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Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.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
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.
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
Conduct monthly audits of resident care and behavioural support plans.
Stated by Adept Care Homes Limited -
Action
Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.
Stated by Adept Care Homes Limited
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
Current arrangements for oversight of care and behavioural support plans are considered appropriate in all the circumstances.
Stated by Adept Care Homes Limited
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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.
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
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.
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
Update the Haven Operational Policy to clarify care-plan timing and require recorded care planning from admission.
Stated by Sussex Partnership NHS Foundation Trust
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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.
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
Implement Dialog+ Care Planning across inpatient services to document physical-health risks, mitigation actions and review plans.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Strengthen ward-level Dialog+ audits, including checks that physical-health risks have documented action plans and follow-up, with feedback to clinical teams.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust -
Action
Implement and audit Inpatient MDT standards to support follow-up of actions identified in physical-health action plans.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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Action
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.
Stated by Birmingham and Solihull Mental Health NHS Foundation Trust
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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.
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
Require admission care plans, 72-hour manager review, at least monthly named-nurse updates, and monthly audits of care-plan reviews and accuracy.
Stated by Alternative Futures Group Limited -
Action
Operate a monthly clinician-led quality and practice development forum to coach and mentor nurses in care-plan best practice.
Stated by Alternative Futures Group Limited
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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.
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
Deliver targeted falls-prevention education through ward teaching, safety huddles, induction and refresher training.
Stated by Barts Health NHS Trust -
Action
Require ward managers and nurses in charge to review new admissions each shift for completed falls assessments and care plans.
Stated by Barts Health NHS Trust -
Action
Introduce routine ward-level audits of falls assessments and care plans, with governance escalation, tracked actions and re-audit.
Stated by Barts Health NHS Trust
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Action
Implement a multidisciplinary falls quality-improvement programme covering footwear, medication review and post-fall multidisciplinary review.
Stated by Barts Health 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
NHS England, which oversees the issues raised, is responsible for responding directly to the Prevention of Future Deaths report.
Stated by Department of Health and Social Care
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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.
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.7
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Action
Implement the Prison Safety Policy Framework requiring ACCT teams to identify, review and record support actions and care-plan decisions.
Stated by HM Prison and Probation Service -
Action
Introduce and complete four local ACCT quality-assurance checks covering opening, reviews, complex-case oversight and closure.
Stated by HM Prison and Probation Service -
Action
Monitor and upload ACCT assurance findings, sharing them for follow-up through case management and monthly Safety Meetings.
Stated by HM Prison and Probation Service
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Action
Implement a single ACCT case-management allocation system assigning open cases to trained Supervising Officers or Custodial Managers.
Stated by HM Prison and Probation Service -
Action
Schedule ACCT reviews around allocated coordinators’ duties and use a buddy system to maintain continuity and prevent over-allocation.
Stated by HM Prison and Probation Service -
Action
Book refresher training for staff who misunderstood care-plan requirements when prisoners missed reviews.
Stated by HM Prison and Probation Service -
Action
Provide one-to-one ACCT coaching to 21 Case Coordinators with support from Safety Leads.
Stated by HM Prison and Probation Service
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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.
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
Deliver further mental capacity and Mental Capacity Act training to trained staff.
Stated by Premiere Health Limited -
Action
Implement a formal mental capacity assessment procedure covering documentation, care-plan recording and best-interest processes.
Stated by Premiere Health Limited
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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.
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 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.
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
Mandate and deliver care-planning training for community and primary-care staff.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Complete and roll out the organisational Care Planning Framework.
Stated by Essex Partnership University NHS Foundation Trust -
Action
Review existing EPR capability for consolidated personalised-care and safety-planning records and update standard operating procedures.
Stated by Essex Partnership University NHS Foundation Trust
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 concerns reflect professional practice failures rather than a systemic organisational failure of care-planning systems or governance.
Stated by Essex Partnership University NHS Foundation Trust
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Position
Clinicians, rather than monitoring systems, remain responsible for identifying clinical-risk changes and initiating out-of-cycle care-plan updates.
Stated by Essex Partnership University NHS Foundation Trust
Data last updated 7 September 2026