First reported 1 Aug 2013•Latest report 2 Jun 2026
Definition
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Includes missing, incomplete, unclear, outdated, uncoordinated, unreviewed or unimplemented formal person-level care plans and established named equivalents such as integrated care or care-and-crisis plans.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
Distinct published reports
Individual concerns
141
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
200
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.
Department of Health and Social Care14
Care Quality Commission9
Sussex Partnership NHS Foundation Trust9
Essex Partnership University NHS Foundation Trust7
NHS England7
Ministry of Justice5
Avon and Wiltshire Mental Health Partnership NHS Trust4
Barts Health NHS Trust4
Norfolk and Suffolk NHS Foundation Trust4
North East London NHS Foundation Trust4
Birmingham and Solihull Mental Health NHS Foundation Trust3
Central and North West London NHS Foundation Trust3
Hc-One Limited3
HM Prison and Probation Service3
Office of the Chief Coroner3
NHS trust67
Ministerial department19
Private limited company15
Healthcare site13
Health and social care service regulator9
Residential care home9
Executive non-departmental public body7
Type not available7
Multi-service care provider6
Nursing home6
English county council5
Independent healthcare provider5
Integrated care board4
Prison or young offender institution4
Coronial office3
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.
Wiltshire and Swindon
Concerns raised1
Failure to specify and record timely review points for critically ill patients
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 concerns
Each 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
Update the junior surgical doctors’ handbook to cover delegation responsibilities and documented follow-up plans.
Stated by Great Western Hospitals NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 18 December 2017.
Somerset
Concerns raised1
Insufficient detail in care plans to record safeguarding requirements
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 concerns
Each 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
Action
Ensure CAMHS care plans are explicit and communicate information clearly, with implementation monitored through clinical supervision.
Stated by Somerset NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 27 November 2017.
Action
Continue staff risk training and team meetings to reinforce clear crisis plans explaining supervision requirements to young people and parents.
Stated by Somerset NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 27 November 2017.
Inner North London
Concerns raised2
Failure to detect missing computer records of CPA care plans
Failure to record CPA care plans in the computer system
This report raised 9 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.
Birmingham and Solihull
Concerns raised4
Delays in issuing care plans for children with allergies
Failure to provide issued care plans to the food provider
Lack of care plans for all pupils who require them
Inaccurate care plans
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 concerns
Each 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.6
Action
Review and rectify Health Care Plan inaccuracies, update medical records, and provide signed, dated plans to catering staff.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Action
Establish a Central Medical Register tracking Health Care Plans, medication, medicine locations, outstanding issues, and incomplete actions.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Action
Require written, signed medical notifications, promptly refer them to the SENCO and school nurse, and record notification handling.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Action
Conduct routine half-term checks comparing displayed and catering-held Health Care Plans with the central master list.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Action
Implement allergy lunchtime controls requiring daily pre-orders, allergy-specific meal preparation, staff-supervised collection, and documented communication of allergy information.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Action
Request parental updates on pupils’ medical conditions once each term in addition to annual updates.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathStated completedThe respondent said that this action was complete when they made their response on 2 October 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
The School does not issue Health Care Plans; responsibility for issuing them rests with the Trust’s school nurse.
Stated by Birmingham Community Healthcare NHS Foundation Trust and The Olive School, Small HeathRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
West Sussex
Concerns raised1
Failure to maintain complete, sufficient and consistent nursing records, handovers, risk assessments and care plans
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.
Inner North London
Concerns raised1
Failure to maintain accurate allergy action plans with medication-use instructions
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 An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Promote personalised written emergency plans for anaphylaxis and provide adaptable templates for healthcare professionals.
Stated by The British Society For Allergy & Clinical ImmunologyStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Work with the borough safeguarding team to determine whether school nurses can access the community patient-record system for shared care-plan information.
Stated by The Bromley by Bow Health PartnershipStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
Action
Investigate whether secondary-care anaphylaxis care plans are already in place and used.
Stated by The Bromley by Bow Health PartnershipStated plannedThe respondent said that this action was planned when they made their response on 3 May 2023.
Action
Implement a centralised IHCP database with renewal flags, notifications, data-team management and clinical oversight.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Complete the whole-service IHCP Quality Standards Audit and extend the annual audit schedule to biannual IHCP audits.
Stated by Compass Wellbeing CICStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
Action
Rewrite the IHCPs prepared by the involved nurse at Bow School to correct identified errors.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Implement measures requiring school nurses to follow up and update IHCP meeting actions routinely.
Stated by Compass Wellbeing CICStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Review all pupil Individual Health Care Plans and verify that emergency-box medicines are prescribed and in date.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Implement monitored procedures for arranging and following up Individual Health Care Plan and medication reviews, including senior oversight and deadline reminders.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Use Safeguarding Committee governance, scheduling, spot checks and compliance reporting to monitor Individual Health Care Plans and medicines.
Stated by Bow SchoolStated completedThe respondent said that this action was complete when they made their response on 3 May 2023.
Action
Attach Individual Health Care Plans and medical alerts to electronic pupil records and add allergy alerts to the cashless catering system.
Stated by Bow SchoolStated in progressThe respondent said that this action was in progress when they made their response on 3 May 2023.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Schools share responsibility for preparing and updating IHCPs and ensuring an appropriate school representative attends review meetings.
Stated by Compass Wellbeing CICRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Norfolk
Concerns raised1
Absence of patient care plans
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 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.
Bedfordshire and Luton
Concerns raised1
Lack of sufficiently specific care plans for required assistance
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 concerns
Each 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
Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.
Stated by Ambassador HouseStated plannedThe respondent said that this action was planned when they made their response on 6 March 2017.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.
Stated by Ambassador HouseDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Brighton and Hove
Concerns raised2
Failure to make mobility central to the care plan
Lack of a coherent, considered and reviewed care plan
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 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.
Surrey
Concerns raised1
Lack of structured care plans for each patient
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 concerns
Each 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
Action
Launch the Offender Care Psychosocial Strategy to support psychologically informed care and reduce reliance on dependence-forming medication where appropriate.
Stated by Central and North West London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 26 February 2017.
Action
Provide Best Practice Care Plan training to HMP Highdown staff.
Stated by Central and North West London NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.
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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.
