Recurring concern
Unreliable recording of required observations in care and custody
Pin
Get email alerts
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.
-
Concerns raised1
Failure to complete observation sheets in line with policy
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.
-
Concerns raised1
Failure to record observations
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.1
-
Action
Audit October AMU fall-patient documentation for compliance with neurological observation requirements and identify improvement and support needs.
Stated by Swansea Bay University Local Health Board
-
Concerns raised1
Failure to record prisoner observations immediately or as soon as practicable
This report raised 16 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
-
Action
Issue learning bulletins reinforcing multidisciplinary ACCT reviews, required timescales, written contributions and prompt recording of observations.
Stated by HM Prison and Probation Service
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Position
National policy already requires immediate recording of observations and does not permit prisons to adopt conflicting local policies.
Stated by HM Prison and Probation Service
-
Concerns raised1
Failure to accurately record and calculate neurological or general 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 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.
-
Concerns raised1
Inaccurate recording of patients' positions in bed on observation charts
This report raised 5 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.
-
Concerns raised1
Failure to document post-operative checks
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to complete leave observation charts contemporaneously and consistently
This report raised 15 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
-
Action
Require hourly physical handover of observation charts, with both allocated staff checking that records are complete and accurate.
Stated by Oxford Health NHS Foundation Trust -
Action
Monitor observation-recording practice through the Matron and make the prohibition on prospective or retrospective entries explicit in the revised Observation Policy.
Stated by Oxford Health NHS Foundation Trust -
Action
Require shift coordinators to sign off relevant observation and leave-record sheets before handover.
Stated by Oxford Health NHS Foundation Trust
-
Concerns raised1
Failure to record observations contemporaneously
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.
-
Concerns raised1
Potential inaccurate timing of recorded observations
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Predictable timing of documented observations
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.1
-
Action
Implement unpredictable ACCT observations, remind staff of requirements, and monitor compliance through management checks and document quality assurance.
Stated by National Offender Management Service Equality, Rights and Decency Group
Data last updated 7 September 2026