Recurring concern

Failure to accurately record the identities of clinicians involved in patient care

First to latest report 24 Nov 2014 — 23 Jun 2025

Reports that mention this concern
11
Times this concern has been raised
12
Stated actions linked to this concern
15

What this concern includes

Includes inaccurate, omitted, or untimely recording of the identity of clinicians who assess, advise on, discharge, or otherwise provide clinical care, where the identity is needed for safe communication, accountability, or subsequent decision-making.

What is not included
  • Excludes failures to identify patients or other non-clinician individuals.
  • Excludes inaccurate recording of clinical observations, assessments, deterioration, decisions, or advice where clinician identity is not the shared concern.
  • Excludes general poor record-keeping or information-sharing deficiencies without a specific failure to record the identity of an involved clinician.

Reports and published responses 11 reports

See individual reports that have raised this concern, and the actions taken in response

  1. North and West Cumbria

    AI-generated summary

    William Walter Jackson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    William Walter Jackson was diagnosed with severe aortic disease and underwent aortic valve and ascending-aorta replacement surgery in June 2013. After becoming unwell in August, a CT scan showed haemorrhage in the descending aorta, but the report did not identify features of a contained rupture; he died on 4 September 2013. The concerns included the lack of a formal record of advice from the Freeman Hospital, uncertainty about whether the CT images were reviewed, and the potential risk to patients from how such advice was given.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of formal recording of sudden clinical interactions

    Wider context from the report

    “(1) The CIC records showed that an A&E doctor had spoken to a Specialist Cardio Thoracic Registrar at the Freeman Hospital. Inquiries of the Freeman showed that there was no record/ recollection of this contact. (2) I understand there is no system at the Freeman to formally record sudden interactions. This means no traceable record and no means by which the Freeman doctor could be identified let alone recall the advice given. (3) The advice appears to have been given without the Freeman doctor actually seeing the CT scan. Has the images been reviewed it is possible that the true state of the deceased’s health would have been ascertained. (4) Independent of the issue of an enquiry being able to establish what advice was given at the time; there is a risk that the way such advice appears to have been given could place patients lives at risk. ”

    Source location

    William Walter Jackson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement an electronic system to record details of advice provided to healthcare professionals at other hospitals.

    Verbatim wording from the response

    “(i) Actions already taken:”

    Source location

    2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Ensure the Cardiothoracic Surgical Team consistently uses the electronic system for external requests for medical opinions.

    Verbatim wording from the response

    “• An electronic system is now in place within Cardiothoracic Surgery to record details of advice given when medical opinion is sought by a healthcare professional in another hospital.”

    Source location

    2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Include electronic-system recording requirements in the induction programme for newly recruited and rotating staff.

    Verbatim wording from the response

    “(ii) Further planned actions:”

    Source location

    2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Further develop the recording system to prompt documentation of key items, including radiological images viewed when providing an opinion.

    Verbatim wording from the response

    “(ii) Further planned actions:”

    Source location

    2014-0509-Response-by-Newcastle-upon-Tyne-Hospital-NHS-Trust
    Page 2 · response
    Published 24 November 2014

    Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026