Recurring concern
Unreliable documentation of clinical triage decisions and advice
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Request correctionFirst reported 6 Apr 2016•Latest report 19 Mar 2025
What this concern includes
Includes failures within a clinical triage process to record calls, advice, discussions, decisions, rationale, actions or outcomes, including triage-team calls and Single Point of Access triage meetings, where missing or inadequate documentation can impair subsequent clinical decision-making or continuity of care.
Not included
- Excludes generic clinical or care-record deficiencies where the undocumented material is not part of a clinical triage process.
- Excludes failures in the quality of triage decisions, urgency recognition or escalation when the triage documentation itself is not deficient.
- Excludes documentation of non-clinical calls, administrative enquiries or unrelated operational processes.
- Excludes failures limited to communicating or implementing a triage decision after the decision and its rationale were reliably documented.
- Reports
- 9
- Individual concerns
- 11
- Date range
- 2016–2025
- Stated actions
- 6
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 document Single Point of Access triage discussions, decisions and actions in patient health records
Failure to document Single Point of Access meeting records and decisions
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.
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
Implement the SPOAA Referral Checklist across the division for all SPOAA meetings.
Stated by Betsi Cadwaladr University LHB
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Concerns raised1
Incomplete triage documentation
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.
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Concerns raised1
Failure to complete the Triage Tool at every Crisis Team contact
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.4
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Action
Embed the national triage tool through practitioner induction, staff education, and trained senior-practitioner completion of triages.
Stated by The Trust -
Action
Audit triage-tool use and documentation monthly through QA5 and review compliance in clinical supervision and quality-assurance processes.
Stated by The Trust -
Action
Induct current and new crisis-team practitioners in crisis processes, triage-tool use and the rationale for senior-practitioner triage.
Stated by Tees, Esk and Wear Valleys NHS FT
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Action
Audit crisis-team triage-tool completion and quality monthly through QA5 and reinforce compliance through clinician supervision.
Stated by Tees, Esk and Wear Valleys NHS FT
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
Immediate emergency responses are requested through 999 emergency services in line with national guidance.
Stated by Tees, Esk and Wear Valleys NHS FT
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Concerns raised1
Failure to document the decision-making process and rationale for redirecting patients from A&E
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.
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
Add vital signs, pain score and diversion-decision rationale to ambulance pre-arrival documentation at Whipps Cross, with random manual auditing.
Stated by Barts Health NHS Trust and North East London NHS Foundation 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
Existing documentation processes at other Barts Health Emergency Departments are considered sufficient for recording decisions to divert patients.
Stated by Barts Health NHS Trust and North East London NHS Foundation Trust
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Concerns raised2
Failure to document important clinical decisions and rationale in the triage of GP referrals
Failure to identify and make accountable the staff member making GP referral triage decisions
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.
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Concerns raised1
Failure to document triage calls and advice
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.
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Concerns raised1
Lack of subsequent notes of telephone triage
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.
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Concerns raised1
Failure to record assessment of mood and suicidal thoughts during prison triage
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.
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
Concerns 2, 3 and 4 relate to BEH-MHT services rather than the services addressed by this response.
Stated by Care UK
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Concerns raised1
Failure to proactively ask and record the type of fit during triage calls
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