mental Health NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

STEPHANIE DANIELS · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Stephanie Daniels, who had a history of serious mental health problems and repeated self-harm, was admitted to the Safire unit on 22 March 2012 after a delay in securing an inpatient bed. She died there on 24 March 2012 after being found unconscious with a ligature around her neck. The principal concerns included inadequate observation and handover, failure to clerk her in, medication-recording and supervision problems, failures in the emergency response, and deficiencies in the subsequent internal investigation.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete and record patient observations
Wider context from the report
“8. Performing and recording observations on other patients I was concerned about the discovery of incomplete written observations for another patient where there are significant gaps in the records and may illustrate a systemic problem because the patient was transferred to a different ward. This was only discovered during the course of the inquest and was brought to the attention of MHSC so that they could carry out their own investigations. ”
Source location
STEPHANIE DANIELS · Prevention of Future Deaths report
Page 10 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Adapt incident reporting to record Rapid Tranquillisation route and whether required physical and safe observations were maintained.

Verbatim wording from the response
“████████ Interim Medical Director, will ensure that all trainees will be informed about the Rapid Tranquillisation protocol through the induction process. In addition, consultants will be made aware of their responsibilities in respect of supervision of junior doctors prescribing. The Trust has amended the prescription card to ensure that Rapid Tranquillisation is clearly identifiable and not confused with PRN (as necessary) medication. The Trust incident reporting system is being adapted to record whether Rapid Tranquillisation was administered intramuscularly or orally and whether physical / safe observations were maintained in line with Trust policy. This is monitored through induction attendance records, pharmacy daily monitoring of prescriptions and Datix incident reporting.”

Source location
2013-0353-Response-by-Manchester-Mental-Health-NHS
Page 2 · response
Published 13 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require contemporaneous, gap-free observation records, countersigning, physical handover, and staff accountability for completion.

Verbatim wording from the response
“I share your concern about incomplete observation forms and the Head of Nursing has instructed staff that observation record forms must be completed contemporaneously and without any gaps. In addition, the nurse in charge must review the observations records during and at the end of the shift and ensure any gaps are addressed and reported through the Datix incident reporting system. The Matrons will monitor the recording of observations and the Trust will audit the compliance with the Safe and Supportive Observation policy.”

Source location
2013-0353-Response-by-Manchester-Mental-Health-NHS
Page 3 · response
Published 13 December 2013
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Require nurse-in-charge end-of-shift review of observation records, correction and incident reporting of gaps, with Matron monitoring and policy-compliance audits.

Verbatim wording from the response
“I share your concern about incomplete observation forms and the Head of Nursing has instructed staff that observation record forms must be completed contemporaneously and without any gaps. In addition, the nurse in charge must review the observations records during and at the end of the shift and ensure any gaps are addressed and reported through the Datix incident reporting system. The Matrons will monitor the recording of observations and the Trust will audit the compliance with the Safe and Supportive Observation policy.”

Source location
2013-0353-Response-by-Manchester-Mental-Health-NHS
Page 3 · response
Published 13 December 2013
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Trust-level policy and procedural concerns are assigned to the NTDA and Manchester Health and Social Care Trust.

Verbatim wording from the response
“As many of the concerns you raise are issues to be dealt with at Trust level, I have ensured that your concerns have been sent to the National Trust Development Authority (NTDA) which provides support, oversight and governance for all NHS Trusts. The NTDA is in contact with MHSCT Trust and has received an action plan which seeks to address the points you have raised.”

Source location
2013-0353-Response-by-Department-of-Health
Page 1 · response
Published 13 December 2013
Open published response
23 Oct2013
Inner North London
Concerns raised1
1. Lack of clarity in nursing observation records
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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John Frank Henry LANSDOWNE · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

John Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of clarity in nursing observation records
Wider context from the report
“1. The jury found that the times observations of Mr Lansdowne took place in the 45 minutes preceding his discovery were unclear, despite a nursing observation record setting these out. ”
Source location
John Frank Henry LANSDOWNE · Prevention of Future Deaths report
Page 2 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to accurately document custody cell checks

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

Concerns raised1

Failure to complete and record patient observations

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of clarity in nursing observation records

Actions described in response 1

Actions described in response 3

Respondent positions 1