Recurring concern
Unreliable care-planning processes
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Request correctionFirst reported 1 Aug 2013•Latest report 2 Jun 2026
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Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.
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.
- Reports
- 120
- Individual concerns
- 141
- Date range
- 2013–2026
- Stated actions
- 200
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 raised2
Failure to widely circulate care plans to involved professionals
Failure to draw up appropriate multi-agency care plans
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.1
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Action
Produce and prominently issue a reflective training vignette through the internal safety alert system, requiring confirmation of action and monitoring implementation through supervision and appraisal.
Stated by Avon and Wiltshire Mental Health Partnership NHS 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 revision of existing policies, systems or procedures was considered necessary in light of the deaths.
Stated by Avon and Wiltshire Mental Health Partnership NHS Trust
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Concerns raised1
Lack of joined-up care and discharge planning in the Acute Medical Unit
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.
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 records show suitable care and treatment were provided, with discharge arrangements planned and coordinated.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Failure to document care plans for family members undertaking care obligations
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 prepare care plans for patients at high risk of pressure sore formation
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.
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
Birmingham Cross City CCG commissions the service and is undertaking work to address the identified care deficiencies.
Stated by NHS England
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Concerns raised1
Failure to provide appropriate care plans addressing the risks of refused urine and blood glucose testing
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.
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
Testing patients who refuse blood or urine samples is constrained by the practical difficulty and unpleasantness of restraint.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Infrequent review of feeding regimes in care plans
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 ensure identified vulnerable patients possess care plans
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.
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 complete patient care plans
This report raised 24 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 documentation more closely and provide nurses with real-time feedback.
Stated by University Hospitals Sussex NHS Foundation Trust -
Action
Review and condense Acute Medical Unit documentation into multidisciplinary paperwork that directs care and reduces duplication.
Stated by University Hospitals Sussex NHS Foundation Trust
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Concerns raised1
Care plans failing to specify swallowing-risk management measures
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.
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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Position
The agency disputes being informed of the SALT assessment, choking risk, or recommendations requiring food preparation and meal supervision.
Stated by John Stanley’s Care Agency
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Position
The agency says it could not supervise eating within the 30-minute visit while completing the existing personal-care tasks without additional allocated time.
Stated by John Stanley’s Care Agency
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Concerns raised1
Failure to document and revise continuing care plans when engagement assumptions change
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.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
Data last updated 7 September 2026