Recurring concern
Unreliable care-planning processes
- Reports that mention this concern
- 120
- Times this concern has been raised
- 141
- Stated actions linked to this concern
- 200
What this concern includes
Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.
What is not included
- Excludes standalone procedural instructions, treatment steps, extubation plans and immediate deterioration-management plans unless the source explicitly identifies them as part of the person's formal care plan.
- Excludes organisational improvement plans, staffing plans and operational contingency plans.
- Excludes discharge planning, risk assessment, family involvement or generic records when that separate control is the concern and formal care-plan reliability is not directly asserted.
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 120 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised2
Lack of management system for checking and ensuring care and behavioural support plans are updated
Failure to update care and behavioural support plans to reflect aggression, risk and risk-reduction measures
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Adept Care Homes Limited
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
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Adept Care Homes Limited
Conduct monthly audits of resident care and behavioural support plans.
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Adept Care Homes Limited
Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.
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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Adept Care Homes Limited
Current arrangements for oversight of care and behavioural support plans are considered appropriate in all the circumstances.
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Concerns raised1
Failure to maintain collaborative, complete and accurate risk assessments and care plans
This report raised 11 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.
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Concerns raised1
Uncertainty about when formal safety plans or care plans should be completed
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Sussex Partnership 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.1
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Sussex Partnership NHS Foundation Trust
Update the Haven Operational Policy to clarify care-plan timing and require recorded care planning from admission.
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Concerns raised1
Lack of care plans addressing identified physical healthcare risks
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- Birmingham and Solihull Mental Health 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.4
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Birmingham and Solihull Mental Health NHS Foundation Trust
Implement Dialog+ Care Planning across inpatient services to document physical-health risks, mitigation actions and review plans.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Strengthen ward-level Dialog+ audits, including checks that physical-health risks have documented action plans and follow-up, with feedback to clinical teams.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Implement and audit Inpatient MDT standards to support follow-up of actions identified in physical-health action plans.
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Birmingham and Solihull Mental Health NHS Foundation Trust
Share learning from the case across inpatient teams on medication-related physical-health risks and documenting risks such as sleep apnoea, obesity and positional asphyxia.
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Concerns raised1
Failure to create and complete required care plans
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Alternative Futures Group Limited
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
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Alternative Futures Group Limited
Require admission care plans, 72-hour manager review, at least monthly named-nurse updates, and monthly audits of care-plan reviews and accuracy.
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Alternative Futures Group Limited
Operate a monthly clinician-led quality and practice development forum to coach and mentor nurses in care-plan best practice.
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Concerns raised1
Failure to produce meaningful mobility care plans
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Barts Health NHS Trust
- Department of Health and Social Care
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
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Barts Health NHS Trust
Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.
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Barts Health NHS Trust
Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.
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Barts Health NHS Trust
Introduce routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.
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Barts Health NHS Trust
Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.
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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Department of Health and Social Care
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
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Concerns raised1
Failure to record and implement support actions in ACCT care plans
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
- HM Prison and Probation Service
Stated actions 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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HM Prison and Probation Service
Implement the Prison Safety Policy Framework requiring ACCT teams to identify, review and record support actions and care-plan decisions.
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HM Prison and Probation Service
Introduce and complete four local ACCT quality-assurance checks covering opening, reviews, complex-case oversight and closure.
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HM Prison and Probation Service
Monitor and upload ACCT assurance findings, sharing them for follow-up through case management and monthly Safety Meetings.
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HM Prison and Probation Service
Implement a single ACCT case-management allocation system assigning open cases to trained Supervising Officers or Custodial Managers.
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HM Prison and Probation Service
Schedule ACCT reviews around allocated coordinators’ duties and use a buddy system to maintain continuity and prevent over-allocation.
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HM Prison and Probation Service
Book refresher training for staff who misunderstood care-plan requirements when prisoners missed reviews.
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HM Prison and Probation Service
Provide one-to-one ACCT coaching to 21 Case Coordinators with support from Safety Leads.
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Concerns raised1
Failure to document capacity appropriately in care plans
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Premiere Health Limited
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
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Premiere Health Limited
Deliver further mental capacity and Mental Capacity Act training to trained staff.
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Premiere Health Limited
Implement a formal mental capacity assessment procedure covering documentation, care-plan recording and best-interest processes.
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Concerns raised1
Failure to complete falls risk assessments and care plans properly
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.
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Concerns raised1
Failure to update and document care plans
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Essex Partnership University 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
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Essex Partnership University NHS Foundation Trust
Mandate and deliver care-planning training for community and primary-care staff.
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Essex Partnership University NHS Foundation Trust
Complete and roll out the organisational Care Planning Framework.
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Essex Partnership University NHS Foundation Trust
Review existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Essex Partnership University NHS Foundation Trust
The concerns reflect professional practice failures rather than a systemic organisational failure of care-planning systems or governance.
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Essex Partnership University NHS Foundation Trust
Clinicians, rather than monitoring systems, remain responsible for identifying clinical-risk changes and initiating out-of-cycle care-plan updates.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026