Recurring concern

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

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First reported 24 Nov 2014•Latest report 23 Jun 2025

Definition

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.

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
11

Distinct published reports

Individual concerns
12

A report can raise multiple concerns

Date range
2014–2025

First to latest report issue date

Stated actions
15

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.

Atrumed Ltd1
Bedfordshire Hospitals NHS Foundation Trust1
Department of Health and Social Care1
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust1
Greater Manchester Mental Health NHS Foundation Trust1
Haughton Thornley Medical Centres1
HM Prison and Probation Service1
HM Prison Service1
Medway NHS Foundation Trust1
Mersey Care NHS Foundation Trust1
Mid Yorkshire Teaching NHS Trust1
NHS Greater Manchester Integrated Care Board1
North London NHS Foundation Trust1
North West Ambulance Service NHS Trust1
Parents of Kinga Cieciorska1

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.

  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
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Data last updated 7 September 2026