Recurring concern

Unreliable documentation and authentication of ECG review

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First reported 31 Oct 2014•Latest report 30 May 2017

Definition

What this concern includes

Includes failures to record, date, time, sign, endorse or otherwise authenticate ECG review findings, reviewer identity, instructions and required follow-up across clinical settings.

Not included

  • Excludes failures to perform or interpret an ECG where the review record itself is not deficient.
  • Excludes failures to act on a clearly documented ECG review when the documentation and authentication process was reliable.
  • Excludes generic clinical-record deficiencies that do not specifically concern documentation or authentication of ECG review.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2014–2017

First to latest report issue date

Stated actions
2

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.

Office of the Chief Coroner1
Royal Sussex County Hospital1
the Royal Wolverhampton NHS Trust1
University Hospitals Sussex NHS Foundation Trust1

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. Black Country

    AI-generated summary

    Mrs Sarah Poole · 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

    Mrs Sarah Poole was admitted to hospital with sudden headache and back pain, but an abnormal ECG was incorrectly considered normal and she was discharged home. She was readmitted the following day, diagnosed with an aortic dissection and underwent emergency surgery, but developed complications and died on 5 November 2016. The principal concern was a failure to record and endorse the reviewing doctor’s name and to consider previous abnormal ECG results during handover.

    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 record and endorse the reviewing doctor’s name on ECGs

    Wider context from the report

    “1. Evidence emerged during the inquest that there were failures to record and endorse the name of the Doctor reviewing the ECG and a failure to take into account previous abnormal ECG results during the handover from the paramedic staff. ”

    Source location

    Mrs Sarah Poole · 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

    Require Senior Decision Makers to review and sign off all ECGs, and audit compliance monthly.

    Verbatim wording from the response

    “The Emergency Department has instigated a policy that all ECGs must be reviewed and signed off by a Senior Decision Maker, i.e. a middle grade Doctor or Consultant.”

    Source location

    2017-0176-Response-by-The-Royal-Wolverhampton-NHS-Trust
    Page 1 · response
    Published 4 August 2017

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Maureen Annette ELLETT · 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

    The report concerns the death of Maureen Annette ELLETT; the circumstances are referred to the Record of Inquest. Concerns included incomplete emergency department documentation and observations, inadequate clinical planning and review, staffing and fatigue issues, and shortcomings in ECG and observation procedures. The report states that the cumulative effect of these issues was considered catastrophic by the inquest.

    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 document ECG review, instructions and reviewer identification

    Wider context from the report

    “(6) When the ECG is shown to one of the Doctors there should be a proper documented note of the identity of the Doctor, the time and date when he or she reviews the ECG, the Doctor's instructions on what should happen next with a time period within which this is to occur and this note should be signed and timed by the Doctor who should also print his or her name. ”

    Source location

    Maureen Annette ELLETT · Prevention of Future Deaths report
    Page 1 · 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

    Introduce an Emergency Department ECG stamp for documenting, signing and dating ECG interpretations and associated management plans.

    Verbatim wording from the response

    “6. A stamp has been devised for use in the Emergency Department on ECG print outs so that doctors can document, sign and date on their interpretation of the ECG and any associated plan for the patient’s management.”

    Source location

    2014-0473-Response-by-Brighton-Sussex-University-Hospitals-NHS-Trust
    Page 3 · response
    Published 31 October 2014

    Open published response
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Data last updated 7 September 2026