Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
87match
F244 - Common information practices shared data and electronic records
There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter...
Matched on
terms: patient, record
HSSIB recommendation
86match
Electronic patient record systems – electronic referrals for ongoing care
EPR systems have been implemented to support the transfer of clinical information as part of a referral; this includes in the management of rejected referrals.
Matched on
terms: patient, record
Committee recommendation
84match
#6 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
Missing or inaccurate telephone numbers in NHS patient records undermined government’s efforts to contact 375,000 people. The contact centre relied on telephone numbers in NHS patient records when calling people to check their needs. Over 20% of the 1.8 million telephone numbers passed to the contact centre from NHS records, for roughly 375,000 people, were missing or found...
Matched on
terms: inaccurate, patient, record
CQC action
83match
Montagu Hospital, Mexborough
Thetrustmustensureitmaintainssecurelyanaccurate,complete,andcontemporaneousrecordinrespectofeachserviceuser,includingarecordofthecareandtreatmentprovidedtotheserviceuserandofdecisionstakeninrelationtothecareandtreatmentprovided.Thisshouldincludeallergystatusandtheissuingofawarningwristbandwhenallergieshavebeendisclosed,andcompleterecordingofpatientfluidandnutritioncharts.Regulation17(2)(c)
Matched on
terms: patient, record
CQC action
83match
Doncaster Royal Infirmary
The trust must ensure it maintains securely an accurate, complete, and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the care and treatment provided. This should include allergy status and the issuing of a warning wristband when allergies...
Matched on
terms: patient, record
Inquiry recommendation
82match
R20 - Stool records for CDI patients
Health Boards should ensure that where a patient has, or is suspected of having, C. difficile diarrhoea a proper record of the patient’s stools is kept. Health Boards should ensure that there is an appropriate form of charting of stools available to enable nursing staff to provide the date, time, size and nature of the stool. Stool charts...
Matched on
terms: patient, record
Inquiry recommendation
82match
R15 - CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration, oxygen saturation and blood pressure.
Matched on
terms: patient, record
HSSIB recommendation
82match
Electronic patient record (EPR) systems – thematic review
How does your organisation identify requirements for an EPR system to account for organisational and user (patients and staff) needs?
Matched on
terms: patient, record
Inquiry recommendation
82match
R38 - Medical record keeping
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care, and that they are routinely audited by senior medical staff.
Matched on
terms: patient, record
HSSIB recommendation
82match
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care undertakes a review to explore the options and determine an appropriate mechanism for write access to health records for independent prescribing organisations. This would inform future developments such as the Single Patient Record, improve the currency of patient information held digitally by NHS organisations, and may remove some...
Matched on
terms: patient, record
PFD report
81match
Lee Hollman
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Matched on
terms: patient, record
CQC action
81match
Worthing Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: patient, record
CQC action
81match
St Richard's Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: patient, record
CQC action
81match
Royal Sussex County Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: patient, record
LGO / SPSO decision
80match
201508104 - Grampian NHS Board
Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner. Following investigation, we were of the view that the practice had taken reasonable action...
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
78match
R14 - Patient records compliance audit
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records. Health Boards should ensure that there is an effective system of audit of patient records, and that there is effective scrutiny of audits by the Board.
Matched on
terms: patient, record
Inquiry recommendation
78match
IBI-4d - Patient Records Audit
Patient Records: Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels of patient access to their personal records, their ability to identify and correct apparent errors in them, their...
Matched on
terms: patient, record
HSSIB recommendation
78match
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the nursing home implements a mechanism to use care records with the lowest risk of having incorrect personal identification data during interactions with the wider healthcare system.
Matched on
terms: patient, record
HSSIB recommendation
78match
Positive patient identification
HSSIB suggests that integrated care boards assure that where a patient misidentification has occurred, healthcare organisations in their geographical footprints have collaborative processes to learn why and to ensure health records are correctly allocated.
Matched on
terms: patient, record
HSSIB recommendation
78match
Creating conditions for learning from deaths and near misses in inpatient and community mental health services: Assessment of...
Organisations can improve patient safety by involving ‘digital experts’ in their electronic patient record system improvement projects. This will support any digital configuration and infrastructure changes required to record person-centred approaches to psychosocial assessments and safety planning.
Matched on
terms: patient, record
Committee recommendation
78match
#1 - Ensure urgent and full implementation of IMMDS review recommendations 6 and 7 on patient records
Without records of which patient has undergone which procedure, or been prescribed which drug, the health system will continue to, in the words of the IMMDS review team, “fly blind”. We recommend that the Government urgently ensures that the accepted recommendations 6 and 7 of the IMMDS review are fully implemented.
Matched on
terms: patient, record
PFD report
77match
Peter Pattinson
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Matched on
terms: patient, record
PFD report
77match
Afifa Qaisar
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Matched on
terms: inaccurate, record
PFD report
77match
Thomas Maher
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Matched on
terms: patient, record
CQC action
77match
Royal Victoria Infirmary
The trust must maintain securely an accurate, complete, and contemporaneous record including a record of the care and treatment provided to patients and of decisions taken in relation to the care and treatment provided.
Matched on
terms: patient, record
Committee recommendation
76match
#24 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
The DWP contact centre relied on telephone numbers in NHS patient records to call clinically vulnerable people who had not yet registered their needs. In some 375,000 cases out of the 800,000 people that the contact centre could not get hold of, or over 20% of the 1.8 million people the centre attempted to contact, it was because...
Matched on
terms: inaccurate, patient, record
Committee recommendation
75match
#13 - Thirteenth Report - Initial lessons from the government’s response to the COVID-19 pandemic
The pandemic has again highlighted the role of high-quality data in enabling effective service delivery, monitoring and improvement. For example, due to missing or inaccurate telephone numbers within NHS patient records, the shielding programme was unable to follow-up letters to 375,000 vulnerable people with phone calls. Local authorities, which were passed the details of individuals who could not...
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
74match
R25 - Accessible financial records
The records kept must be easy to manage by staff and easily comprehensible to others, including people with learning disabilities and autistic people, carers and relatives.
Matched on
terms: record
HSSIB recommendation
74match
Local integrated investigation pilot 1: Incorrect patient identification
The Ambulance Trust is designing a confirmation checkpoint, which will be included in the electronic patient record for ambulance crews to confirm the correct identification.
Matched on
terms: patient, record
PFD report
73match
Stuart Aaron Collins
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Matched on
terms: patient
PFD report
73match
Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Matched on
terms: patient, record
PFD report
73match
Zeeyad Hamadi
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Matched on
terms: patient, record
PFD report
73match
Desrae Tucker
Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
Matched on
terms: patient, record
PFD report
73match
Charles Bradley
Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Matched on
terms: patient, record
PFD report
73match
David Chatburn
The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Matched on
terms: patient, record
PFD report
73match
Frederick Hall
Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.
Matched on
terms: patient, record
PFD report
73match
Linda Fisher
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Matched on
terms: inaccurate, patient
PFD report
73match
Daniel McCallum Keane
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Matched on
terms: patient, record
Inquiry recommendation
73match
R19 - ICN instructions recorded
Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in the patient notes and are included in care planning for the patient.
Matched on
terms: patient, record
Inquiry recommendation
73match
COVID-M3.4 - Data Systems for High-Risk Individuals
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient...
Matched on
terms: patient, record
HSSIB recommendation
73match
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June...
HSIB recommends that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record, and also support alerting functionality.
Matched on
terms: patient, record
CQC action
73match
Kettering General Hospital
The service should consider implementing a system to ensure an effective storage of patient records. This includes but is not limited to accessible medical and nursing records.
Matched on
terms: patient, record
CQC action
73match
Ellesmere Port Hospital
The trust must assess and manage the risks relating to the electronic patient records system and transcription services. The trust must improve the quality of the services provided and ensure this did not impact on delays to patients care and treatment.
Matched on
terms: patient, record
Scottish FAI
73match
Maureen Smyth
In my view is essential that such reports are promptly filed in the patients medical records, and that a dated entry (perhaps by use of a stamp) indicating receipt of the report is made in the running clinical notes within the records, so that any doctor looking at the clinical notes will be alerted to the fact that...
Matched on
terms: patient, record
Scottish FAI
73match
Judith Laing
The need for a review of procedure at Inverclyde Royal Hospital on how amended reports/results/findings are introduced into a patient’s medical records, how the existence of an amended report/result/finding or opinion is highlighted in the patient’s medical records, and how any amendments are brought to the immediate attention of those treating a patient. I consider there should be...
Matched on
terms: patient, record
Scottish FAI
73match
J.K. Sweeney, L. Sweeney, E.P. McQuade, S.C. Tait, G.M. Ewing and J. Morton
5.1 Doctors generally, and general practitioners in particular, should take steps to ensure that medical notes are made and kept in such a way as to maximise their ability to identify repeated episodes of loss of consciousness, loss of or altered awareness, in the case of patients who are or may become drivers. 5.2 When a doctor is...
Matched on
terms: patient, record
Inquiry recommendation
73match
R22 - Relative discussions recorded
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient’s continuing care is recorded in the patient’s notes to ensure that those caring for the patient are aware of the information given.
Matched on
terms: patient, record
LGO / SPSO decision
72match
21-018-569c - The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: patient, record
LGO / SPSO decision
72match
21-018-569a - Norfolk & Suffolk NHS Foundation Trust (21 018 569a)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: patient, record
HSSIB recommendation
70match
Advanced airway management in patients with a known complex disease
HSSIB recommends that NHS England identifies and implements a system for sharing clinical information about people with a known difficult airway. This is to improve access to this information for healthcare professionals and reduce the risk of a person’s known difficult airway not being recognised.
Matched on
terms: patient