Recurring concern

Incomplete composite child health records

First to latest report 18 Oct 2018 — 19 Jun 2019

Reports that mention this concern
2
Times this concern has been raised
2
Stated actions linked to this concern
0

What this concern includes

Includes failures of the red book or directly associated child-health record process, including sporadic completion, unclear expectations, failure to use it for information sharing, and reliance on parents to relay information because professionals or trusts lack a dependable composite record.

What is not included
  • Excludes generic clinical-record deficiencies where the assertion does not concern a composite child health record or the red-book process.
  • Excludes failures limited to transferring or accessing records between healthcare organisations when the red book or composite child-health record process is not the deficient control.
  • Excludes failures to review or act on complete child health information after it has been reliably consolidated and made available.
  • Excludes routine child-health documentation, such as isolated weight or immunisation entries, unless the failure leaves the composite record of health concerns incomplete.

Reports and published responses 2 reports

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

  1. Manchester South

    AI-generated summary

    Mason Logue · 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

    Mason Logue, who had been born prematurely and had a complex medical history, was found unresponsive in his mother’s bed at home on 28 October 2017. The post-mortem examination did not identify a clear cause of death, and the medical cause was recorded as unascertained. Concerns included limited integration and information sharing between services, the absence of an overarching supportive care plan and a single professional coordinating his care, and difficulties arising from differing protocols and the lack of a single IT system across NHS trusts.

    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

    Failure of health professionals to understand and use the red book for information sharing

    Wider context from the report

    “The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult. The red book was not utilised as a tool for sharing information other than by the Health Visitor to record standard information e.g. weight. The purpose and value of the red book was unclear amongst the health professionals. It was clear that clinicians in hospitals rarely utilised it. ”

    Source location

    Mason Logue · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Manchester South

    AI-generated summary

    Joseph James GRANTHAM · 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

    Joseph James Grantham was born with a neural tube defect and later developed laryngomalacia. He became unresponsive at church on 9 July 2017, and resuscitation efforts were unsuccessful; the post-mortem found no cause of death and the death was attributed to natural causes. Concerns included delays and gaps in sharing clinical information, unclear responsibility for his care, unavailable records, and insufficient communication about monitoring requirements between healthcare services.

    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

    Failure to maintain a complete composite child health record in the red book

    Wider context from the report

    “6. Joseph's red book had been completed sporadically. The inquest heard from a number of witnesses who indicated that practice re completion of the red book amongst health professionals nationally was mixed and that there was no clear guidance for or expectation amongst health professionals that they would be widely used other than for post birth weight recording and immunisations. As a result there was no composite record of health concerns for a young child such as Joseph. Differing IT systems meant that health professionals in different trusts were reliant on verbal information passed to parents placing a significant burden on parents and a risk that key information was not available. ”

    Source location

    Joseph James GRANTHAM · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

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