Recurring concern

Unreliable recording of care plan and risk assessment reviews

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First reported 24 Jun 2015•Latest report 15 Jan 2024

Definition

What this concern includes

Includes failures in recording, preserving or assuring records of care plan and risk assessment reviews, including omitted review records, missing outcomes, inaccurate entries and records falsely indicating that reviews occurred.

Not included

Excludes the substantive quality of a care plan or risk assessment where the review record itself is reliable.
Excludes generic clinical or care-record deficiencies that do not concern recording care plan or risk assessment reviews.
Excludes failures to carry out protective actions after a review was accurately recorded, unless the review-recording control is also deficient.
Excludes unrelated observation, incident, medication or other safety records unless the assertion specifically concerns a care plan or risk assessment review.

Reports: 4
Individual concerns: 4
Date range: 2015–2024
Stated actions: 9

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Essex Partnership University NHS Foundation Trust1

Radcliffe Manor House1

Sussex Partnership NHS Foundation Trust1

Swansea Bay University Local Health Board1

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.

15 Jan2024
Essex
Concerns raised1
1. Failure to record risk assessment completion and outcomes
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
2. Action
  Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
3. Action
  Audit Home Treatment Team assessments regularly and share findings with the team to improve assessment documentation.
  Stated by Essex Partnership University NHS Foundation TrustStated planned
1. Action
  Randomly audit patient records monthly for discrepancies in RAG-rated risk assessments and take action where discrepancies are found.
  Stated by Essex Partnership University NHS Foundation TrustStated completed
AI-generated summary

Nadia Wyatt · 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

Nadia Wyatt, a 53-year-old woman experiencing severe anxiety, separation anxiety and depression, died by hanging on 26 July 2023 after taking sleeping tablets and apparently drinking wine. The principal concerns included failures in record-keeping, care planning, risk assessment and risk management, including inappropriate copying from another patient’s care plan and potential over-reliance on her husband as a carer.

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 risk assessment completion and outcomes
Wider context from the report
“(1) Failure to update Nadia’s records with the outcomes of referrals that were made and whether such referrals were accepted or declined, either for Nadia or her carer. (2) Failure to include within her records considerations and professional opinions reached on the prospect, or not, of readmission for in-patient treatment together with the final decision and rationale. (3) Lack of bespoke care plans tailored to Nadia’s needs. Notwithstanding the fact Nadia had begun to disengage and declined to be involved in her care planning, more personalised plans could have been drafted taking into account her personal characteristics, needs and past medical history. (4) Evidence of “cutting and pasting” into Nadia’s care plan from another patient’s care plan. (5) Failing to undertake risk assessments at all relevant and appropriate stages and/or failure to record that such an assessment had in fact taken place and what the outcome was. (6) Failing to provide a “RAG” rating to risk assessments and/or to indicate where required that a risk exists. (7) Failure to include risk management and contingency planning within Nadia’s care plans as well as key elements of her condition at that time, including her recent inpatient admission. (8) The potential for over-reliance on Nadia’s husband, albeit he was only too willing to support her and care for her, and the need to balance maintaining Nadia’s care and treatment in the community with the need to support her carer as well. ”
Source location
Nadia Wyatt · 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
Revise line-management supervision forms to cover record-keeping quality, responsibilities, policy, values and professional accountability.

Verbatim wording from the response
“Response: The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”

Source location
Response from Essex Partnership NHS
Page 1 · response
Published 19 January 2024
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
Remind Crisis Response and Home Treatment Service staff in team meetings about documentation and record-keeping requirements.

Verbatim wording from the response
“Response: The Trust has revised line management supervision forms to include quality of record keeping, their professional responsibilities, Trust policy and values, and NMC accountability frameworks in respect of record keeping. In addition to discussions during supervision the Crisis Response and Home Treatment Service has been reminded of this in their team meetings.”

Source location
Response from Essex Partnership NHS
Page 1 · response
Published 19 January 2024
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
Audit Home Treatment Team assessments regularly and share findings with the team to improve assessment documentation.

Verbatim wording from the response
“In order to ensure the assessments undertaken by the Home Treatment Team are comprehensive and the findings (including the rationale for the decisions made) are clearly documented, regular audits on Home Treatment Team assessments will be undertaken and the findings shared with the team to continuously improve practice.”

Source location
Response from Essex Partnership NHS
Page 1 · response
Published 19 January 2024
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
Randomly audit patient records monthly for discrepancies in RAG-rated risk assessments and take action where discrepancies are found.

Verbatim wording from the response
“The Trust also randomly audits patients’ records on a monthly basis to identify any concerns with RAG rating of risk assessments in order for actions to be taken where discrepancies are found.”

Source location
Response from Essex Partnership NHS
Page 3 · response
Published 19 January 2024
Open published response
19 Jul2022
Nottinghamshire
Concerns raised1
1. Falsification of records to indicate completed care plan and risk assessment reviews
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Evaluate shortlisted digital care planning systems to improve linked risk assessment, trend analysis and point-of-care record keeping.
  Stated by Trustees of Radcliffe Manor HouseStated in progress
2. Action
  Fully implement the selected digital care planning system for all residents.
  Stated by Trustees of Radcliffe Manor HouseStated planned
3. Action
  Improve management oversight of care plan documentation.
  Stated by Swift Management Services LimitedStated completed
AI-generated summary

Beryl Simcock · 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

Beryl Simcock, who lived in a care home because of dementia, suffered several falls, including a fall on 10 June 2021 that caused an impacted fractured neck of femur and led to a severe deterioration in her health. The concerns included inadequate care-plan and risk-assessment reviews, potentially inaccurate records, insufficient oversight, and inadequate information for her family when she was deprived of her liberty.

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
Falsification of records to indicate completed care plan and risk assessment reviews
Wider context from the report
“I was concerned about the lack of written policies for care planning and review. I was concerned that reviews of care plans and risk assessments were either not done (and the records falsified to suggest that they were) or that they were done by someone unsuited to the task. This was not identified despite audit activity during the relevant period. I was also concerned that at times when Mrs Simcock was deprived of her liberty the care home did not ensure that her family were given adequate and timely information to enable them to provide independent scrutiny of the care and restrictions in place. ”
Source location
Beryl Simcock · 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
Evaluate shortlisted digital care planning systems to improve linked risk assessment, trend analysis and point-of-care record keeping.

Verbatim wording from the response
“A summary of the report is attached. (The full report contains details of the care plans of a number of residents from which they could be identified.) The main thrust of the report is that the paper-based care plan system currently used by the Home makes the identification of risk and progression to mitigation difficult, and this has not been helped by the fact that risk assessment procedures have been adapted from various sources. The two major recommendations of the report are:”

Source location
Response from Radcliffe Manor House
Page 1 · response
Published 27 September 2022
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
Fully implement the selected digital care planning system for all residents.

Verbatim wording from the response
“• In order to improve care planning and record keeping, the Home should introduce a digital care planning system which will enable the linking of care plans to risk assessments; this digital system should also be capable of providing good quality trend analysis and facilitating point-of-care-delivery record keeping.”

Source location
Response from Radcliffe Manor House
Page 1 · response
Published 27 September 2022
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
Improve management oversight of care plan documentation.

Verbatim wording from the response
“Where the home is now The original safeguarding was taken very seriously by the trustees and management team, and several initiatives (with the active involvement of the CQC and the GP) were immediately implemented to improve safety. These included:”

Source location
Response from Swift Management services
Page 2 · response
Published 27 September 2022
Open published response
5 Oct2017
Swansea and Neath Port Talbot
Concerns raised1
1. Failure to record care plan reviews and their outcomes
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Christopher John Llewellyn Roberts · 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

Christopher John Llewellyn Roberts was pronounced dead at his home on 19 October 2015 after an overdose involving prescribed opiate medication. He was receiving treatment for mental illness, and his medication use was described as chaotic. The report raised concerns that a care plan review was not recorded, including whether a recent overdose attempt had been considered, and that nomad trays may be unsuitable for some patients.

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 care plan reviews and their outcomes
Wider context from the report
“1. The care plan review was not recorded which would not allow another person reviewing the file to ascertain that a care plan review had taken place and what the outcome of that review was. It was also the case that a lack of documentation would not demonstrate whether CMHT had considered the matter of the attempt on his own life by the deceased in the weeks leading up to that review, when considering whether to amend or retain the care plan in place at the time. ”
Source location
Christopher John Llewellyn Roberts · Prevention of Future Deaths report
Page 2 · concerns
Open source report
24 Jun2015
Brighton and Hove
Concerns raised1
1. Failure to document risk assessment reviews
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 concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Review and redesign Trust-wide Care Programme Approach processes, including developing the new policy and preparing for electronic-record rollout.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
2. Action
  Track risk-assessment dates in the East ATS caseload spreadsheet and monitor and audit compliance, escalating required action.
  Stated by Sussex Partnership NHS Foundation TrustStated in progress
AI-generated summary

Alice MEAD · 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

Alice Mead was known to mental health services and was receiving care under the Care Programme Approach. The inquest concluded that she took her own life on 20 January 2015. Concerns included the failure to replace her care co-ordinator, inadequate response to her requests for a medication review, delayed action following urgent concerns, and a lack of documented review of her risk assessment.

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 risk assessment reviews
Wider context from the report
“(4) There was no evidence that Alice’s risk assessment was reviewed and updated during December 2014 or January 2015. If it was, such reviews should have been documented in accordance with the Care Programme Approach. They were not ”
Source location
Alice MEAD · 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
Review and redesign Trust-wide Care Programme Approach processes, including developing the new policy and preparing for electronic-record rollout.

Verbatim wording from the response
“The Care Programme Approach (CPA) is in the process of being reviewed across the Trust. This work is being led by ████████, Director of Occupational Therapy and Recovery Practice. We have a newly constituted CPA steering group, with cross care group representation and we are agreeing the new processes in preparation for the roll out of Carenotes (the new electronic records system). A new CPA policy has been drafted and we hope to launch it in September 2015. When the new CPA policy is launched there will be full staff training in place. Information leaflets and short films will be available and all information will be available on the Trust’s intranet. The training will be co-produced with service users and peer trainers to ensure a holistic approach.”

Source location
2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
Page 1 · response
Published 24 June 2015
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
Track risk-assessment dates in the East ATS caseload spreadsheet and monitor and audit compliance, escalating required action.

Verbatim wording from the response
“Staff in the East ATS and MHRRS, responsible for assessing service users’ risk, have undergone bespoke Applied Suicide Intervention Skills Training (ASIST). This internationally renowned training was delivered in June 2015 by Grassroots, Suicide Prevention charity. To ensure risk assessments are up to date we have developed a new East ATS caseload spread sheet to capture risk assessment dates; supervisors will monitor this frequently, audit compliance, and escalate to the Team Leaders if action is required.”

Source location
2015-0239-Response-by-Sussex-Partneraship-NHS-Trust
Page 2 · response
Published 24 June 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to record risk assessment completion and outcomes

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

Concerns raised1

Falsification of records to indicate completed care plan and risk assessment reviews

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.3

Concerns raised1

Failure to record care plan reviews and their outcomes

Concerns raised1

Failure to document risk assessment reviews

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.2

Actions described in response 4

Actions described in response 3

Actions described in response 2