Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
Source spread
Where this theme appears
This theme appears across 26 independent accountability sources, so the source mix matters as much as the headline total.
62 inquiry recs
648 PFD reports
27 committee recs
62 HSSIB recs
555 CQC actions
4 HMICFRS recs
2 ICIBI recs
89 PPO recs
7 IOPC recs
10 NAO recs
25 IMB recs
9 IMB reports
2 patient safety alerts
12 Scottish FAIs
18 Article 2 learning points
2 detention investigation recs
658 DHR recs
203 PHSO decisions
464 LGO/SPSO decisions
8 CQC enforcement actions
1 MNSI report
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(62)— showing 50 strongest matches
17 — Moratorium if records inadequate
Recommendation: a moratorium must be declared if records of organ retention are inadequate during which there should be an immediate cataloguing of organs retained;
Unknown
15 — Hospital records of organs and tissue
Recommendation: every hospital keep proper records (preferably computerised) as to the source, consent to retain, usage and disposal of organs and tissue;
Unknown
14 — University records track organ use
Recommendation: University records shall identify receipt, use, dispersal and ultimate disposal of any organ or sample.
Unknown
13 — University audit trail to clinical record
Recommendation: University records shall provide a confidential audit trail back to the clinical record.
Unknown
12 — Review and update medical records
Recommendation: The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death …
Unknown
11 — Review records and develop audit trail
Recommendation: Records should be reviewed and updated and an audit trail should be developed and put in place.
Unknown
R26 — Six-monthly financial accounts to families
Recommendation: Information about the use of cash and other property and six-monthly accounts (or such period as appropriate upon discharge of the person) should be available to the service user concerned where possible and to the family where appropriate. Where appropriate …
No response yet
R25 — Accessible financial records
Recommendation: 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.
No response yet
R22 — Easy Read documents
Recommendation: All documents relevant to the service user’s experience and intended for their information must be made available in Easy Read format.
No response yet
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: 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 …
Gov response: The government agrees with the Inquiry that data systems need to be improved to identify individuals at high risk during a pandemic. The government’s 10 Year Health Plan and existing data policy work provide a …
Accepted
R38 — Medical record keeping
Recommendation: 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.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
18 — School information on children in writing
Recommendation: Any information about children which is to be used for the purposes of their compulsory care and which is provided by their school-teacher should be provided in writing (15.38).
Unknown
40 — Written notice to wings of prisoner arrival
Recommendation: All establishments should have a procedure for notifying wings in writing that a prisoner is currently charged with, or has been convicted of, an offence under the Protection from Harassment Act 1997.
Unknown
38 — Wing files required for admission to wing
Recommendation: Prisoners should not be admitted to a wing without their current wing file, save with the permission of a governor or the approval of the night orderly officer. Important entries in it should be made in red.
Unknown
37 — Checklist for files on transfer
Recommendation: To ensure that all files accompany prisoners on their transfer to another establishment, they should be ticked off at the reception of the sending establishment against a checklist. Prisoners should not be allowed to leave unless all their files have …
Unknown
36 — Telling receiving prison reason for transfer
Recommendation: Whenever a prisoner is transferred to another establishment, the receiving establishment should be told what the reason for the transfer is. If the transferring prisoner is a particularly problematic one, the receiving establishment should be warned beforehand.
Unknown
35 — Police National Computer link to prisons
Recommendation: The Police National Computer should be linked to the whole of the prison estate. In the meantime, any intelligence the police may have about prisoners which could affect their management in prison should be sent to the police liaison officers …
Unknown
34 — Facts of offences in conviction lists
Recommendation: The list of a prisoner’s convictions sent to the prison should include a short statement of the facts of each offence and the charges the prisoner is facing.
Unknown
33 — Policy on disclosing medical reports to prisons
Recommendation: In the light of such legal advice as the Courts Service receives, it should publish a policy on the disclosure to the prison of medical or psychiatric reports on a prisoner submitted to the court.
Unknown
29 — Content of NOMIS staff training
Recommendation: The training which staff receive on NOMIS should not merely address how to log on, enter information and retrieve it. It should reinforce the need for any information which is to be entered to be accurate, comprehensive and unambiguous. It …
Unknown
25 — NOMIS flag for change of status date
Recommendation: If a convicted prisoner is not due to be released when they complete their sentence because they were remanded in custody awaiting trial on other charges, NOMIS should flag up the date on which their change of status is due …
Unknown
24 — NOMIS to record facts of offences
Recommendation: Information about a prisoner’s convictions and outstanding charges held on NOMIS should include a short statement of the facts of each offence or charge.
Unknown
5 — Operating systems (interoperability)
Recommendation: NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS by December 2028. Work on the development of a mandatory information standard with requirements for interoperability between …
Gov response: The report also makes recommendations for the regulators, including CQC, which we will ensure are taken seriously, and on technology. We have implemented the maternity outcome signal system, which provides near real-time safety alerts, but …
Response Unclear
85 — Access to records for former child migrants
Recommendation: We therefore recommend that that all institutions which sent children abroad as part of the child migration programmes should ensure that they have robust systems in place for retaining and preserving any remaining records that may contain information about individual …
No response yet
R24 — Clear records and disclosure policies
Recommendation: Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with learning disabilities and autistic people themselves where possible.
No response yet
R13 — Full staff access to care plans
Recommendation: All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
No response yet
R6 — Named person approval for transfers
Recommendation: The named person responsible for the care plan must both review and approve the preparation of anyone with a learning disability transferring to a new environment within or external to the Trust in which they are cared for. This approval …
No response yet
R20 — Stool records for CDI patients
Recommendation: 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 …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R19 — ICN instructions recorded
Recommendation: 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.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R15 — CDI patient observations records
Recommendation: 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.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R14 — Patient records compliance audit
Recommendation: 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 …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
F244 — Common information practices shared data and electronic records
Recommendation: 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 …
Gov response: Accepted. There is both a need for common information practices that support the extraction of data to central systems to support improvements in data quality and service provision, and a need for electronic patient systems. …
Accepted
IBI-4d — Patient Records Audit
Recommendation: 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 …
Gov response: NHS England is supporting the NHS frontline to digitise its data. Linked to this, the Frontline Digitisation programme aims for all secondary care trusts to have an electronic patient record system (EPR) that meets its …
Accepted in part
34 — Report unresolved problems to regional office
Recommendation: If no solution is found after all diligent attempts, the parties should keep records of their attempts and the reasons why they have failed, such records to be lodged by way of report to the relevant NHS Executive Regional Office.
Unknown
32 — Transcripts of judges' remarks to prison
Recommendation: When a judge asks for any remarks which they make to be brought to the attention of the Prison Service, the court should assume responsibility for commissioning a transcript of what has been said and sending a copy to the …
Unknown
31 — Court responsibility for warrant and conviction documents
Recommendation: There should be someone in court whose responsibility it is to ensure that the dock officer gets copies of the warrant authorising the prisoner’s detention, the list of their convictions, and the indictment or charge sheet.
Unknown
30 — Reports accompanying prisoners from court
Recommendation: To avoid prisoners leaving court without being accompanied by bail information reports or pre-sentence reports, the probation officer should ensure that a copy of the report is available for the escort contractor, and there should be someone in court whose …
Unknown
28 — Avoiding information overload; terminals for NOMIS
Recommendation: Information overload should be avoided by enabling officers to get to the information they need quickly and to bypass the information they do not need. The technology should be up to date, and sufficient terminals should be provided to ensure …
Unknown
26 — Security Departments entering shareable information on NOMIS
Recommendation: Although there are no plans for security information to be entered onto NOMIS in its first phase, Security Departments should enter any information which can be shared with the majority of staff when the first phase of NOMIS becomes operational.
Unknown
BRIS-18 — Provide parents of young children with copies of all inter-professional healthcare letters
Recommendation: Parents of those too young to take decisions for themselves should receive a copy of any letter written by one healthcare professional to another about their child’s treatment or care.
Unknown
BRIS-17 — Ensure patients receive copies of all inter-professional letters about their care
Recommendation: Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Unknown
R30 — Fluid balance monitoring
Recommendation: Health Boards should ensure that where patients require fluid monitoring as part of their clinical care, nursing staff complete fluid balance charts as accurately as possible and sign them off at the end of each 24-hour period.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R27 — Positional change records
Recommendation: Health Boards should ensure that where a patient requires positional changes nursing staff clearly record this on a turning chart or equivalent. Compliance should be monitored by a system of audit.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R26 — Wound documentation
Recommendation: Health Boards should ensure that where a patient has a wound or pressure damage there is clear documentation of the nature of the wound or damage in accordance with best practice guidance, including the cause, grade, size and colour of …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R24 — TVN instructions recorded
Recommendation: Health Boards should ensure that where a TVN is involved in caring for a patient there is a clear record in the patient notes and care plan of the instructions given for management of the patient.
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
R22 — Relative discussions recorded
Recommendation: 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 …
Gov response: The Scottish Government accepts its responsibility for the failings identified in the report and we apologise unreservedly for the suffering and loss caused. We accept in full all of the report's recommendations.
Accepted
IHRD-24 — Blood Test Result Documentation
Recommendation: All blood test results should state clearly when the sample was taken, when the test was performed and when the results were communicated and in addition serum sodium results should be recorded on the Fluid Balance Chart.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
38 — Improve perinatal mortality recording
Recommendation: Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units …
Gov response: 103. We accept this recommendation. We will explore the feasibility of publishing data about the safety and quality of maternity services at individual Trust level. 104. As recommended by the Morecambe Bay Report, MBRRACE-UK has …
Accepted
14 — Recording cell-share requests
Recommendation: The guidelines should contain guidance on how such requests should be recorded, but there is no need for such requests to be treated as formal applications under the requests and complaints procedures.
Unknown
SP50 — Healthcare trust risk information visibility
Recommendation: The Department of Health and Social Care / NHS England should ensure that all healthcare trusts involved in the care of children and young people who are at risk of acts of violence against others have systems that ensure that: …
Gov response: The Department of Health and Social Care (DHSC) and NHS England are the lead organisations. Progress and next steps: - The Single Patient Record is currently being designed and scoped. - This is part of …
Accepted
Prevention of Future Deaths reports(648)— showing 50 strongest matches
Nicola Matthews
Concerns: The coroner identified incomplete documentation of ward round decisions and a lack of clear, documented follow-up arrangements for patients discharged from inpatient care, particularly those at risk of self-harm. This meant staff lacked clarity on discharge plans and medication.
Overdue
Peter Pattinson
Concerns: Family requests for bed rails to be raised were not acted upon, documented, or risk assessed, and repairs were delayed. Additionally, daily statements were missing and unpaginated.
Response (European Care Group): • Bed rail risk assessments are now conducted within 24 hours of admission and reviewed monthly or when needs change. • A daily checking system for bed rail condition has … (AI summary)
Responded
Felix Cembrowicz
Concerns: The electronic Rio record system did not migrate historical patient records, including relapse management plans for discharged patients, leaving staff unaware of important patient histories and delaying assessments.
Response (Avon and Wiltshire NHS Trust): • A new requirement has been included in the initial assessment/admission process for re-referred patients to establish if historic relapse management plans exist and to search historic electronic and paper … (AI summary)
Responded
John Lansdowne
Concerns: The coroner identified unclear observation times and a missing observation sheet from medical records, alongside inconsistent understanding among nursing staff regarding patient observation requirements during bathing.
Overdue
Susan Jill Hammond
Concerns: The coroner noted that written allergy warnings on hospital documentation were overlooked and suggested clearer indications on patient files. Concerns were also raised about inadequate handovers during patient transfers, where the accompanying nurse had insufficient knowledge of the patient's condition.
Response (United Lincolnshire Hospitals NHS): • The prescription chart was modified to include a red-coloured section for "Drug allergies and sensitivities" with expanded space for details. • A structured handover tool, SBAR, was implemented for … (AI summary)
Responded
John Morgan
Concerns: The coroner noted inconsistencies in whiteboard use across Wales, raising concerns about potential over-reliance on whiteboards instead of patient notes, the risk of human error leading to incorrect information, and the possible continued use of a "DNR red star" system in some health board areas.
Response (Welsh Government): • The incident was reported to the Welsh Government under the Serious Patient Safety Incident reporting process. • The Chief Nursing Officer for Wales issued a request to all Nurse … (AI summary)
Responded
Winston Llewellyn Johns
Concerns: The coroner noted that crucial low blood sugar information was not considered in the advice provided by the ambulance operator. Additionally, the ambulance service's computer program did not account for critical clinical information, leading to incorrect CPR advice.
Overdue
John William Wright
Concerns: The hospital did not investigate the cause of a patient's fall as a Serious Untoward Incident, and appropriate electronic records were not made. It was also unclear if falls prevention training and recording protocols applied to all staff.
Overdue
William Joseph Wilkinson
Concerns: Required one-to-one nursing was not consistently available, and a lack of direct orthopaedic input in the Emergency Department led to unnecessary admission. Also noted were incomplete fluid balance charts and staff difficulties with the computer system.
Overdue
Stuart Aaron Collins
Concerns: The coroner noted issues with Mr Collins' initial assessment in A&E, the failure to perform hourly nursing observations, and incomplete nursing documentation. Concerns were also raised about the management and accessibility of hand sanitiser gel.
Response (South Tees Hospitals NHS Foundation Trust): • The Accident and Emergency Department introduced a "Patient Status or Glance Board" to note patients requiring regular observations and specific investigations. • Hand sanitiser dispensers were removed from the … (AI summary)
Responded
Keith Fleming
Concerns: The coroner noted a lack of recorded vital signs and impressionistic assessment of physical symptoms, which meant healthcare staff were unaware of a dehisced bowel anastomosis and internal abscess leading to a catastrophic infection.
Overdue
Chloe Grace Flavell
Concerns: The coroner noted concerns regarding the management of the reception area before triage, which could lead to significant delays in providing immediate care, particularly for children. A more appropriate and efficient system is needed to minimise these delays.
Overdue
Daniel Williams
Concerns: The coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.
Response: • All Inpatient staff received training packs and completed e-learning on 'Personalised Care Planning 2013 Record keeping and communication' in November. • The Trust developed and distributed guidance for checking … (AI summary)
Responded
James Withers
Concerns: The coroner identified delays in cardiologist review, missing medical notes, and poor communication among staff and with the family. Concerns included the Do Not Attempt Resuscitation (DNAR) process lacking family discussion, and a doctor incorrectly assuming the status.
Overdue
Andrew John Fallon
Concerns: Insufficient staffing levels in the Emergency Department led to doctors being overwhelmed and significant treatment delays, particularly for patients with severe health issues, exacerbated by the volume of minor complaints.
Overdue
Grace Mary Bates
Concerns: The coroner identified the lack of availability of a specialist diabetic nurse at the hospital over the weekend.
Response: • A business case for the appointment of a minimum of one specialist diabetic nurse was submitted and approved. • The appointment of a specialist diabetic nurse is awaited. (AI summary)
Response: • The NHS Services Seven Days a Week Forum developed ten clinical standards for urgent and emergency care, intended to reduce risks from weekend admissions, including for diabetes. • NHS … (AI summary)
Responded
Zeeyad Hamadi
Concerns: The coroner noted a lack of routine patient weighing, poor medical record keeping, and confusion regarding the funding and logistical arrangements for a prisoner seeking private healthcare outside the prison, further complicated by a lack of formal policy.
Response (Department of Health): • The Department of Health stated that several concerns, including record-keeping, liaison between prison and hospital staff, security issues, and ownership of the situation at the prison, were not for … (AI summary)
Overdue
Christine Nutbeam
Concerns: The coroner noted a lack of procedure for transferring patient information between NHS Trusts and concerns about the absence of vomiting symptoms in nursing notes, which were not communicated to the anaesthetist or surgeon. The report also questioned if asking about recent vomiting should become a standard pre-operative question.
Overdue
John Malone
Concerns: The hospital discharge letter sent to the GP lacked vital information, including admission and discharge details, potentially contributing to a patient's fall and subsequent subdural haemorrhage shortly after discharge.
Overdue
Desrae Tucker
Concerns: Concerns included insufficient recording and consideration for anti-embolic stockings in the patient's notes, and the absence of prescribed anti-coagulant medication upon discharge.
Overdue
Bertha Cray
Concerns: The coroner notes the potential for 'nil by mouth' signage to be inadvertently altered due to the design of double-sided signs and the lack of clarity regarding the cause of a past alteration, raising a risk of recurrence.
Response (Barts Health NHS Trust): • The Trust concluded its investigation into the concerns regarding 'nil-by-mouth' signs. • The Trust confirmed that the use of double-sided 'nil-by-mouth'/'sips of water' signs was not standard practice. • … (AI summary)
Responded
Matthew Dunham
Concerns: The coroner noted delays in acting on an emergency mental health referral and a lack of clear understanding of appropriate team roles. Concerns also included insufficient action on specific suicidal ideation and poor information sharing between mental health professionals.
Overdue
Frederick Davidson
Concerns: The coroner noted inadequate note-keeping practices and a communication breakdown between staff regarding nasogastric tube placement and feeding authorisation. Concerns were also raised about the delayed recognition of pneumothorax on X-ray and subsequent treatment.
Overdue
Caroline Lee
Concerns: The coroner identified a lack of recognition by medical staff regarding the significance of potassium results and insufficient communication from the laboratory to ward staff about abnormal results.
Overdue
Jack William Partington
Concerns: Concerns noted inadequate neonatal nursing handover, care planning, and isolated treatment decisions. Also, a lack of national policies for paralysing agents in neonates and insufficient ventilatory pressure monitoring post-intubation.
Response (Department of Health): • The Department of Health stated it would notify the British Association of Perinatal Medicine of the case. (AI summary)
Overdue
Kirk Duboise
Concerns: The coroner noted a delay in summoning an ambulance and that relevant forms were not seen by staff assessing the risk of self-harm for a new prisoner.
Response (Care UK): • Care UK introduced and disseminated a colour code system for summoning ambulances and issued a Governor's notice to staff. • Training on ACCT (Assessment, Care in Custody and Teamwork) … (AI summary)
Overdue
Michael James Meyler
Concerns: The coroner noted inadequate circulation of self-harm/suicide risk documents to healthcare and wing officers within the prison, alongside a failure to attach these to ACCT plans. There were also no clear procedures for logging that wing officers had reviewed relevant prisoner information.
Response (HM Prison and Probation Service): • The Governor of HMP Manchester issued a notice to staff in January 2013 to remind colleagues of the need to make regular entries on NOMIS. • The Governor of … (AI summary)
Overdue
Yuki Ivy Norman-Knight
Concerns: The coroner identified concerns regarding St Stephens Gate Medical Practice's systems for practice nurses to access patient medical history, a lack of guidelines for nurses to refer patients to doctors, and no triggers for receptionists to book doctor's appointments, particularly for young children or babies.
Response (St Stephens Gate): • The practice reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. • The practice is arranging for a paediatrician to present … (AI summary)
Responded
Nellie Travis
Concerns: The coroner noted the hospital's Falls Risk Assessment tool was subjective and its utility depended on individual nurse opinion, especially when completed by non-Trust staff. A more objectively assessed tool was identified as necessary.
Overdue
Afifa Qaisar
Concerns: The coroner identified issues with inaccurate drug administration records, unavailability of resuscitation equipment, the patient not being notified to the RMO, delays in platelet transfusions, and a lack of fluid balance charting.
Overdue
Andrew Hall
Concerns: Inadequate documentation and communication among mental health, healthcare, and prison staff regarding the deceased's condition and self-harm risk were identified. Also noted were insufficient observation, unadministered medication, and deficiencies in CCTV systems and staff training.
Response (HM Prison and Probation Service): • The prison stated that ACCT reviews include recorded information from the mental health team, and mental health staff receive ACCT training, with further courses arranged for visiting psychiatrists. • … (AI summary)
Overdue
Charles Bradley
Concerns: The coroner noted inadequate and ineffective record-keeping and communications at Arrowe Park Hospital, evidenced by issues with patient transfer information and inconsistent documentation of a patient's fall.
Overdue
David Chatburn
Concerns: The coroner identified issues with the GP's clinical management of the patient's mental health, including the absence of specialist referral and lack of recognised assessment tools. Concerns were also raised about bureaucratic barriers preventing GPs from easily accessing mental health services.
Response (Department of Health): • Department of Health officials consulted NHS England regarding the coroner's report. • The Department of Health noted that from April 2014, patients with mental health conditions gained the legal … (AI summary)
Overdue
Robert Jones
Concerns: The coroner identified that CT scan results should be made promptly available to all departments involved in patient care, and appropriate action should be taken without delay and within a reasonable timescale.
Response: • The Health Board stated it would ensure CT scan results are made available promptly and routinely monitored. • The Radiology department will undertake sampling of scan-to-report times for emergency … (AI summary)
Responded
Margaret Walker
Concerns: Concerns were raised regarding the delay in obtaining and sharing details of Mrs Walker's previous diabetes medication and acceptable blood test results. Her medical condition and blood test readings were not appropriately recorded in clinical notes, and an available defibrillator was not applied before ambulance personnel arrived.
Response (5 Boroughs Partnership NHS Foundation Trust): • The Trust stated it had reviewed its medicines reconciliation policy and processes and would issue further guidance. • The Trust addressed staff competency in clinical note recording through supervision … (AI summary)
Responded
Lee Hollman
Concerns: The coroner identified concerns regarding the maintenance of accurate and updated medical records, specifically relating to medication details. There was also a lack of an effective system for issuing repeat prescriptions and reviewing patients according to guidelines.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners' (RCGP) GP Curriculum includes guidance on accurate medical record-keeping and information management. • The RCGP highlighted a 2011 joint statement with the Royal … (AI summary)
Response (Riverside Surgery): • The practice reviewed and rewrote its repeat prescribing policy, specifically for psychotropic medications. • The clinical IT system was updated to improve the recording of medication changes and to … (AI summary)
Responded
Frederick Hall
Concerns: The coroner noted a lack of skill and knowledge among staff regarding NG tube insertion and storage, alongside delayed responses to consultant instructions and patient deterioration. Deficiencies in communication between staff, poor record-keeping standards, and a need for more nursing/medical staff were also identified.
Overdue
Nicos Michael
Concerns: Inconsistent and incomplete documentation of the patient's allergies across multiple hospital records meant this critical information was not consistently available to staff or shared with the GP. Current medical reporting and computer systems do not adequately ensure allergy information is readily accessible for patient treatment.
Response (East Kent Hospitals University): • The Trust stated there was no consistently recorded allergy to penicillin in the deceased's healthcare records. • The Trust noted the deceased did not articulate a penicillin allergy at … (AI summary)
Responded
Rosemary Oladejo
Concerns: A lack of adequate communication between the GP practice and the responsible clinician meant the responsible clinician was unaware of the GP's unilateral titration of a patient's amitriptyline and its prescribed timing.
Response (Hillingdon Commissioning Group): • The CCG initiated an investigation into the case and requested a report from Central North West London Trust (CNWL). • Recommendations on medicines reconciliation were shared with Hillingdon, Brent, … (AI summary)
Response (Central North West London NHS Trust): • The Trust stated it would circulate a Clinical Risk Alert in the coming weeks, referencing this case in an anonymised form. • The Trust indicated it would present this … (AI summary)
Responded
Mary Wanya
Concerns: The coroner identified significant delays in urgent psychiatric assessments, particularly out-of-hours, and an insufficient system for mentally ill patients on the Medical Admissions Unit. Concerns were also raised about the Level 3 Investigation Report omitting critical medical issues.
Overdue
Abiola Dosunmu
Concerns: The coroner noted failures to communicate proteinuria from A&E to the ward and the significance of elevated ESR and CK to the patient, family, or GP. This contributed to a missed opportunity to diagnose and treat a connective tissue disorder.
Response (King's College Hospital NHS Foundation Trust): • The Trust stated it would refer the case for inclusion in formal teaching for Foundation doctors and had shared the incident at departmental governance meetings. • The Emergency Department … (AI summary)
Responded
Margaret Connor
Concerns: The coroner noted insufficient procedures for checking wheelchairs before use, resulting in some being used with missing or faulty footplates. There was also a lack of independent wheelchair checks and doctors were misinformed about a patient's injury despite staff awareness.
Response (Heathers Nursing Home): • All staff received updated health and safety guidance and a written directive on wheelchair use and management. • Wheelchairs were numbered, allocated to residents, and their footplates were checked … (AI summary)
Responded
Linda Fisher
Concerns: The coroner noted concerns regarding the reliance on patient-reported weight for medication dosage when direct weighing was not possible, and the lack of processes for obtaining and communicating relevant family medical history to medical staff.
Response (Blackpool Teaching Hospitals NHS Foundation Trust): • The Trust stated that familial history was obtained, contradicting the finding that it was not obtained. • The Trust indicated that the timing of obtaining the familial history had … (AI summary)
Responded
Courtney Mills
Concerns: The coroner noted repeated difficulties in obtaining a specific medication (Clonidine) for a patient, caused by prescription errors and a lack of communication between the GP surgery and the hospital. These issues led to delays that put the patient at risk of withdrawal symptoms.
Response (Waterside Medical Centre): • The GP contacted the pharmacist and the on-call paediatrician to address the immediate issue of obtaining Clonidine medication. • The GP supplied a handwritten prescription for a thirty-day supply … (AI summary)
Response (Portsmouth Hospitals NHS Trust): • The Trust stated that its Children's Assessment Unit (CAU) has an established process for prescribing and dispensing non-routine medicines when community pharmacists encounter difficulties. • The Trust confirmed it … (AI summary)
Responded
Gary Bradshaw
Concerns: The coroner noted delays in diagnosis, issues with incomplete blood test reporting, and medication prescribed before test results were known. Concerns also included an insufficient threshold for flagging critical blood-calcium levels, inadequate record-keeping, and apparent gaps in patient escalation to intensive care.
Response: • Staff have been reminded of the correct electronic and handwritten procedures for ordering blood tests, and consultants have been instructed to follow up on all ordered investigations. • Trust … (AI summary)
Response (Department of Health): • The Department of Health noted that the National Institute for Health and Care Excellence (NICE) would develop a guideline on renal stones. • The Department of Health noted that … (AI summary)
Responded
Rainer Wickens
Concerns: The coroner noted delays in treating a patient's clot risk, gaps in medical notes, and poor verbal communication during handovers between treating doctors. There was also a communication breakdown that delayed a CTPA scan.
Response (St Georges Healthcare NHS Trust): • The Trust stated it had discussed missed opportunities for early incident reporting with clinicians involved in Mr. Wickens' care. • The Trust confirmed ongoing training is being provided to … (AI summary)
Responded
Denise Prior
Concerns: The coroner noted inadequate record-keeping practices at St Richards Hospital regarding the recording and prescription of oxygen levels, and issues with the application or deviation from the NEWS system.
Response (Western Sussex Hospitals NHS Trust): • The Trust undertook a thorough investigation and review. • The Trust enclosed an action log detailing the actions taken. (AI summary)
Responded
Thomas Maher
Concerns: Concerns included missing medical records, inconsistent falls risk assessments, and an inactive fall alarm during a patient's fall. The coroner also identified difficulties with inter-hospital patient transfers and incompatible electronic and paper patient record systems.
Response (Central Manchester University Hospital NHS Trust): • The Trust implemented a new process for scanning records of deceased patients and high-level incidents into the electronic patient record system, with a long-term aim for all patient records … (AI summary)
Responded
Daniel McCallum Keane
Concerns: The coroner noted inadequate record-keeping and unclear processes for prescribing medication within the GP practice. Concerns were also raised about the GP's lack of action after being alerted to a patient's extreme risk and difficulty managing their diabetes.
Response (Department of Health): • The patient safety expert group (primary care) at NHS England is undertaking work on safer discharge from hospital. • NHS England is currently considering the long-term implications of developing … (AI summary)
Responded
John Cook
Concerns: The DNA CPR form lacked the issuing consultant's hospital and contact details, and its validity wording was unclear, leading to misinterpretation. There is no clear process for retrieving and marking expired or invalid forms.
Response (NHS England): • NHS England stated it would not recommend changes to the DNACPR form to include a telephone number. • NHS England noted that Oxford University Hospital NHS Trust conducts regular … (AI summary)
Responded
Select committee recommendations(27)
#176 —
Recommendation: Rudimentary facts are often missing. Niki Scordi told us that âbasic information like accurate contact detailsâ is often missing in initial referrals. 332 Carrie Peters added that âpractical changes like someone having moved address or having a different officerâ are …
Response attribution not verified
#9 — Increase NHS digital and social media presence for reproductive health conditions consistently
Recommendation: With women and girls relying on online spaces and a proliferation of femtech apps to fill gaps in their knowledge of reproductive health conditions, the NHS should increase its own digital and social media presence in relation to reproductive health …
Response attribution not verified
#8 — Improve NHS website with interactive tools, guidelines, accessibility, and mental health support
Recommendation: To supplement improvements in the provision of information on the NHS website, we recommend the inclusion of an interactive tool which can help women to determine whether they might have a reproductive health condition. We further recommend that information on …
Response attribution not verified
#7 — Enhance NHS website and app to be comprehensive, accessible, inclusive, and highly-visible
Recommendation: We know that many women and girls are using online spaces to get information and seek help while there are gaps in support in medical fields. It is therefore imperative that the NHS and trusted sources become a first-port-of-call to …
Response attribution not verified
#44 — Require Government to outline plans for upholding prison healthcare equivalence and integrating services
Recommendation: The Government must set out how it will ensure that the principle of equivalence in prison healthcare is upheld in practice. This should include a plan to address the operational barriers to healthcare delivery—such as staffing shortages, late receptions, escort …
Response attribution not verified
#182 —
Recommendation: Voluntary sector organisations ârepeatedlyâ told HM Inspector of Probation that they would like direct access to probation case management systems. 345 âAccess to the authority systems OASys and nDelius would put us in a better position for keeping abreast of …
Response attribution not verified
#178 —
Recommendation: Previously, âvoluntary sector providers had direct access to probation case management systemsâ: the case management tool nDelius and the risk assessment tool OASys (see Box 8). 336 They were able to receive and share updates on people on probation, but …
Response attribution not verified
#24 —
Recommendation: 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 …
Response attribution not verified
#6 —
Recommendation: 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 …
Response attribution not verified
#15 —
Recommendation: Departments rely on accurate and timely data to understand how people move through the asylum system, but significant gaps remain in the information held across different parts of the process. The NAO found that a reliable, single record is not …
Response status not verified
#19 —
Recommendation: We are concerned about reports of older prisoners being released without prescription medication or without being registered with a GP. We recommend all older prisoners are supported to register with a GP prior to release; where a prisoner is unable …
Response attribution not verified
#1 — Ensure urgent and full implementation of IMMDS review recommendations 6 and 7 on patient records
Recommendation: 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 …
Response attribution not verified
#26 —
Recommendation: DHSC told us it is trying to improve contact information by asking clinically extremely vulnerable people to ensure their GP records are up to date and will continue to update the records as patients improve their record keeping with their …
Response attribution not verified
#13 —
Recommendation: 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 …
Response attribution not verified
#22 —
Recommendation: Adult adoptees told us that one of the harms they experienced was the loss of their health records. The Government should introduce an adoption marker on health records so that requests for medical history can be sensitively handled and additional …
Response attribution not verified
#10 — HMRC's internal system failures perpetuate incorrect letter delivery to affected taxpayer despite interventions.
Recommendation: We have raised this case with HMRC on several occasions in the past, but the taxpayer affected has continued to receive letters, including demands for payments.32 HMRC told us that addresses on its VAT system feed through into other systems, …
Response attribution not verified
#7 — Ensure accessible information on autism assessment process is available from pre- to post-diagnosis.
Recommendation: People with autism who may find it difficult to advocate for themselves can struggle to navigate the diagnosis process. The Government should work with NHS Trusts to ensure that information about the autism assessment process is accessible and available to …
Response status not verified
#7 —
Recommendation: Results obtained from genomic testing must typically be considered in the context of an individual’s specific circumstance—including their symptoms, personal and family medical history and ethnicity—in order for the clinical significance of those results to be interpreted correctly. These personal …
Response attribution not verified
#3 —
Recommendation: Doctors may not be able to rely on patients to remember previous concussions or head traumas, especially if these happened at different times playing different sports. They must instead be able to rely on robust information that should be collated …
Response attribution not verified
#6 — Include specific questions on honour-based abuse within the Domestic Abuse Risk Assessment tool
Recommendation: The Government must include specific questions on honour-based abuse in the Domestic Abuse Risk Assessment tool to help both victims and police officers identify risks confidently and accurately.
Response attribution not verified
#22 — HMRC's outdated Child Trust Fund records hinder tracing tool, making account retrieval challenging.
Recommendation: HMRC has not kept its records on Child Trust Funds up to date, affecting the quality of its tracing tool. This means young people trying to trace their accounts through the Government Gateway are receiving data from HMRC that have …
Response attribution not verified
#2 — Retrospective mesh implant audit insufficient for capturing all adverse patient experiences
Recommendation: Although the retrospective audit of mesh implants is an encouraging first step, it will be unlikely to reflect and take into account all of the adverse effects women have experienced due to the nature of data used in the audit. …
Response attribution not verified
#29 —
Recommendation: We urge the NHS to record the pain history of women undergoing procedures so that their needs can be prepared for. The NHS should be able to anticipate that someone who has previously struggled, for example with a smear test, …
Response status not verified
#6 — Home Office Country Policy Notes show concerning inaccuracies affecting asylum claim decisions.
Recommendation: We share expert witnesses’ concerns about the performance of the Home Office Country Policy and Information Team and the accuracy and timeliness of Country Policy and Information Notes (CPINs). We heard several examples of outdated or otherwise inaccurate CPINs leading …
Response attribution not verified
#19 — HMRC's data on unclaimed Child Trust Fund accounts remains significantly out-of-date.
Recommendation: HMRC’s understanding of accounts yet to be claimed is nearly two years out-of-date: its most recent estimate of the number of Child Trust Fund accounts yet to be claimed 22 Qq 27, 86; Hansard, HC written answer, Child Trust Fund, …
Response attribution not verified
#21 — HMRC has not actively protected Child Trust Fund customers or monitored provider behaviour.
Recommendation: HMRC judged that, by 2013, the risk of tax loss from people opening Child Trust Funds they were not entitled to had fallen significantly. Few Child Trust Funds were opened after this point. We questioned whether HMRC had also assessed …
Response attribution not verified
#20 — HMRC significantly reduced Child Trust Fund monitoring and compliance activity since 2013.
Recommendation: HMRC receives annual returns from providers with information about Child Trust Funds, including the number of accounts held and the number that have not been accessed by their owners. It told us that in the period when new accounts were …
Response attribution not verified
HSSIB safety recommendations(62)— showing 50 strongest matches
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that HM Prison and Probation Service ensures that the development of the Digital Prison Services system includes interoperability with healthcare IT systems. This will ensure that information which does not impinge on the confidentiality requirements of either system, …
Safety Recommendation
Medication not given: discharge from an acute hospital to the community
How does your organisation support staff to quickly and easily identify what medication a patient is currently taking and their medication history?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
Does your organisation ensure it is easy for staff to access information in patients’ records relevant to decision making about anticoagulant medication?
Learning Prompt
Medication not given: anticoagulation before and after a procedure
How does your patient record system support staff to document and clearly display the rationale behind any decision to pause anticoagulant medication?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation capture information when patients self-administer time critical medications?
Learning Prompt
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 …
Safety Recommendation
Wrong patient details on blood sample
Trusts can seek to understand ‘work as done’ by staff and take a safety science approach when developing blood sampling and labelling policies.
Learning Prompt
Wrong patient details on blood sample
It is recommended that NHSX should take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling.
Safety Recommendation
Residual drugs in intravenous cannulae and extension lines
Patients with multiple IV access sites are believed to be at greater risk of residual drugs in cannulae and extension lines. Recording of IV sites is not consistent.
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
In adult care, administration of flushes is rarely reconciled or recorded on perioperative documentation.
Learning Prompt
Residual drugs in intravenous cannulae and extension lines
It may be beneficial to increase the use of body maps to record the presence of all indwelling items, such as cannulae, catheter and drains, during an anaesthetic procedure. The body map could be used as part of an enhanced …
Safety Observation
Management of chronic asthma in children aged 16 years and under
It may be beneficial if children were coded as having suspected asthma if under five years of age and on inhalers without an asthma diagnosis, recognising that the lack of a formal diagnosis leads to suboptimal care.
Safety Observation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
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 …
Safety Recommendation
Local integrated investigation pilot 1: Incorrect patient identification
The Ambulance Trust now includes the importance of patient identification, including using the NHS number to verify a patient’s identification, in its mandatory training. HSIB notes the following specific national safety risk The NHS number is a unique identifier for …
Safety Action
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.
Safety Action
Local integrated investigation pilot 1: Incorrect patient identification
It may be beneficial if the Ambulance Trust adjusts its call audit tool to assess whether patient identification is correctly confirmed.
Safety Observation
Local integrated investigation pilot 1: Incorrect patient identification
It may be beneficial if further national work is undertaken on the use of the NHS number as a unique identifier, specifically in identifying patients.
Safety Observation
Local integrated investigation pilot 1: Incorrect patient identification
It may be beneficial if the Ambulance Trust develops mechanisms to capture the NHS number at the point of initial contact.
Safety Observation
Local integrated investigation pilot 1: Incorrect patient identification
HSIB recommends the Acute Trust work with the Ambulance Trust to develop and implement a standardised approach to verifying and confirming a patient’s identification during the handover process. HSIB makes the following safety observations
Safety Recommendation
Local integrated investigation pilot 1: Incorrect patient identification
HSIB recommends that the Acute Trust explores the barriers to checking three identifiers when confirming a patient’s identification for their wristband, and takes appropriate action.
Safety Recommendation
Local integrated investigation pilot 1: Incorrect patient identification
HSIB recommends that the Ambulance Trust develops and implements a standardised approach to patient identification in the emergency operations centre.
Safety Recommendation
Local integrated investigation pilot 2: Incorrect patient details on handover
It would be beneficial if there was national guidance on the principles for good design of tools to support the critical task of patient identification.
Safety Observation
Local integrated investigation pilot 2: Incorrect patient details on handover
It would be beneficial if it was easier for trusts to find clear national guidance on what a good patient identification check looks like to assist the quality and consistency of trust guidance.
Safety Observation
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that NHS England and NHS Improvement leads a review of risks relating to patient identification in outpatient settings, working with partners to engage clinical and human factors expertise. This should assess the feasibility to enhance or implement layers …
Safety Recommendation
Local integrated investigation pilot 2: Incorrect patient details on handover
It may be beneficial if the Acute Trust considers the results of current research to understand whether a way of visually identifying patients with dementia would be appropriate to help positive patient identification. HSIB notes the following specific national safety …
Safety Observation
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the Acute Trust tests its positive patient identification procedure for patients with dementia in order to identify risks and support the development of effective mitigating controls.
Safety Recommendation
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the Acute Trust carries out additional personal identification data verification when an NHS number is not available.
Safety Recommendation
Local integrated investigation pilot 2: Incorrect patient details on handover
HSIB recommends that the Ambulance Trust carries out additional personal identification data verification when a successful Patient Demographic Service search via NHS Spine has not been achieved.
Safety Recommendation
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.
Safety Recommendation
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 …
Safety Recommendation
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.
Safety Action
Patients at risk of self-harm: continuous observation
Is there comprehensive, clear, and accessible documentation available to both mental and physical healthcare staff?
Learning Prompt
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
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.
Safety Observation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
How does your organisation ensure discharge correspondence is updated if a patient has further clinical input after the correspondence was written?
Learning Prompt
Clinical investigation booking systems failures: written communications in community languages
It may be beneficial if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
Safety Observation
Clinical investigation booking systems failures: written communications in community languages
It may be beneficial if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
Safety Action
Electronic patient record systems – electronic referrals for ongoing care
HSSIB recommends that NHS England/Department of Health and Social Care, in collaboration with relevant Royal Colleges: commissions the development of advice and guidance request and response templates for specialties where these do not exist, including general practice supports effective implementation …
Safety Recommendation
Electronic patient record (EPR) systems – thematic review
How does your organisation identify whether an EPR system meets relevant standards, such as those that support clinical risk management and interoperability?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation identify whether an EPR system can perform the tasks needed to meet organisational requirements and meet expected national standards?
Learning Prompt
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?
Learning Prompt
Patient care in temporary care environments
Does your organisation have a means of tracking individual patients who are in a temporary care environment to support their clinical observations, understanding their needs and a process by which they document the length of time they have been in …
Learning Prompt
Medication not given: anticoagulation before and after a procedure
How does your organisation consider factors relating to equipment which may affect the successful implementation of EPR/ePMA systems?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure information and documentation used to support the care pathway are aligned across different organisations?
Learning Prompt
Online prescribing: challenges and opportunities to improve patient safety
Independent prescribing organisations can improve patient safety by ensuring that patient information contained in the NHS App is not used as a sole source of verification when making clinical decisions, as this is outside the purpose of the App and …
Safety Observation
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care develops a policy and implements a mechanism to enable appropriate NHS patient information to be shared with independent prescribing organisations. This is to ensure independent prescribing organisations can access verified …
Safety Recommendation
Electronic prescribing and medicines administration systems and safe discharge
The use of paper and electronic systems in parallel should be minimised to reduce the risk of error caused by multiple data entry/retrieval sources.
Safety Observation
Unplanned delayed removal of ureteric stents
The NHS Summary Care Records (SCR) system is being developed to allow for specific patient groups to be flagged. It may be beneficial for the British Association of Urological Surgeons to liaise with NHSX should opportunities arise in the future …
Safety Observation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHSX, supported by NHS England and NHS Improvement, implements a discovery programme into the roadmap for the digital personal child health record focused on developing support, self-reporting and alerting for asthma self-care.
Safety Recommendation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Telephone triage Difficulties in communication were identified, relating to the availability and presentation of clinical records, documentation and communication of information from triage calls, and availability of interpretors particularly in urgent circumstances. The usual reliance on family members to provide …
Learning Prompt
Access to critical patient information at the bedside
It may be beneficial for healthcare organisations to provide guidance to support decisions in clinical areas that balance confidentiality and the visibility of critical patient information for patient safety.
Safety Observation
NCEPOD recommendations(42)
Time to Get Control?
Wording not shown. See the report on NCEPOD's website.
Time to Get Control?
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
CQC inspection actions(555)— showing 50 strongest matches
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.
Must Do
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.
Must Do
Weston General Hospital
Develop the focus on the quality and safekeeping of care records
Should Do
Westmorland General Hospital
The service must ensure appropriate systems are used for maintaining accurate, complete and contemporaneous records for service users
Must Do
Westmorland General Hospital
The trust must ensure all patients are clinically assessed and National Early Warning Scores are documented for all patients.
Must Do
Westmorland General Hospital
The trust must ensure pain is assessed in line with clinical standards, administered in a timely way and recorded in patient notes.
Must Do
West Cumberland Hospital
The trust must improve the quality and accuracy of record keeping ensuring clinical records are contemporaneous, detailed, signed and clearly show the care and treatment patients receive and when they have received it.Regulation17(1)(2)(c)(d).
Must Do
The York Hospital
The trust should consider introducing auditing of consent and patient records.
Should Do
The York Hospital
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Must Do
The York Hospital
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Must Do
The York Hospital
The service must ensure ED staff maintain detailed records of patient’s care and treatment, so they are clear, up to date and stored securely.
Must Do
The Princess Royal Hospital
The trust should continue to work on the completion and quality of care records.
Should Do
The Princess Royal Hospital
The trust should ensure that the service use electronic system for patient’s records.
Should Do
The Princess Royal Hospital
The service should continue to ensure records are stored securely and contain a clear and contemporaneous account of the care and treatment provided.
Should Do
The Princess Royal Hospital
The service should ensure records are completed consistently to assess and mitigate individual patient safety risks.
Should Do
The Ipswich Hospital
The service must ensure that women’s records are completed in line with trust policy.
Must Do
Sunderland Royal Hospital
The trust must ensure staff appropriately record mental capacity assessments and decisions made in service user’s best interests.
Must Do
Sunderland Royal Hospital
The trust must ensure staff appropriately record mental capacity assessments and decisions made in service users' best interests.
Must Do
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.
Must Do
St Austell Hospital - Penrice Birthing Unit
The service should ensure staff sign and date all records.
Should Do
St Austell Hospital - Penrice Birthing Unit
The service should ensure there is clear documentation of how women and birthing people meet the criteria for using the free-standing midwifery-led units for care in labour.
Should Do
St Albans City Hospital
The trust should ensure patient resuscitation and treatment plan records are completed and information is easy to locate.(Regulation 17).
Should Do
St Albans City Hospital
The trust should ensure that pain scores are clearly recorded (Regulation 12).
Should Do
St Albans City Hospital
The trust should ensure that records are always clear, up-to-date or easily available to all staff providing care (Regulation 17).
Should Do
St Albans City Hospital
The trust must ensure that patient medical records are accurate, complete and contemporaneous including risk assessment and nutritional assessments.
Must Do
South Tyneside District Hospital
The trust must ensure medicines are stored appropriately, and records of medication including controlled drugs, are maintained appropriately.
Must Do
South Tyneside District Hospital
The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately record mental capacity assessments and decisions made in service user’s best interests.
Must Do
South Tyneside District Hospital
The trust must ensure service user records are audited appropriately to evidence ongoing compliance with the requirements of the Mental Capacity Act 2005 and to identify missed opportunities to safeguard service users.
Must Do
South Tyneside District Hospital
The trust must ensure staff appropriately record mental capacity assessments and decisions made in service users' best interests.
Must Do
Southport & Formby District General Hospital
The trust should continue to work towards electronic patient records to promote accuracy of holistic record keeping.
Should Do
Scarborough Hospital
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Must Do
Scarborough Hospital
The trust must ensure that patients records are maintained securely, are accurate, complete, and contemporaneous records maintained in respect of each service user.
Must Do
Scarborough Hospital
The service must ensure ED staff maintain detailed records of patient’s care and treatment, so they are clear, up to date and stored securely.
Must Do
Salford Royal Hospital
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
Must Do
Salford Royal Hospital
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
Must Do
Russells Hall Hospital
The trust must ensure that they maintain an accurate, complete and contemporaneous record in respect of each service user, including a record of care and treatment provided to the service user and of decisions taken in relation to the care …
Must Do
Royal Victoria Infirmary
The service should ensure that consent is recorded in all patient contact.
Should Do
Royal Victoria Infirmary
The service should consider methods of recording pain relief that allows for review of care given.
Should Do
Royal Victoria Infirmary
The service should ensure that records are accessible to all people as necessary to deliver people’s care and treatment in a way that meets their needs and keeps them safe.
Should Do
Royal Victoria Infirmary
The service should ensure that records are accessible to all people as necessary to deliver people’s care and treatment in a way that meets their needs and keeps them safe.
Should Do
Royal Victoria Infirmary
The service must ensure that staff complete mental capacity and best interest decisions, when obtaining consent and that they clearly document the assessment and decisionmaking-making process.
Must Do
Royal Victoria Infirmary
The service must ensure that patient records include plans for managing risks.
Must Do
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.
Must Do
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.
Must Do
Royal Shrewsbury Hospital
The trust should ensure that emergency department records are stored securely in all areas.
Should Do
Royal Shrewsbury Hospital
The trust should continue to work on the completion and quality of care records.
Should Do
Royal Shrewsbury Hospital
The service should continue to ensure records are stored securely and contain a clear and contemporaneous account of the care and treatment provided.
Should Do
Royal Shrewsbury Hospital
The service should ensure records are completed consistently to assess and mitigate individual patient safety risks.
Should Do
Royal Preston Hospital
The service must ensure that staff complete patient records accurately and in a timely manner.
Must Do
HMICFRS recommendations(4)
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
FRS 2023-25 CoC Recommendations: Avon Fire and Rescue Service
Cause of concern: The service still doesn’t have an effective system to make sure it gathers and records relevant and up-to-date risk information to help protect firefighters, the public and property during an emergency. We found examples of the risk …
Recommendation
ICIBI immigration recommendations(2)
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should develop robust contingency plans to prepare for future crisis events. These plans must focus on the accurate collection and assurance of data.
An inspection of the Home Office’s Afghan resettlement schemes (October 2022 – …
The Home Office should prioritise and adequately resource the cleansing of applicant data relating to all Afghan resettlement schemes to provide as accurate a dataset as possible.
PPO death in custody recommendations(89)— showing 50 strongest matches
The Head of Healthcare
The Head of Healthcare should ensure that the clinical record is an accurate reflection of significant interactions between staff and prisoners.
The Head of Healthcare
The Head of Healthcare to provide reflective and supportive supervision to the RMN who provided care to Mr Louis overnight on the 26 April 2023, and specifically to address the record keeping issues identified. To ensure that the RMN is …
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff fully and accurately document all clinical interactions and decisions, in line with the standards specified by the General Medical Council and Nursing and Midwifery Council.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that: • prison staff record key information about their contact with prisoners on NOMIS, the prison records database, accurately and in a timely manner; and that • healthcare staff make contemporaneous records …
The Head of Healthcare
The Head of Healthcare should: • ensure that all healthcare staff are aware of the need to document all clinical care in a prisoner’s SystmOne record; and • carry out audits to ensure this is being done.
The Head of Healthcare
The Head of Healthcare should ensure daily clinical records for segregated prisoners capture and clearly reflect clinical thinking and assessment, in line with Nursing and Midwifery Council practice and communication standards.
The Head of Healthcare
The Head of Healthcare should ensure that all clinical assessments are fully documented in the patient’s medical record.
The Governor
The Governor should ensure that staff complete all relevant sections of a prisoner’s personal records and wing documents; and fully document all significant interactions and decisions.
The Head of Healthcare at HMP Frankland
The Head of Healthcare should ensure clinic letters are obtained and are available to view within the patient’s SystmOne medical records. This will ensure continuity of care and support the ongoing management of diagnosed health conditions.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff make detailed, timely and accurate entries in prisoners’ medical records in line with the Nursing and Midwifery Council’s Code and the Health and Care Professions Council’s Standards of Conduct.
The Head of Healthcare
The Head of Healthcare should ensure healthcare staff keep accurate and timely records of significant contacts.
The Head of Healthcare of HMP Liverpool
The clinical reviewer concluded that healthcare staff did not always adequately record their contact with prisoners. The Head of Healthcare will want to ensure this is improved.
The Governor
The Governor should ensure that staff fully document all significant interactions and decisions in prisoners’ personal records as well as other relevant documents; and implement robust auditing.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that all relevant information about a prisoner is documented and shared appropriately and that there are robust quality assurances process in place to check this is happening routinely.
The Governor
The Governor should ensure that PERs are always updated to record relevant events.
Manx Care
Manx Care should implement electronic medication administration records.
The Director at Parc
The Director at Parc should ensure that staff assess risk based on all relevant information, including that held in medical records;
The Head of Healthcare
The Head of Healthcare should ensure that when healthcare staff undertake clinical assessments of acutely unwell patients, they complete a comprehensive assessment that includes obtaining a patient’s past medical history to inform a safe and comprehensive ongoing clinical treatment plan.
The Head of Healthcare
Records of initial health screens are accurate.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should formalise the way that PS incidents are assessed and the handover of care from healthcare to prison staff including: • The development and introduction of a PS assessment template for SystmOne, to include …
The NHS Commissioner for South Central
The NHS Commissioner for South Central should write to the Ombudsman, setting out how they intend to improve clinical record keeping at HMP Winchester.
The Head of Healthcare
The Head of Healthcare should ensure that all external hospital appointment locations are cross referenced against referral information/hospital confirmation letters to ensure patients are taken to the correct appointment location.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff share important information about a prisoner’s risk to himself with prison staff.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff accurately complete the medical information section of the escort risk assessment in full.
The Head of Healthcare
The Head of Healthcare should carry out an audit to ensure that healthcare staff appropriately consult prisoners’ full medical records when they raise concerns about their health.
The Governor and Head of Healthcare at HMP Lincoln
review processes to ensure staff consider PERs and SASH forms and record that they have done;
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review reception procedures to ensure that all staff supporting individuals and completing initial risk assessments have access to relevant information, including digital PERs, SASH forms and prison records.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review their information sharing protocol for prisoners with serious medical conditions such as epilepsy.
The Head of Healthcare
All referral forms include learning disability and autism in the list of significant conditions.
The Head of Healthcare
Staff use the alert function on SystmOne to include significant conditions such as ADHD and autism on the patients record.
The Head of Healthcare at HMP Drake Hall
The Head of Healthcare at HMP Drake Hall should ensure that healthcare staff take appropriate action in response to abnormal readings for blood pressure and cholesterol, in line with the National Institute for Health and Care Excellence (NICE) guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that there is a system in place for prisoners with chronic disease to be monitored and assessed effectively.
The Head of Healthcare
The Head of Healthcare should ensure there is a system in place for GPs to follow-up and action abnormal blood test results and blood pressure readings.
The Governor and The Head of Healthcare
The Governor and The Head of Healthcare should review the arrangements in place to ensure that information about changes to a prisoner’s risk and management is communicated promptly between operational and healthcare staff.
The Head of Healthcare
The Head of Healthcare should investigate why the reason for Mr Rigby’s GP appointment on 1 December 2023 was not included on the appointment ledger and take appropriate action.
The GP provider
The GP provider should ensure that all GPs are using the GMCs guidance on record keeping including when using remote consultation methods.
The Deputy Director of Immigration Prison Teams (North and South)
The Deputy Director of Immigration Prison Teams (North and South) should ensure that HOIE staff: share and record their contact with prisoners (and detainees) in prison records, including ACCT documents;
The Head of Healthcare
The Head of Healthcare should remind staff to ensure that patients understand the risks of refusing medical tests and clearly document this in medical records.
The Director of HMP Peterborough
The Director should ensure that all relevant interactions with prisoners, including those with the foreign national coordinator, are accurately recorded in the prisoner’s NOMIS record.
The Serco Contract Director for Prisoner Escort and Custody Services …
The Serco Contract Director for Prisoner Escort and Custody Services (PECS) must ensure that information is recorded in a detainee’s PER after every significant interaction, including any medical treatment given.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that accurate information is given from the scene of an emergency incident to staff in the control room about the condition of a prisoner.
The Head of Healthcare
The Head of Healthcare should ensure that all prisoners with multiple NHS numbers have their records merged within 24 hours of arriving at Wandsworth.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff: are fully competent in using the National Early Warning Score (NEWS2) effectively; complete full and accurate clinical observations; follow protocols for clinical escalation in line with NEWS2 and sepsis pathways; and …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should examine Reception practices and devise a plan to ensure that all relevant staff read and appropriately respond to information contained in Person Escort Records when processing prisoners.
The Head of Healthcare
The Head of Healthcare should check and ensure that all staff, including agency staff, have been trained to access the digital Person Escort Record.
The Head of Healthcare
The Head of Healthcare should conduct an urgent review of the following areas of mental healthcare delivery at Wakefield: ▪ develop a protocol for disseminating transfer handover information, within a centralised email system, not to an individual staff member’s email, …
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that healthcare professionals completing segregation unit health screens have access to the prisoner’s medical history and are always given the opportunity to speak to the prisoner.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should ensure that staff manage prisoners at high risk of complications from COVID-19 in line with national guidance. Key actions and decisions should be fully documented in prisoners’ medical and personal records.
The Head of Healthcare
The Head of Healthcare should ensure that newly arrived prisoners with long-term medical conditions are managed appropriately, including: • prompt referrals to the GP at the prison; • offering a further opportunity for a secondary health screen if a prisoner …
The Director and Head of Healthcare (HMP Northumberland)
The Director and Head of Healthcare should ensure that all staff undertaking risk assessments for prisoners taken to hospital understand the legal position on the use of restraints and that, in all cases: healthcare staff complete the medical section of …
IOPC learning recommendations(7)
Recommendation - West Midlands Police, April 2021
The IOPC recommends that West Midlands Police takes steps to ensure that an appropriate and consistent level of information is included in custody records/Electronic Detention Logs (EDLs) when completing a pre-release risk assessment. This should include considering: - minimum standards …
Stop and search, Harlesden - Metropolitan Police, October 2018
The IOPC recommends that Metropolitan Police Service officers ensure that all detainees are informed as soon as practicable if the charges against them change and that this is reflected in the relevant documentation. Our investigation found that a man was …
Recommendation - Devon and Cornwall Police, August 2020
The IOPC recommends that Devon and Cornwall Police take whatever action is necessary to ensure hostage negotiators are aware that BWV or voice recording equipment is being used throughout the duration of negotiations to ensure that all conversations and decisions …
National recommendations - National Police Chiefs' Council, August 2020
The IOPC recommends that the National Police Chiefs’ Council (NPCC) should give due consideration to records of historic convictions still held on microfiche and how they will be managed within the new system that will be replacing the Police National …
National recommendations - National Police Chiefs' Council, August 2020
The IOPC recommends that the National Police Chiefs’ Council (NPCC) writes to all forces to determine for each whether their Police National Computer (PNC) training and/or guidance is up to date with the College of Policing guidance and specifically whether …
Concerns for man's welfare - Cleveland Police, May 2022
The IOPC recommends that Cleveland Police should implement a system or protocol to ensure that potential discrepancies in address – in which a reporting person provides an address that does not exactly match those available to select on Force systems …
Police contact with a woman and her partner, prior to the woman’s …
The IOPC recommends the Metropolitan Police Service (MPS) should amend the ‘Gathering Evidence’ section of its Domestic Abuse (DA) Policy. Currently it says, ‘Officers must ensure that they gather as much information as practicable… and record the information gathered and …
NAO audit recommendations(10)
Protecting and supporting the clinically extremely vulnerable during lockdown
NHSE&I and NHS Digital should set out how they will improve the accuracy of patient telephone numbers to improve the speed of communication with patients;
Accepted
DWP Report on Account 2022/23
DWP should: b develop the capability to record detected underpayments across all benefits as part of any planned updates to its IT systems.
Rejected
DWP Report on Account 2022/23
DWP should: b perform more in-depth analysis to determine the root cause of a greater number of detected underpayments; and
Partially accepted
DWP Report on Account 2022/23
b establish an ?early warning system? to record types of underpayment errors that happen repeatedly and take action before they develop into significant issues. As part of setting up this system DWP should: ? encourage frontline staff to refer large …
Partially accepted
DWP Report on Account 2022/23
a work with HMRC to review the level of assurance over the integrity of National Insurance records and identify ways to reduce error in the records.
Accepted
The Department for Environment, Food and Rural Affairs annual report and accounts …
I also recommend that EA develop more robust controls over the input and maintenance of data in its property, plant and equipment records.
Accepted
The Department for Environment, Food and Rural Affairs annual report and accounts …
I recommend that EA, with support from the Department, carries out a review of the data quality and cleanse the property, plant and equipment records prior to embarking on a large revaluation exercise.
Accepted
Environment Agency Annual Report and Accounts 2021-22
I also recommend that the Environment Agency develops more robust controls over the input and maintenance of data in its property, plant and equipment records.
Accepted
Environment Agency Annual Report and Accounts 2021-22
I recommend that the Environment Agency carries out a review of the data quality and cleanse the property, plant and equipment records prior to embarking on a large revaluation exercise.
Accepted
The Affordable Homes Programme since 2015
Discuss with Homes England and the GLA what data gaps it has and how to address them in a proportionate way. This includes data to support its economic modelling, evaluate benefits and ensure adequate oversight
Accepted
IMB annual reports(9)
Gatwick, Stansted, Luton and Lunar House (2022)
The IMB report for Gatwick, Stansted, Luton airports and Lunar House covers the period ending January 2022, noting a significant increase in detained individuals. While C&C officers are generally compassionate, the Board highlights ongoing concerns about the inadequacy of holding rooms at all locations for increasing numbers, extended stays, and vulnerable individuals. Key issues include limited space, lack of natural light, absence of showers, and persistent problems with access to onsite healthcare professionals and timely medication.
PRISON
Key concerns
Dover (2022)
The Dover Independent Monitoring Board's 2021 report details critical issues at the Tug Haven, Kent Intake Unit (KIU), and Frontier House Short-Term Holding Facilities. While some initial improvements were noted in induction processes and staff interactions, the facilities were largely unsuitable for their purpose, particularly Tug Haven, which routinely held detainees overnight in overcrowded, unheated tents with inadequate sleeping, washing, and food provisions. Significant concerns were raised about poor hygiene, brief and ineffective medical screenings leading to undetected serious injuries, and excessive lengths of stay, causing distress and confusion among detainees, including vulnerable families and children.
PRISON
Key concerns
Kent Coast Short Term Holding Facilities (STHF) (2022)
The IMB report for Kent Coast STHFs in 2022 documented a year of unprecedented small boat arrivals, leading to significant overcrowding and challenges across Western Jet Foil, Kent Intake Unit, and Manston. A primary concern was the widespread practice of detaining individuals for periods far exceeding the statutory 24-hour limit in conditions deemed unsuitable, particularly at Manston. While staff were commended for their compassion, critical issues persisted regarding lack of privacy for sensitive interviews, inadequate basic provisions, poor sleeping arrangements, and insufficient information for detainees about their processing journey.
PRISON
Key concerns
Lincoln (2024)
HMP Lincoln, a Category B reception and resettlement prison, continues to treat prisoners fairly and humanely despite challenges from its Victorian infrastructure and high transient population. Positive aspects include improved cleanliness, effective neurodiversity support, and dedicated staff. However, key concerns persist regarding maintenance backlogs, slow access to specialist mental health facilities, property management issues, and inadequate support for remand prisoners and vulnerable populations.
PRISON
Key concerns
Littlehey (2024)
HMP Littlehey, a Category C training prison for sex offenders, generally maintained a safe and humane environment with positive developments like a new wing and in-cell phones. Despite commendations for healthcare and resettlement efforts, the IMB remains critically understaffed, hindering its monitoring capacity. Key challenges include persistent cell sharing, poor property transfer management, healthcare resource deficits, and inadequate educational provision, many of which are repeated concerns.
PRISON
Key concerns
Pentonville (2025)
HMP Pentonville, a category B local prison, faced significant challenges including severe overcrowding, crumbling infrastructure, and a rise in drug use. While some improvements were noted in safety management, the Board raised serious concerns about inhumane living conditions, inadequate key work provision, and delays in support for vulnerable prisoners. The report highlights the impact of capacity pressures on regime delivery and resettlement efforts, stressing the need for urgent investment in the prison's fabric and resources.
PRISON
Key concerns
Ashfield (2025)
The reporting period for HMP Ashfield was marked by significant change, including a new contract with Serco and the establishment of a new therapeutic community. While the Board found the prison generally safe, with high prisoner satisfaction in feeling secure, there were increases in self-harm and violence incidents compared to unusually low previous year figures. Key concerns include persistent staffing challenges impacting morale, inadequate social and dementia care for the aging population, and issues with the new split-week regime affecting purposeful activity and pay.
PRISON
Key concerns
Scotland and Northern Ireland short-term holding facilities (STHF) (2025)
This report monitors Short-term Holding Facilities (STHFs) in Scotland and Northern Ireland, highlighting significant variations in standards and persistent concerns despite positive staff interactions at times. Key issues include a lack of independent oversight for Controlled Waiting Areas, the continued mixed-sex detention at Larne House, and inconsistent, often inadequate, healthcare provisions, particularly the removal of prescription medication. The Board also raised concerns about substandard accommodation, excessively long detention periods in unsuitable conditions, and a strikingly low number of formal complaints, indicating systemic barriers to raising grievances.
PRISON
Key concerns
Durham (2022)
HMP Durham, a reception and resettlement prison, housed 976 prisoners at year-end, with 61.6% on remand, operating above its certified capacity. The Board commends staff for managing a challenging environment, noting that 93% of prisoners feel safe. Key concerns include persistent overcrowding, the increasing time unsentenced prisoners spend on remand due to court backlogs, and inadequate access to dentistry and certain induction processes. The report highlights improvements in staff attendance at key meetings and UoF monitoring, but also calls for better embedding of BWVC use and addressing regime limitations affecting education and resettlement.
PRISON
Key concerns
IMB individual recommendations(25)
Wymott (2020)
Management of the delivery of healthcare appointment slips remains problematic (see paragraph 6.2.4). Can a more reliable method be found?
Governor / Director
Bristol (2024)
Healthcare concerns are one of the top issues raised with the IMB by prisoners at HMP Bristol. Are you satisfied that the contract with Oxleas NHS Foundation Trust meets the needs of the prisoners?
Governor / Director
In Progress
Portland (2020)
Checks need to be put in place to ensure that critically unwell prisoners, suffering significant health problems, cannot be unilaterally transferred. Should this ever be necessary, it should not happen without prior negotiation with the receiving establishment and the provision of up to date and comprehensive medical records.
HMPPS
Noted
Thameside (2023)
Address the continued deficiencies of on wing CMS which have a major impact on prisoners’ lives.
Governor / Director
In Progress
Guys Marsh (2023)
Records of prisoner learning achievements can be piecemeal and inaccurate. Has the Prison Service conducted any quality assurance on these records and if so, is the Prison Service confident that these records are fit for purpose?
HMPPS
Thameside (2025)
What is being done to improve record keeping across departments, e.g. key worker entries, minutes of meetings, action trackers, CSIP paperwork, accurate recording of foreign national prisoner language levels?
Governor / Director
Send (2025)
The Board would like to see a process in place for healthcare professionals to record why prisoners decline breast screenings (6.1).
Governor / Director
North West and Midlands STHF (2025)
For the seventh year in succession, the Board repeats its concern at the lack of proper procedures that would allow the Home Office or its contractors to routinely provide detained individuals with access to their own medication. The Board considers the welfare of some of those who have been detained may have been adversely affected by this situation, depending on …
Home Office
Exeter (2020)
Will the Prison Service undertake to improve the arrangements within the prison estate and with its transport contractors in giving prisoners’ property a higher priority and ensure better care and management of property on transfer between prisons? (See paragraph 5.8).
HMPPS
In Progress
Exeter (2020)
Will the Prison Service increase support given to prisons regarding how the required data collection and reporting processes can be practically applied to make a positive impact on the operation of the prison and the lives and experiences of prisoners? (See paragraph 4.2).
HMPPS
In Progress
Durham (2020)
What can be done to improve prison staff entries into prisoner portfolios?
Governor / Director
Wormwood Scrubs (2021)
When a prisoner refuses to attend a hospital appointment, can the reason for that refusal be noted on the relevant documentation?
Governor / Director
Usk and Prescoed (2021)
As reported in our 2020 report, up to fifty per cent of the OASys documents received in HMP Usk vary in quality with the “start custody” section either remaining blank or the quality of recording falling short of expectation. See 7.3.3
HMPPS
In Progress
Bristol (2022)
The actual waiting times for access to specialist mental health services experienced by prisoners appear to be longer than reported. This is due to the design of the reporting rules covering different stages of the pathway. Will the rules be reviewed so that the reported figures accurately reflect the total time waited?
Ministry of Justice
Thameside (2024)
The Board has concerns about how some ACCT documents are being completed, especially the lack of healthcare attendance at first case reviews (FCRs) in over half of the audited documents seen.
Governor / Director
Pentonville (2024)
The 2022 Prisoners’ Property Framework has yet to have any positive impact on the transfer of property between prisons. Will HMPPS commit to an evidence-based review of the Framework?
HMPPS
In Progress
Onley (2024)
As the Board has stated in every annual report for many years, missing, mislaid and delayed prisoner property continues to be a problem, particularly on transfer between prisons. The aim of the Prisoners’ Property Policy Framework is to improve the management of property, but this has not been met. The manual, paper-based system is error-prone and inefficient. It relies on …
Ministry of Justice
In Progress
Five Wells (2024)
How can the healthcare department improve prisoner understanding of changes to their medication?
Governor / Director
Wealstun (2025)
As referenced in previous reports, how will the Governor ensure that information in an ACCT file only includes paperwork for one week whilst archiving and storing the remainder? The size of some files make them difficult to navigate by staff and IMB members, thus potentially failing to see the continuity clearly.
Governor / Director
Styal (2025)
Are there any plans to decrease the amount of paperwork required for assessment, care in custody and teamwork (ACCT) assessments and observations through digitalisation and possibly the use of hand-held technology, which may reduce potential duplication or human errors?
HMPPS
Yarl’s Wood (2020)
The Board recommends that the systems and procedures in place for processing small boat migrants are more careful and thorough to ensure that those arriving at IRCs do so accompanied by the correct personal information.
Home Office
Thorn Cross (2022)
To ensure that sending prisons complete records fully (6.6.7) (4.0.2).
HMPPS
In Progress
Foston Hall (2023)
A significant number of healthcare appointments are missed. What can be done to improve communication to prisoners about appointments and enable their attendance?
Governor / Director
Hewell (2024)
Are the current health needs assessments, including mental health assessments, still fit for purpose given the changing demographics of the prison population?
HMPPS
In Progress
Yarl’s Wood IRC (2023)
R35 medical reports should be audited. The IMB should have access to oversight of this process.
NHS / Healthcare Provider
National patient safety alerts(2)
Health investigations(680)
Independent investigation: Alan ScottStella Scott, Allerton, Liverpool (2008) — Rec 2
All clinical business units in Mersey Care NHS Trust need to implement a more dynamic approach to how it audits and reviews the quality of clinical documentation. The quality of documentation was not of the standard expected in Mr SU‟s community mental health records. In particular, there was no depth …
north_west
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xv)
The Trust should make arrangements for a system of record keeping which enables clinicians and all other mental health staff with responsibility for monitoring a service user to have access to the entirety of the case notes.
london
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (iii)
The Trust and Council should ensure that risk assessment is appropriately carried out and properly recorded on the forms provided for that purpose.
london
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 14
The Trust should audit the effectiveness of the new electronic record system on a random sampling basis at six monthly intervals for the first year of running and on an annual basis thereafter.
north_west
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 8
The Trust should consider making the distinction between Voluntary and Informal patients on admission documentation. This to include: policy revision and documentation revision as required; the requirement for the assessment and documentation of capacity of all service users on admission who are not admitted under detention.
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 16
In order that adequate care can be maintained the trusts and social services should ensure that hand-over procedures are developed to enable all staff to be fully acquainted with the patient’s history and care plans. Hand-overs should not be merely oral.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
The trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 11
Tertiary services should follow local CMHT models for the integration of records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 6
Trusts and social services should review the standard of recording, and consider adopting a system of unified records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 14
In order that adequate care can be maintained the trusts and social services should ensure that hand-over procedures are developed to enable all staff to be fully acquainted with the patient’s history and care plans. Hand-overs should not be merely oral.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
Social services and trusts and should review the standard of recording, and consider adopting a system of unified records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
The trusts should consider the desirability of including in CPA documentation a note of the advice given to the patient on driving.
south_east
Independent investigation: Jean Darbyshire, Wigan (2009) — Rec 12
In the long term the Trust must conduct an audit of all service users with the same name, held within the same team, during all record keeping audits. In the short term the Trust must: conduct a record review of the clinical records of the three services users of the …
north_west
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (x)
The Trust should introduce a handover procedure, to be supervised by the Consultants, whereby junior psychiatrists coming to the end of a placement are required to make an entry in the case notes of their patients describing the salient problems and the way in which they are being managed.
london
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (ix)
The Trust should ensure that the case notes of every patient attending at the Out-patient Clinic have a front sheet setting out primary information about the patient and summarising the actions taken.
london
Independent investigation: Bridget MaclennanElizabeth Valad, Camden — Rec 15
All Trusts should ensure that information directly relevant to risk management is easily available and easily accessible (for example, by storing such information in a specifically designated part of the clinical records). The design of electronic patient records must allow for this also.
london
Independent investigation report into the care and treatment of Yusuf — Rec 2
There were minor recording errors that IT solutions could solve. Namely that the ST6 doctor was still being recorded as a foundation doctor, the child’s height was pulled through from SystmOne16 and the BMI calculations used height/weight (kg), which is more appropriate for adults, when BMI centiles are more appropriate …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.2.4
The Social Work Department should review the written clinical information that it requires to carry out its supervisory functions and ensure that this is contained within the individual’s case file. In the view of the Inquiry, this should include a formal risk assessment and risk management plan, including a crisis …
scotland
Independent investigation: Stefan Welch, Brighton (2010) — Rec 6
The Trust will conduct an audit of Brighton and Hove community-based services to ensure that all clinical documentation is completed in accordance with Trust policy expectations. This will be completed within six months of the publication of this report.
south_east
Independent investigation: Simon Breed, Wood Green (2004) — Rec R8
The trust immediately reviews the way in which all records (both electronic and paper) are secured following the occurrence of any serious incident to ensure there is no recurrence of the loss of vital clinical information.
london
Independent investigation: Simon Breed, Wood Green (2004) — Rec R7
The trust reviews its SUI policy to ensure that the loss of any patient’s health records is treated as an SUI.
london
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.11
Practitioners should be reminded of the professional requirement to maintain accurate and contemporaneous records. The Independent Investigation Team recommends that the Clinical Governance Lead for HPFT is given a copy of this report in order to assess the training needs of staff in the EIP Service with regard to note …
east_of_england
Independent investigation: Ryan Walsh, Cheshunt (2008) — Rec 25.3
EIP may wish to consider reviewing their policies and procedures regarding the recording of medication and/or prescriptions in order to ensure that a full record of the medication dispensed is maintained. The EIP Service should scan or otherwise record copies of prescriptions issued to service users in the service user’s …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Prison Service should ensure, by the end of 1996, that it has in place a database and a fully effective system whereby prisoners' IMRs, including those of remand prisoners, follow them wherever they may be in the system. The provision should encompass access to the system for all those …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec A
Case conferences should be recorded more fully.
east_of_england
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.8
There should be a unified case record for every patient that is filed logically, is capable of being viewed and searched in its entirety, and is accessible to all who might reasonably require to refer to it. The current set of records should include all key documents. There should be …
south_west
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 13
The outcome of discussions about individual patients at team meetings should go into their electronically maintained records.
north_east_yorkshire
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 12
Patient records should be maintained electronically with one core record to which all team members should have access and onto which entries by all mental health workers (including medical staff) relating to the patient must be added.
north_east_yorkshire
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 4
When a service user is known to have used violence in the past any additional risks should be identified and used to prepare an updated risk assessment and a management plan for that risk. Drinking alcohol and using illicit substances should always be recorded and included in the risk assessment. …
south_west
Independent investigation: Patricia PhilpottsBen Philpotts, Trevarrian (2010) — Rec Recommendation 2
Recognition of current risk profile: Mental health staff must obtain and record as much relevant information as possible about a new service user with complex issues or uncertainty with the formulation of diagnosis or appropriate treatment in order to understand their initial presentation and to put their situation within an …
south_west
Independent investigation: Michael Kahan, Manchester (2008) — Rec 15
The Trust should complete a regular audit of the quality of case records to test timeliness and performance against quality standards in the Trust Records Management Policy.
north_west
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 29
A comprehensive, regularly updated chronological history should be maintained which is accessible by all those (authorised to do so) who are dealing with the patient.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 28
Trusts should ensure that all professionals keep up to date, contemporaneous notes that are organised methodically and in such a way that they are readily accessed (by those authorised to do so) and easily understood.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 6
Trusts should give serious and urgent consideration to implementing a unified computerised record keeping system on which all entries relating to the day to day working with a client are recorded, by all mental health professionals.
north_east_yorkshire
Independent investigation: Lynda Lovatt, South Shields (2004) — Rec 3
Recording and communication issues Record keeping by most agencies was good. The manual handwritten nature of the GP records could be considerably improved and should be with the benefit of computer technology. Practitioners should be more prepared to pick up the phone, particularly in urgent cases – rather than just …
north_east_yorkshire
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.iv.f
Similarly, the Trust should develop a procedure for the retrieval of appropriate clinical and other information in circumstances where the original records have been lost, stolen or damaged.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.iv.e
The Trust should develop standards for record keeping consistent with national agreed standards for mental health.
north_west
Independent investigation: Liaquat Ali, Bury (1999) — Rec 2.iii.a
The recording of information should follow agreed guidelines. For example, those provided by the British Association of Social Workers on confidential and ethical recording.
north_west
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec n.
That detailed records, including a careful note of dates and times, are kept whenever an approved social worker makes an application and delegates the power to convey the patient to hospital. A form should be devised for the purpose, and it should be attached to the application and the report …
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec k.
That, provided community mental health staff make an adequate record of client examinations and interviews (in the patient‘s medical, nursing or social work notes, etc), keep their CPA documentation up-to-date, and complete any audit records required of them, they should not be required to complete any other documentation.
midlands
Independent investigation: Lewis Hodge, Birmingham (1999) — Rec e.
That, in the case of in-patients, each patient‘s named nurse is formally responsible for obtaining all of the patient‘s previous hospital notes, and that, in the case of community patients, the keyworker is made responsible.
midlands
Independent investigation: Leo Norris (10 days old), Brixham (2010) — Rec 26
DPT will develop and incorporate into the Clinical Record Self Monitoring Process question/s to check the completeness of the clinical record; that it records all contact, or attempted contact, with an individual client, and reflects all clinical discussions, informal or formal, concerning the individual client, to improve the completeness and …
south_west
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 22
The panel recommends that the Trust review the Norfolk Mental Healthcare (NHS) Trust policy relating to Preservation, Retention and Destruction of Records within three months. (Paragraph 12.7)
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 13
The panel recommends that the Trust introduce the use of a single case file to be used by all professional staff. Such a file would follow the patient so that inpatient staff and community staff would have access to the same information and all entries would be made to a …
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 5
The panel recommends that the Trust ensures within three months that a copy of all the incident report forms for every inpatient and community incident is located in the relevant patient’s health and social care notes. (Paragraph 5.11)
east_of_england
Independent investigation: John West, Sheringham Norfolk (2004) — Rec 4
The panel recommends to the Trust that the quality of the notes of all practitioners and the use of CPA documentation are audited through Management Supervision and the Trust wide audit of CPA documentation. The audit should monitor the adherence of the standards set out in the Norfolk CPA policy …
east_of_england
Independent investigation: John Stevens, Woking (2001) — Rec 19
We recommend that North West Surrey Mental Health Partnership Trust keep copies of all notes and statements which may be used as evidence in criminal or other proceedings and that managers undertake training to assist staff in the preparation of these.
south_east
Independent investigation: John Stevens, Woking (2001) — Rec 9
We recommend that the North West Surrey Mental Health Partnership NHS Trust develop and maintain an effective and robust information system, which as a minimum, allows for the collation of all CPA and risk forms, provides access to such information at all hours, and facilitates regular CPA meetings.
south_east
Independent investigation: Joseph Day, Folkestone (2001) — Rec 1
The East Kent Community NHS Trust and Kent County Council should ensure that there is a robust system in place to ensure that all relevant information about a patient is recorded in a way that allows it to be easily accessed by all members of the care team, including those …
south_east
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 14
In all cases where a patient absconds from compulsory detention and does not return within one month: (cid:2) a summary of the treatment and care of that patient whilst an in-patient should be prepared and retained in the patient’s clinical record (cid:2) a copy should be sent to the patient’s …
london
Scottish Fatal Accident Inquiries(12)
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 the report …
Nicola Welsh
The appropriate authorities should ensure that common abbreviations and phrases are used to denote observations and symptoms and the tests carried out to check for or eliminate certain conditions are standardised. In this way others requiring to access notes can be confident of what they mean and the steps carried out at the time when the patient was seen. Guidelines …
Dec 2003
Richard Hugh McGhie
However I wish to make it clear to Sedexo that such record keeping is not acceptable and in the case of another prisoner suffering from epilepsy might have disastrous consequences for that prisoners care. One hopes that appropriate corrective measures will be taken to ensure all such logs are fit for purpose in the future and it may well be …
Mar 2012
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 a system …
Jan 2013
Ronald William McAllister
That a comprehensive review be undertaken by greater Glasgow Health Board as soon as reasonably practicable of the following; (i) the training of staff involved in the delivery of haemodialysis to patients; (ii) the procedures for documenting and recording the checks conducted on patients during sessions of haemodialysis; and (iii) the auditing of the practice and procedures in place for …
Mar 2013
Claire Lesley Fairbairn
3. In terms of section 6(1)(e) of the said 1976 Act that other facts which are relevant to the circumstances of Claire Lesley Fairbairn’s death are as follows: (i) the desirability of a paramedic forming part of an emergency ambulance crew and (ii) the keeping of accurate patient records by ambulance crew.
Jan 2015
Elijah Stirling
Those providing ante-natal care to women considering vaginal birth after Caesarean section (hereafter VBAC) should discuss and record the risks relating to the pregnancy and birth, the risks and benefits of VBAC versus Caesarean section (hereafter C-section) and the planned mode of delivery. Where the drug Syntocinon is to be employed in inducing a VBAC birth, there should be set …
Mar 2015
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 advising an …
Dec 2015
Stephen Masson
The sheriff having considered the information presented at the Inquiry, in terms of section 26(1)(b) of the Act, in having regard to matters mentioned in section 26(4) of the Act recommends that: (1) A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals immediate access …
Mar 2023
John Willock
I trust that these two Recommendations will be fully implemented and that the consequential amendments to Process 18 become operational in the near future. (i) Call Handlers and Nurse Advisors within NHS 24 should ask open questions of a caller with a view to forming a “holistic view” of the patient’s overall health and wellbeing; (ii) Nurse Advisors within NHS …
Oct 2013
John Perry
I consider that it would be helpful if that information was provided. In a similar vein, I consider that it would be beneficial if the Doctor carrying out the assessment the day after admission had a copy of the Prisoner Escort Form. It seems to me that if there are still issues with accessing that data base as a result …
Jan 2013
Isabella Gillies
There will obviously be situations in which it will be inappropriate to weigh a patient due to that patient's condition but in that situation consideration should be given to obtaining the weight from another source, such as earlier hospital records or by reference to the G.P.. I question therefore whether the steps already taken by Fife Health Board go far …
Sep 2005
Article 2 learning points(18)
— LP B
The Medical Record should be properly updated within 24 hours of any action taken or decisions made.
PPG
— LP 1
A brief review of the available SystmOne medical record should be made by staff prior to performing initial health-screening to validate the answers made to the template-driven questions.
PPG
Accepted
— LP 16
Everyone seeing a prisoner should write in a record, either in SystmOne or the prison record. The counsellor and substance misuse worker should write in SystmOne and the Chaplain in the prison record (P-NOMIS). It is good practice to have regular case conferences for complex cases, with documentation of an …
HMP Altcourse and HMPPS
Accepted
— LP 12
Staff employed by Birmingham and Solihull Mental Health NHS Foundation Trust should be reminded of the specific requirements in PSI 73/2011, P-NOMIS to add case notes about behavioural issues or which detail specific issues that might help the care of the offender by staff generally.
PPG
Accepted
— LP 10
There should be an effective system for following up requests for medical records if these fail to arrive.
PPG
Accepted
— LP 14
Greater priority should be given to seeking back records from previous establishments, particularly for those prisoners with complex needs or challenging behaviour, where assessments from a previous sentence may be particularly useful.
The Governor
Accepted
— LP Healthcare 6
Individual staff log-in details should not be shared or used by other members of the healthcare team to make entries to the electronic Patient Record.
Healthcare Provider
— LP Healthcare 5
Paper documentation which is generated and subsequently scanned to the electronic Patient Record should clearly identify the location, date, time and author along with their designation.
Healthcare Provider
— LP Healthcare 3
The opening of an ACCT and a summary of key issues and actions from ACCT reviews should be documented in the clinical record to ensure that this information is easily accessible to members of the healthcare team. In addition, the ACCT flag function should be used to ensure that all …
Healthcare Provider
— LP 16
(a) We recommend that guidelines be developed and implemented at HMP Pentonville as to what should and shouldn’t be recorded in ACCT and SystmOne. These guidelines could be integrated into existing documentation. To make it easier for staff, we recommend that these guidelines include examples of what should and shouldn’t …
HMPPS
— LP 2
The CARATS teams should record information about their interviews with prisoners in unit history sheets, and share assessments with staff who are managing prisoners, particularly when an ACCT (formerly F2052SH) process has been opened. These records should be available when required for any future investigations.
HMPPS
Implemented
— LP 2
We recommend that PECS and GEOAmey review the access for staff in the custody suite at Southampton Magistrates’ Court to update computerised or manual records to ensure it is sufficient to enable compliance with requirements.
PECS and GEOAmey
Accepted
— LP 2
We recommend that there should also be a brief but informative entry on the electronic record.
HMPPS
Accepted
— LP 17
To make better use of pre‐existing information, we recommend that psychiatric assessment guidelines used on HMP Pentonville’s Healthcare unit reference the need to source and consider the results of medical and psychiatric assessments that may have been conducted by other institutions.
PPG
Accepted
— LP 12
We recommend that HMP Pentonville’s Healthcare unit reviews its use of ‘Special Observation forms’ and clarifies what value, if any, they are adding to the care and management of a prisoner who is on an observation regime.
PPG
Accepted
— LP 11
Managers at HMP Birmingham should remind prison staff in contact with prisoners of the importance of documenting events in a prisoner’s Prison National Offender Management Information System record.
The Governor
Accepted
— LP 14
We are aware that the project to improve the effectiveness of the Person Escort Record is a work in progress and that our observations may have been overtaken as the new form is piloted and developed. However, we invite the Project Group on the Person Escort Record to consider the …
HMPPS
Accepted
— LP Healthcare 4
The date and time of an individual’s transfer to secondary care and discharge back to prison should be documented in the clinical record. This should include any required actions which are identified on discharge from secondary care.
Healthcare Provider
Detention investigations(2)
Assessment of government progress in implementing the report on the … — Rec 17
SystmOne templates should be urgently amended so that detainee healthcare records no longer identify detainees as prisoners.
Immigration Detention
Assessment of government progress in implementing the report on the … — Rec 18
NHS England should continue to roll out staff training on SystmOne/HJIS, and should make sure that patient consent is consistently recorded by conducting a national case fle audit and ensuring that this is a mandatory feld in HJIS.
Immigration Detention
Independent reviews(30)
Caldicott Review 2013 — Rec 1
People must have the fullest possible access to all the electronic care records about them, across the whole health and social care system, without charge. An audit trail that details anyone and everyone who has accessed a patient's record should be made available in a suitable form to patients via …
Health & Social Care
Shelley NHS Hospital Food Review — Rec 5
Technology: Every hospital to implement a digital meal ordering system by 2022, leading to: a) Safe ordering and mapping to patients' care plans. b) Menu offers tailored to patients' dietary needs and personal preferences. c) Minimum time between ordering and meal service. d) Reduction in waste.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 28
For non-surgical procedures, a record of consent must be held by the provider.
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 21
Until such a system is developed, a National Breast and Cosmetic Implant Registry should be established and operational within 12 months. All cosmetic surgery providers need to keep a minimum data set that should be defined by the RCS Interspecialty Group. This should include details of the implant, the surgeon, …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 20
A system should be developed by the MHRA to link the Unique Device Identifier for all implants to the patient's electronic record, enabling routine collection through Hospital Episode Statistic (HES) data. This information would enable assessment of implant performance, and the tracking and tracing of patients in case of a …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 12
All providers must keep full patient records, including clear operative records and precise details of any implant or device used. Providers should also be able to access data of implant cohorts readily and this should be available to regulatory authorities. Details of the surgery and implant used must be sent …
Health & Social Care
Mental Health Taskforce 2016 — Rec 45
The Department of Health and HSCIC should advocate the adoption of data-rich Summary Care Records that include vital mental health information, where individuals consent for information to be shared, by 2016/17.
Health & Social Care
Harris Review: Deaths in Custody — Rec 77
A record of any time a prisoner has spent on an ACCT/or the crisis plan of a SAVRAS must be recorded on System 1(or replacement) so that it is available for prison healthcare staff.
Justice & Legal
Francis Inquiry (Mid Staffs 2010) — Rec 12
The Trust should review its record-keeping procedures in consultation with the clinical and nursing staff and regularly audit the standards of performance.
Health & Social Care
Jackson Review — Rec 26
There should be financial penalties for any health authority which, without good reason, fails to provide copies of medical records requested in accordance with the Pre-Action Protocol for the Resolution of Clinical Disputes.
Other
Black Review on Health and Work — Rec 6
The paper-based sick note should be replaced with an electronic fit note, switching the focus to what people can do and improving communication between employers, employees and GPs.
Health & Social Care
Shaw Detention Review — Rec 26
Recommendation 26: I recommend that the Home Office consider how rapidly it can move towards a system of electronic record keeping for the PER and IS91RA.
Immigration
Shaw Detention Review — Rec 25
Recommendation 25: I recommend that the Home Office commission a formal review of the quality of PERs and that any deficiencies are addressed. In the meantime, all staff should be reminded of the importance of completing PERs fully.
Immigration
Morecambe Bay Investigation — Rec 38
Mortality recording of perinatal deaths is not sufficiently systematic, with failures to record properly at individual unit level and to account routinely for neonatal deaths of transferred babies by place of birth. This is of added significance when maternity units rely inappropriately on headline mortality figures to reassure others that …
Health & Social Care
Wessely Review — Rec 40
A patient's capacity to consent to their admission must always be assessed and recorded, including on the application form.
Health & Social Care
Accepted
Wessely Review — Rec 5
It should be harder for treatment refusals to be overridden, and any overrides should be recorded, justified and subject to scrutiny (see Annex on Treatment Choices).
Health & Social Care
Accepted
Stevenson/Farmer Review — Rec 33
We recommend that Government and the NHS work to improve patient access to their personal health record, empowering employees to share their data and information with their employer when they wish to do so, where it can be done safely and securely, to support people to thrive in work.
Employment & Work
Accepted
Ockenden Review — Rec 11
Obstetric anaesthesia. Essential action: In addition to routine inpatient obstetric anaesthesia follow-up, a pathway for outpatient postnatal anaesthetic follow-up must be available in every trust to address incidences of physical and psychological harm. Documentation of patient assessments and interactions by obstetric anaesthetists must improve. The determination of core datasets that …
Health & Social Care
Accepted
Cass Review — Rec 28
The NHS and the Department of Health and Social Care needs to review the process and circumstances of changing NHS numbers and find solutions to address the clinical and research implications.
Health & Social Care
Accepted
Caldicott Review 2013 — Rec 8
Consent is one way in which personal confidential data can be legally shared. In such situations people are entitled to have their consent decisions reliably recorded and available to be shared whenever appropriate, so their wishes can be respected. In this context, the Informatics Services Commissioning Group must develop or …
Health & Social Care
Tickell Review of the EYFS — Rec 14
I recommend that an insert is added to the early childhood health record, known as the Red Book, to encourage parents and carers, or their nominee, to enter information arising from this early years summary and from children's interaction with other professionals, for example speech and language therapists.
Education
Litchfield WCA Review Year 5 — Rec 24
The Department ensures that it seeks the most appropriate evidence for people with learning disabilities, including Hospital Passports and care or support plans. The Department should consider options in each case rather than defaulting to a GP report.
Employment & Work
Paterson Inquiry — Rec 2
We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than writing to the GP and sending a copy to the …
Health & Social Care
Tickell Review of the EYFS — Rec 13
I recommend that the EYFS should include a requirement for practitioners, including childminders, to provide on request to parents and carers, at some point between the ages of 24 – 36 months, a short written early years summary of their child's development in the prime areas.
Education
Coates Prison Education Review — Rec 4
The government should explore legislation to enable data on individuals sentenced to custody to be shared so prisons can access prisoners' previous records of educational attainment from the National Pupil Database.
Justice & Legal
Coates Prison Education Review — Rec 2
Every prisoner must have a Personal Learning Plan that specifies the educational activity that should be undertaken during their sentence. This should be in a consistent digital format that can follow the prisoner through the system if they move prisons. This plan should be informed by initial assessment, be subject …
Justice & Legal
Calvert-Smith SFO Review — Rec 4
The SFO must immediately communicate – to investigators within guidance and to all staff – that in the event of any information concerning an ongoing investigation or prosecution coming to them from a defendant or suspect, or any representative of either, it must be fully recorded and shared with the …
Justice & Legal
Wessely Review — Rec 113
Every inpatient child or young person should have a personalised care and treatment plan which records the views and wishes of the child or young person on each issue. Government should consider whether there should be a statutory duty for such a plan where the child or young person does …
Health & Social Care
Accepted
Wessely Review — Rec 3
MHA regulations and forms should be amended to require professionals to record how the principles have been taken into consideration, and to enable local auditing and monitoring and CQC to consider this as part of their monitoring and inspection role.
Health & Social Care
Accepted
Farmer Review (Men) — Rec 9
Contact details of family and significant others should be mandatorily requested by prisoner escort services before a prisoner leaves court and immediately added to his prison file, with this and other information on key relationships updated on an ongoing basis and sent with him when he moves establishments. If a …
Justice & Legal
PHSO casework decisions(203)
P-001344 — South Tees Hospitals NHS Foundation Trust
Mr N complained the Trust recorded incorrect medical information and failed to amend or delete it upon request, causing him annoyance and frustration.
NHS in England
Mar 2022
P-004727 — An independent provider in the Redbridge area
Ms N complained the Provider added another patient's notes to her medical records, leading to a referral for unnecessary surgery, delayed check-ups for her eye disease, and increased stress.
NHS in England
Jan 2026
P-001385 — Lewisham and Greenwich NHS Trust
Ms E complained the Trust gave her incorrect treatment, documented incorrect medication information, lost ECG reports, and failed to respond to her further concerns, causing her and her daughter PTSD.
NHS in England
May 2022
P-001446 — A medical practice in the London Borough of …
Mr Y complained the Practice failed to advise a nursing home to hospitalise his father, inform him of his deteriorating health, and kept inadequate records, causing a delay in hospitalisation and his father's death.
NHS in England
May 2022
P-002247 — Bromley Healthcare
Ms A complained that various NHS organisations held incorrect information in her medical records, including a misdiagnosis of psychosis, which negatively impacted her care.
NHS in England
Oct 2023
P-003026 — County Durham and Darlington NHS Foundation Trust
The Trust included false and damaging information about her in her daughter’s cognitive assessment report, causing mental health deterioration, a suicide attempt, and separation from her daughter.
NHS in England
Oct 2024
P-003578 — A practice in the Halton area
Mr J complained about inaccurate medical records regarding weight loss, medication, and carpal tunnel treatment, which he said negatively impacted his mental health and treatment.
NHS in England
May 2025
P-003710 — A practice in the Croydon area
Mr F complained the Practice failed to communicate blood pressure test results and delayed GP appointments following a lung health check and cardiology letter, causing distress.
NHS in England
Jul 2025
P-001196 — University Hospitals Sussex NHS Foundation Trust
Mrs W complained the Trust mismanaged her severe back pain, stopping medication and ignoring her history, leading to cancelled surgery and permanent paralysis.
NHS in England
Oct 2021
P-001373 — The Dudley Group NHS Foundation Trust
Mr O complained that information about his heart rhythm after surgery was not shared correctly or timely, leading to a loss of trust in clinicians.
NHS in England
Apr 2022
P-001403 — Liverpool Women's NHS Foundation Trust
Mrs A complained a doctor incorrectly stated she had three endometriosis surgeries, impacting her subsequent care and causing distress.
NHS in England
May 2022
P-001410 — A medical practice in the Torbay area
Ms U complained that her liver function test results were incorrectly recorded and she was not advised about abnormal findings, causing her to lose confidence and change practices.
NHS in England
Jun 2022
P-001742 — University Hospitals of North Midlands NHS Trust
Mr A complained his mother's GP failed to timely diagnose lymphoma and the hospital neglected her, wrongly discharging her with unaddressed mental health and speech issues.
NHS in England
Jan 2023
P-001842 — The Priory Hospital
Miss O complained a consultant psychiatrist at the Hospital falsely recorded her weight as 45kg instead of 38.2kg in 2008, affecting her physical and mental health and care.
NHS in England
Jan 2023
P-001720 — A practice in the Wirral area
Mr O complained his GP practice failed to correctly interpret blood pressure and cholesterol results from 2016-2018, leading to his chronic heart disease diagnosis.
NHS in England
Jan 2023
P-001774 — A practice in the Staffordshire area
Mr E alleged the Practice's staff failed to correctly assess his wife's heart attack symptoms, provide advice, or record information, leading to a missed opportunity for life-saving treatment. He also complained about poor complaint handling.
NHS in England
Feb 2023
P-001866 — University Hospitals Sussex NHS Foundation Trust
Mr A complained the Trust's dermatologist refused to rewrite a GP letter, gave misleading advice, failed to correct medical records, and prescribed inappropriate medication for his eczema.
NHS in England
Mar 2023
P-001861 — A practice in the East Riding of Yorkshire …
Mrs I complained the Practice failed to inform her of developing diabetes after blood tests between 2017-2020, leading to an emergency hospital admission with serious confusion.
NHS in England
Mar 2023
P-002005 — East Kent Hospitals University NHS Foundation Trust
Mrs A complained about inadequate oncology and neurology care for Mr A, including incorrectly reported scans, a missed brain tumour diagnosis opportunity, and failure to provide pain relief.
NHS in England
May 2023
P-003895 — A GP practice in the Leicester area
Ms U complained the Practice failed to disclose high platelet results, conduct follow-up tests in 2018, and a GP laughed about her condition in 2020, potentially delaying her cancer diagnosis.
NHS in England
Sep 2023
P-002322 — Manchester University NHS Foundation Trust
Ms R complained the Trust added an incorrect clinical code for a behavioural disorder to her records in 2013. She alleged this caused distress and a loss of faith in the Trust.
NHS in England
Nov 2023
P-002509 — A practice in the Rochdale area
Mr and Mrs C complained a GP practice delayed confirming a PMDD diagnosis, showed unprofessionalism, and committed a data breach by sending another patient's information.
NHS in England
Mar 2024
P-002641 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs T complained A&E dismissed her serious symptoms and incorrectly stated she discharged herself, leading to two weeks of severe pain at home.
NHS in England
May 2024
P-002605 — London North West University Healthcare NHS Trust
Mr L complained the Trust failed to provide him with test results from a cancer referral, despite numerous attempts, causing him distress and agony.
NHS in England
May 2024
P-002691 — Gloucestershire Hospitals NHS Foundation Trust
Miss F complained the Trust failed to record/communicate about her father's restraint and discharged him without treating constipation or urine retention, contributing to his death.
NHS in England
Upheld
Jun 2024
P-002979 — Mersey Care NHS Foundation Trust
The Trust communicated false information in her discharge summary, failed to provide adequate physical/mental healthcare, forced appointments, and neglected/tortured her, leading to mental health decline.
NHS in England
Sep 2024
P-003001 — North London NHS Foundation Trust
Mrs U complained the Trust included untrue information in her father's discharge summary and report, conflicting with his assessment, and interfered with his choice of power of attorney.
NHS in England
Sep 2024
P-003155 — Manchester University NHS Foundation Trust
Mrs A complained the Trust incorrectly recorded her heart diagnosis in her medical records after an echocardiogram, potentially invalidating insurance and impacting future care.
NHS in England
Nov 2024
P-003109 — West Hertfordshire Teaching Hospitals NHS Trust
A doctor misdiagnosed her husband, missing a blood clot in his lungs, leading to his avoidable death and significant financial and emotional impact on his young family.
NHS in England
Nov 2024
P-003299 — Mersey and West Lancashire Teaching Hospitals NHS Trust
Mrs W complained Mersey and West Lancashire Teaching Hospitals NHS Trust gave her father incorrect medication and restricted visitors, preventing family goodbyes.
NHS in England
Jan 2025
P-003270 — North Bristol NHS Trust
Mrs L complained the Trust incorrectly recorded she declined a breast screening, didn't send a further invitation, and failed to amend her medical records after her cancer diagnosis.
NHS in England
Partly Upheld
Jan 2025
P-003342 — Northern Care Alliance NHS Foundation Trust
Miss A complained doctors failed to inform her of lung nodules found in a 2021 CT scan until 2024, by which time her cancer was incurable, alleging it could have been treatable earlier.
NHS in England
Feb 2025
P-003592 — A practice in the North East Derbyshire area
Mrs A complained a GP practice failed to perform a physical examination for her severe pain, refused pain relief, and omitted crucial information from a neurosurgery referral, causing prolonged suffering and delayed diagnosis.
NHS in England
Jun 2025
P-003729 — Portsmouth Hospitals University NHS Trust
Mr O complained the Trust prematurely discharged his wife, mismanaged medication, ignored her broken shoulder, delayed emergency response, and had poor communication, leading to her earlier death.
NHS in England
Upheld
Jul 2025
P-003740 — A practice in the Cheshire West and Chester …
Miss I complained that three practices removed diagnoses, shared her medical information, tampered with records, and failed to upload them electronically between 1981 and 2005. She alleged this led to her not knowing about a genetic condition.
NHS in England
Aug 2025
P-003942 — Oxford University Hospitals NHS Foundation Trust
Ms T complained the Trust only offered hormone therapy for Mr R's prostate cancer, informed him of brain cancer against his wishes, and provided inappropriate physiotherapy after hip replacement, which she believed led to his deterioration.
NHS in England
Upheld
Sep 2025
P-004087 — East Kent Hospitals University NHS Foundation Trust
Mr N complained the Trust provided incorrect initial treatment, poor personal care, inaccurate records, and delayed seeing a doctor, alongside an unclear complaints process.
NHS in England
Sep 2025
P-004068 — A practice in the Ribble Valley area
The Practice provided inadequate care and failed to promptly diagnose IBS or parasitic infections, exacerbated by inaccurate medical records, causing Ms X ongoing pain and distress.
NHS in England
Sep 2025
P-004297 — University Hospitals Birmingham NHS Foundation Trust
Miss T complained the Trust failed to manage her mother's diabetes, did not provide condition updates, failed to notice her mother was unresponsive, and incorrectly recorded the cause of death.
NHS in England
Partly Upheld
Nov 2025
P-004459 — Northern Care Alliance NHS Foundation Trust
Mrs B complained the Trust provided inappropriate care to her husband, Mr B, alleging issues like mixed records, cancelled tests, and poor communication, which she believes contributed to his death.
NHS in England
Dec 2025
P-004483 — Worcestershire Acute Hospitals NHS Trust
Mr N complains about incorrect details in his medical records from 2004-2005 concerning how he contracted HIV, causing mental distress and reputational damage.
NHS in England
Dec 2025
P-004742 — Stockport NHS Foundation Trust
Mr P complained an orthopaedic surgeon performed an inappropriate fasciotomy for Dupuytren’s disease and incorrectly documented that he requested the surgery and achieved good correction.
NHS in England
Jan 2026
P-004594 — Dorset Healthcare University NHS Foundation Trust
Mr U complained a practice wrongly stopped his aspirin, leading to a heart attack, and the Trust recorded inaccurate mental health information in his medical records.
NHS in England
Jan 2026
P-001069 — Taunton and Somerset NHS Foundation Trust
Mr O complained the Trust gave him a 'false negative' emphysema diagnosis in 2017, omitted vital information from a letter to his GP, and wrongly claimed he didn't follow up a referral.
NHS in England
Not Upheld
May 2021
P-001114 — Southern Health NHS Foundation Trust
Mrs I complained the Trust changed her mental health referral from urgent to routine without notice, delayed contact, recommended unsuitable medication, and did not provide individual psychotherapy.
NHS in England
Partly Upheld
Sep 2021
P-001220 — Royal Free London NHS Foundation Trust
Mrs G and Mr G complained about inadequate care for Mrs S, citing poor condition assessment, delayed response to low blood pressure/confusion, and issues with both operations.
NHS in England
Partly Upheld
Oct 2021
P-001229 — University Hospitals Birmingham NHS Foundation Trust
Mr L complained doctors failed to act on his father Mr E's CT scan results and inappropriately discharged him, and that the Trust's complaint responses left questions unanswered.
NHS in England
Dec 2021
P-001491 — Leeds Teaching Hospitals NHS Trust
Mr R complained the Trust failed to detect changes in his MRI scans, leading to a misdiagnosis of Relapsing Remitting MS instead of Progressive MS and ineffective medication.
NHS in England
Aug 2022
P-001489 — An Inpatient Service in the Darlington area
Mr I complained the Inpatient Service disclosed his personal health records without consent and incorrectly recorded his treatment, causing psychological injury and financial loss.
NHS in England
Aug 2022
P-001560 — Moorfields Eye Hospital NHS Foundation Trust
Miss O complained of incorrect diagnosis and medication for her left eye condition, leading to constant pain, depression, and inability to continue normal activities.
NHS in England
Sep 2022
LGO / SPSO decisions(464)
NIPSO-202001704 — Belfast Health and Social Care Trust
Error created uncertainty and caused patient upset, but did not impact on the care she received.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
NIPSO-29583 — Lurgan Medical Practice
We found that a medical assessment performed during a home visit was carried out in line with good medical practice, but that the GP should have recorded what had been discussed with the patient and her family, and what they should do if her symptoms did not improve.
NIPSO (NI Public Service…
Health & Social Care
Dec 2020
21-001-259a — Central London Community Healthcare NHS Trust (21 001 …
Summary: We found fault with the record keeping by the district nurses and the way they ordered dressings. We also found there was a lack of a multidisciplinary team approach to Mr B’s care. We found the Council did not action its safeguarding enquiry immediately and it was not open …
LGO (Local Government & …
Health
Upheld
Apr 2022
21-015-380c — Dignus Healthcare Ltd (21 015 380c)
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Adult Care Services
Upheld
Sep 2022
21-015-380b — Coventry & Warwickshire Partnership NHS Trust (21 015 …
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Health
Not Upheld
Sep 2022
21-015-380a — Dignus Healthcare Ltd (21 015 380a)
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Health
Upheld
Sep 2022
21-015-380 — Coventry City Council
Summary: Mr and Mrs K complained about a delay in their son Mr A’s diabetes being diagnosed, and about a care provider destroying Mr A’s care records. We found fault by the care provider in destroying Mr A’s records and in how it responded to the complaint. We did not …
LGO (Local Government & …
Adult Care Services
Not Upheld
Sep 2022
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 …
LGO (Local Government & …
Adult Care Services
Upheld
Oct 2022
21-018-569a — Norfolk & Suffolk NHS Foundation Trust (21 018 …
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 …
LGO (Local Government & …
Health
Not Upheld
Oct 2022
201405121 — Scottish Prison Service
Mr C raised a number of complaints with the prison about disciplinary reports that were noted on his computerised record. Mr C asked the prison to provide copies of the relevant paperwork in relation to each report or remove them from his record. The prison confirmed that there was no …
SPSO (Scottish Public Se…
Prisons
Upheld
Aug 2015
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 …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2016
201810096 — Scottish Prison Service
Mr C attended his brother's integrated case management (ICM) case conference. This meeting is held each year when the prisoner and those involved in supporting them get together to discuss their sentence management. A document used to minute the discussions is then shared with all attendees. On receiving this document, …
SPSO (Scottish Public Se…
Prisons
Upheld
Jul 2020
202301188 — Lothian NHS Board - Acute Division
C complained that Lothian NHS Board (Board 1) unreasonably failed to maintain records of specialist advice they provided to another board (Board 2). C attended A&E at Board 2 with symptoms of significant pain, problems passing urine and lack of sensation. On the specialist advice of neurosurgery at Board 1, …
SPSO (Scottish Public Se…
Health
Partly Upheld
Dec 2024
NIPSO-202002199 — Northern Health and Social Care Trust
We upheld a complaint from a woman who said that her late mother should not have been discharged from Antrim Area Hospital.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
PSOW-202307000 — Betsi Cadwaladr University Health Board
Mr A complained about the lack of timely dental communication, updates and engagement by Betsi Cadwaladr University Health Board’s (“the Health Board’s”) orthodontic services in relation to his son, Child B. He questioned how the orthodontist services could have made decisions about his son’s dental care without seeing him. Child …
PSOW (Public Services Om…
Health
May 2024
PSOW-202402126 — Cwm Taf Morgannwg University Health Board
Miss T complained that Cwm Taf Morgannwg University Health Board has not provided the necessary treatment to deal with her chronic pain. The Ombudsman found that whilst the Health Board had responded to Miss T’s concerns informally, it failed to correctly escalate her complaint in accordance with its complaints process …
PSOW (Public Services Om…
Health
Sep 2024
PSOW-202404887 — Betsi Cadwaladr University Health Board
Mrs A complained that Betsi Cadwaladr University Health Board (“the Health Board”) failed to update her or respond to her second complaint about her late daughter’s care and treatment. She said that 16 months after she submitted the complaint, the Health Board said that it was unable to respond to …
PSOW (Public Services Om…
Health
Nov 2024
PSOW-202409193 — Cardiff and Vale University Health Board
Ms A complained that Cardiff and Vale University Health Board cancelled her thyroidectomy surgery on the day of the procedure because she was a smoker. Ms A was removed from the waiting list and referred for smoking cessation. Ms A said that the Health Board had not previously advised her …
PSOW (Public Services Om…
Health
May 2025
22-004-890 — Surrey County Council
Summary: We will not investigate this complaint about the Council failing to keep accurate records and of having an inappropriate comment in Mr X’s records. This is because there is not enough evidence of fault and significant injustice to justify an investigation.
LGO (Local Government & …
Adult Care Services
Aug 2022
21-016-387 — Plymouth City Council
Summary: Mr X and Miss Y complained that despite granting conditional approval for a vehicle crossing the Council has since rejected their application. The Council’s failure to ensure the information available on its website regarding vehicle crossings is accurate and up to date regarding its processes is fault. This fault …
LGO (Local Government & …
Transport And Highways
Upheld
Aug 2022
22-008-171 — Torbay Council
Summary: We will not investigate Mrs X’s complaint the Council has issued an education and health care plan containing inaccurate personal information about Ms Y and without her consent. There is insufficient injustice. Mrs X can go to the Information Commissioner if she has data protection concerns. We cannot lawfully …
LGO (Local Government & …
Education
Oct 2022
23-013-143 — London Borough of Enfield
Summary: Miss X complained about how the Council has handled her housing application. She also complains about the Council’s poor communication and said it had failed to properly consider her and her mother, Ms Z’s medical information. We find the Council was at fault. This caused them significant distress. The …
LGO (Local Government & …
Housing
Upheld
May 2024
201300749 — Scottish Prison Service
Mr C, who is a prisoner, complained about aspects of a review of his supervision level, after he was involved in a fight at the prison. He previously had a low level of supervision but, following the fight, this was reviewed and increased to a high level. He complained that, …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Sep 2013
201203949 — A Medical Practice in the Highland NHS Board …
Mr C had a history of heart problems and was previously a patient of the practice. He said that, while he was their patient, they twice lost blood samples although the explanation given was that they were lost by the hospital. Mr C also complained that on one occasion when …
SPSO (Scottish Public Se…
Health
Partly Upheld
Oct 2013
201300588 — Scottish Prison Service
Mr C, who is a prisoner, complained that the prison had not amended an intelligence report (adverse information obtained by the Scottish Prison Service that affects an individual prisoner) on him to accurately reflect the outcome of suspected drug use, and that the prison had not passed an accurate version …
SPSO (Scottish Public Se…
Prisons
Upheld
Dec 2013
201300285 — Scottish Prison Service
Mr C complained about the handling of an intelligence entry (adverse information obtained by the Scottish Prison Service (SPS) that affects an individual prisoner) from some years ago. He was concerned that he was not told about the entry at the time. Our investigation found that the SPS had handled …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Dec 2013
201302276 — A Medical Practice in the Greater Glasgow and …
Mrs C complained that she saw a nurse at her medical practice twice to report a lump on her breast but nothing was done. In between these appointments, she attended a mobile breast screening clinic for a mammogram (an x-ray of the breast) and, after being recalled for further investigations, …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2014
24-018-961 — Sefton Metropolitan Borough Council
Summary: Mrs B complained about the standard of care her mother, Mrs X, received when the Council organised a placement at Lakeside View Care Home. We uphold the complaint, having identified several areas of fault with the care provided to Mrs X, and inaccurate care records. There was also fault …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2025
201804064 — A Medical Practice in the Tayside NHS Board …
Mrs C complained that the practice had failed to properly investigate a series of complaints she had made about entries in her and her children's medical records. Mrs C believed the practice's conclusions were unreasonable given the available evidence. Mrs C also complained that the practice failed to communicate appropriately …
SPSO (Scottish Public Se…
Health
Not Upheld
Oct 2020
201901728 — Greater Glasgow and Clyde NHS Board - Acute …
A few hours after a surgical procedure, C underwent a second operation due to an internal haemorrhage (a loss of blood from a blood vessel that collects inside the body). Following the second operation, C complained to the board about the documenting of their operations, the estimation of their blood …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2021
NIPSO-21053, 21181, 21182 — Northern Ireland Ambulance Service TrustBelfast Health and Social …
The Chief Executives of three health trusts have apologised after an error in recording a patient’s date of birth led to him being confused with another patient.
NIPSO (NI Public Service…
Health & Social Care
Jul 2021
NIPSO-202001919 — Northern Health and Social Care Trust
A woman complained about how long it took the Northern Health Trust to provide her late son with a routine test for heart disease, and about its subsequent failure to monitor his condition.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2023
NIPSO-202002149 — Northern Health and Social Care Trust
The Northern Trust failed to keep proper records of a patient's food intake, and didn't provide him with insulin after he experienced an episode of hypoglycaemia.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2024
NIPSO-202005762 — GP
A woman claimed that if her late husband’s weight loss been investigated properly his cancer may have been detected sooner. We found it was a ‘significant failure in care and treatment’ that his GP didn’t send him for further diagnostic treatment.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jun 2025
PSOW-202004109 — Hywel Dda University Health Board
Mrs M complained about the care and treatment that her daughter, Ms D, received from the Health Board’s Mental Health Services following the onset of 2 acute psychotic crises. Mrs M complained that, on 20 December 2019: 1.The Health Board failed to arrange for a Section 12 approved doctor to …
PSOW (Public Services Om…
Health
Upheld
Apr 2022
PSOW-202208013 — Cardiff and Vale University Health Board
Mr S complained that Cardiff and Vale University Health Board failed to pick up a referral for his father. Mr S said that it was only discovered when he contacted the Health Board for an update and an explanation as to why it was missed was not provided. The Ombudsman …
PSOW (Public Services Om…
Health
Jun 2023
21-003-942 — London Borough of Hounslow
Summary: The complainant complained the Council failed to include in her late mother’s financial assessment the valuation it had placed on her home resulting in her being liable for the full costs of her residential care. The complainant says the Council failed to seek an independent valuation as provided for …
LGO (Local Government & …
Adult Care Services
Not Upheld
Jan 2022
22-010-600 — Tameside Metropolitan Borough Council
Summary: We will not investigate Mrs B’s complaint about the Council’s failure to keep her informed about her daughter’s, Ms C’s needs, or inaccuracies contained in Ms C’s hospital Passport. This is because further investigation by us could not add to the Council’s response.
LGO (Local Government & …
Adult Care Services
Dec 2022
21-018-192 — Lancashire County Council
Summary: We find fault with the Council. The Council did not keep accurate records about what was discussed with Miss S before she agreed to go to a Care Home. It also did not arrange funding with the local Integrated Care Board (ICB) to cover the interim period Miss S …
LGO (Local Government & …
Adult Care Services
Upheld
Dec 2022
23-021-262 — East Sussex County Council
Summary: We will not investigate Mr X’s complaint about inaccurate information being included in Section D of his child’s Education, Health, and Care (EHC) plan. This is because an investigation would not lead to any further findings or outcomes as the Council has appropriately remedied the injustice caused by the …
LGO (Local Government & …
Education
May 2024
24-006-460 — Medway Council
Summary: We will not investigate this complaint about data recorded about the complainant and his family by the Council in a assessment document. This is because the complaint does not meet the tests in our Assessment Code on how we decide which complaints to investigate. There is no evidence of …
LGO (Local Government & …
Children S Care Services
Jul 2024
24-022-755 — London Borough of Redbridge
Summary: We will not investigate Mr X’s complaint that the Council recorded and shared inaccurate information in a report to the courts and failed to respond to the Information Commissioner’s request for information. The law prevents us from investigating what happens in court, including the preparation and contents of court …
LGO (Local Government & …
Children S Care Services
May 2025
24-012-078 — London Borough of Croydon
Summary: Mrs X complained the Council provided an inadequate refuse service for her clinical waste. The Council was at fault for poor record keeping, failing to investigate Mrs X’s concerns appropriately and for providing inaccurate information about changes to its service. This caused Mrs X avoidable frustration and uncertainty for …
LGO (Local Government & …
Environment And Regulation
Upheld
May 2025
25-003-564 — London Borough of Hammersmith & Fulham
Summary: We will not investigate this complaint about a missing social services record as it is best dealt with by the Information Commissioner’s Office and the courts.
LGO (Local Government & …
Other Categories
Jun 2025
201102068 — Scottish Prison Service
Mr C complained that the Scottish Prison Service (SPS) failed to explain the outcome of a risk assessment he had undergone. Mr C said that he had asked the psychologist who completed the risk assessment for further information, but that she failed to respond. We were, however, unable to find …
SPSO (Scottish Public Se…
Prisons
Not Upheld
Apr 2012
201204718 — A Medical Practice in the Tayside NHS Board …
Mr C complained about the care and treatment provided to him by the medical practice. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix, we were unable to take this complaint further, and …
SPSO (Scottish Public Se…
Health
Jun 2013
201204712 — A Medical Practice in the Tayside NHS Board …
Mr C complained about the care and treatment provided to him by the medical practice. We started our investigation, but Mr C died before it was completed. As we had no contact details for Mr C's next of kin or executor/executrix, we were unable to take this complaint further, and …
SPSO (Scottish Public Se…
Health
Jun 2013
201100100 — Borders NHS Board
Mr C made three complaints about the treatment that the board's mental health service gave his brother (Mr A). Mr A had long term mental health difficulties including paranoid schizophrenia (a condition that may cause hallucinations, delusions and muddled thoughts and behaviours). He lived independently and had been prescribed Modecate …
SPSO (Scottish Public Se…
Health
Not Upheld
Jun 2013
201204914 — A Medical Practice in the Ayrshire and Arran …
Mr C went to the practice because he had lower back and left leg pain, together with numbness. After his second visit, he was referred for physiotherapy, and then to hospital for a consultant opinion and an MRI scan (a scan used to diagnose health conditions that affect organs, tissue …
SPSO (Scottish Public Se…
Health
Not Upheld
Jul 2013
201204913 — Ayrshire and Arran NHS Board
Mr C visited a hospital accident and emergency department (A&E) with lower back and left leg pain and increasing periods of numbness. He was discharged with an appointment to see a consultant twelve days later. Within a short time of being discharged, however, Mr C returned to hospital as he …
SPSO (Scottish Public Se…
Health
Upheld
Jul 2013
Domestic Homicide Reviews(658)— showing 50 strongest matches
Lambeth — recommendation 4.5
Any agency in this review check and correct factually incorrect information identified in this report held in relation to the victim (in particular but not exclusively LPT, C&YPS. G&St T).
London Probation Trust | Lambeth Children …
Probation Service
Lincoln — recommendation 1
The Safeguarding Midwives will continue to remind all Midwives via their annual Midwifery Mandatory Training Safeguarding sessions to document all safeguarding information on the Electronic Maternity system in addition to any paper documentation and inform the Safeguarding Midwives if they become aware of any domestic abuse within a relationship so …
United Lincolnshire Hospital Trust
United Lincolnshire Hospitals NHS …
Lincoln — recommendation i)
The names of those who attend appointments with patients should be asked as well as their relationship and recorded in the patients record.
GP Practice
Cheltenham — recommendation 8b (LOCAL)
NHS Gloucestershire Safeguarding teams to look to a solution for how risks relating to domestic abuse are consistently recorded across health partners.
NHS Gloucestershire Safeguarding teams
Cheltenham — recommendation 8a (NATIONAL)
All NHS Integrated Care Boards to provide a solution for how domestic abuse risks presented to and by a patient are documented within clinical records, so that NHS staff do not inadvertently increase their patient’s risk of harm from or to others
All NHS Integrated Care Boards
West Lancashire — recommendation 23
WLCSP to seek assurances through the ICB that all GP Practices operating within West Lancashire are reminded of key points which are already recommended practice. To include the following: Read coding and recording Dealing with incoming letters Dealing with non- attendances by adults with care and support needs (the “vulnerable”) …
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
Norfolk — recommendation P
Remind colleagues to capture on information management system any new information on vulnerabilities or support needs of customers.
Norwich City Council
Norwich City Council
Gloucester — recommendation 3
Gloucestershire CCG to encourage primary care that patient records should be flagged with social care history, substance misuse as well as the children of the index patient.
Gloucestershire Clinical Commissioning Group
Gloucestershire Clinical Commissioning Group
Gloucester — recommendation 2
Gloucestershire CCG to encourage primary care that when registering a patient, to enquire about household members and social history.
Gloucestershire Clinical Commissioning Group
Gloucestershire Clinical Commissioning Group
Portsmouth — recommendation 4
Review of the Ghost patient process.
Named GPs | Hampshire and Isle …
NHS Hampshire and Isle …
Wokingham — recommendation R6
Berkshire Cancer Centre (BCC) will improve assessment documentation and interagency sharing of documentation.
Royal Berkshire NHS Foundation Trust
Royal Berkshire NHS Foundation …
Haringey — recommendation 15.1
Upon receiving permission to publish, Haringey Safer Communities Partnership should attach a full and unredacted copy of this report to the victim's son's Social Care Records should he later wish to find out more information about his mother’s death.
Haringey Safer Communities Partnership
Doncaster — recommendation 7
That Doncaster Clinical Commissioning Group disseminate the learning from this review to all GP’s in respect of the requirement to fully explore and document within patient records where anti-depressants are prescribed, including where there is a diagnosis of depression.
Doncaster Clinical Commissioning Group
Cheshire West and Chester — recommendation 8
Managers to inform staff of the importance of including information of significant others details within the patient record.
Cheshire and Wirral Partnership NHS Foundation …
Cheshire and Wirral Partnership …
Swindon — recommendation 19
Agree ‘alert’ terminology on the electronic patient record to ensure when relevant, staff consider the use of DASH risk assessment
Great Western Hospital
Great Western Hospitals NHS …
Swindon — recommendation 10
1. Develop locality Safety Alert highlighting this incident and the expected standards of record keeping in progress notes. 2. Disseminate locality Safety Alert and ensure all teams respond to state that the Safety Alert has been shared and understood 3. Monitor quality of progress notes on monthly basis in team …
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Swindon — recommendation 9
For teams to ensure that there is no disparity when documenting information regarding the same incident.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Swindon — recommendation 7
Ensure that the Swindon Intensive Team validate progress notes in real time.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Pembrokeshire — recommendation 2
Acute Services, supported by the Lead VAWDASV and Safeguarding Practitioner to review the documentation used in Emergency Departments to record routine enquiry
Hywel Dda University Health Board
Hywel Dda University Health …
Swindon — recommendation 13
That where a victim of domestic abuse discloses criminal offences a record is made of their preferred outcome.
Wiltshire Police
Wiltshire Police
Swindon — recommendation 11
When a GP Practice member has discussions with a patient around their ability to cope with thoughts of self-harm this needs to be fully documented. It should include all the patient comments on how they are feeling and managing their feelings, rather than being summed up in a single phrase …
Swindon GP Practices | Swindon ICB
NHS Bath and North …
Swindon — recommendation 9
Indexing of closed pare records to be reviewed facilitate easier access.
Swindon Borough Council Children Families and …
Oxford — recommendation 2
A review of the way at risk information is held in the patient record so that it fully complies with the latest guidance.
Oxfordshire Clinical Commissioning Group
Oxford — recommendation 1
A new protocol to govern the transfer of at risk records from one Practice to another must be devised.
Oxfordshire Clinical Commissioning Group
Lancaster — recommendation 8.
All records of consultations involving a child should include details of any accompanying adult. Where this is another family member, the clinician should confirm that this person has consent for examination and treatment of the child from someone with parental responsibility.
East Lancashire Clinical Commissioning Group
Somerset — recommendation 1
Somerset Partnership CAAS to record electronic risk alerts, screening and information following assessment of all patients.
Somerset Partnership NHS Foundation Trust
Somerset Partnership NHS Foundation …
Somerset — recommendation 1
With ASC case recording the AIS functionality to copy case notes from one family member to another should be used to facilitate full record keeping where relevant.
Somerset County Council Adult Social Care
Somerset — recommendation 2
Where DASH assessments are changed by police staff or police officers after the event, the rationale for that change should always be recorded. The recording of decision making rationale would allow for more effective ongoing case review.
Avon and Somerset Police
Avon and Somerset Police
Sefton — recommendation 1
Lifeline Sefton workers should always use the same file when an individual starts a new treatment episode, rather than closing one file and re-opening another, to ensure continuity and a full treatment history within a single file.
Lifeline
West Berkshire — recommendation 5
It is recommended that policy and practice be reviewed in all teams with a view to ensuring that times of contacts are routinely entered on RiO progress notes. Measure of success: A quarterly audit will show that times of contact with patient are clearly documented in the patient records. Accountable …
Berkshire Healthcare NHS Foundation Trust
Berkshire Healthcare NHS Foundation …
Sefton — recommendation 1
Ensure appropriate recording is in place. A particular emphasis on accurate recording of professionals involved in the case, response to risk, sharing information in a timely manner, evidence of information shared, and achieved outcomes. To ensure consistent input of information.
Sefton Women’s and Children’s Aid
Haringey — recommendation National 2
That proper recording of all such events within a NHS setting and the risk assessment leads to appropriate information sharing to other agencies that are in contact with either the potential victim or the client. The records must show a decision making process which has considered information sharing and shows …
NHS
NHS
Herefordshire — recommendation ANS2
When Care Notes Electronic records are introduced, separate records should be created for carers who are in receipt if direct interventions from Trust services with links to the patient’s records so that other services within the Trust can have access to carer records. Separate interventions for a carer would be …
Admiral Nursing Service
Herefordshire — recommendation 10
Provide clear guidance on the process for ascertaining that a carers assessment has been requested, and undertaken or refused, should be reviewed, including its documentation and reference to actions in RIO.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Herefordshire — recommendation 8
Review the Herefordshire Memory Assessment and Older Person Services sharing of information with clinicians, patients and carers, including the practice of copying or addressing letters to patients. This will also consider the sharing of information regarding medication and care planning.
2gether NHS Foundation Trust
Gloucestershire Health and Care …
Chiltern — recommendation Panel Recommendation
BCC Children’s Services undertakes a review of the processes for recording and indexing information received and of referrals made, to ensure that key information is recorded and acted on appropriately.
BCC Childrens’ Services
Chiltern — recommendation SCAS Recommendation
To provide assurance that the new Electronic Patient Records system is being followed appropriately.
SCAS
South Central Ambulance Service …
Chiltern — recommendation Panel Recommendation
To ensure follow up letters to GP practices are sent and recorded.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Chiltern — recommendation TVP Recommendation 1
Neighbourhood Policing Teams to record any actions (multiagency or otherwise) taken as part of safety planning for a Domestic Abuse victim in the victim’s Risk Management Occurrence on NICHE.
D/Supt– C&PVPSU
Chiltern — recommendation TVP Recommendation 4
Thames Valley Police to develop a system through NICHE/MINERVA (record management system) to alert the DAIU Detective Inspectors when a high risk domestic abuse victim’s review is required.
Performance Management Lead | D/Supt – …
Chiltern — recommendation STARS Recommendation
Team leaders attending MARAC to record the MARAC discussions in the client record on ILLY and feedback information from keyworkers.
South Staffordshire and Shropshire Healthcare Trust …
Chiltern — recommendation Panel Recommendation
Department of Health to consider a central database for hospitals to access accurate and timely information about treatments and medications a patient has received when attending either their GP or another hospital.
Department of Health
Department of Health and …
Kingston upon Thames — recommendation 17
Usage of ‘roll back’ (the deletion and reinsertion of records to ensure that contacts are on the system in chronological order) to be reviewed
Kingston Children’s Social Care
Kingston upon Thames Council
Kent — recommendation 3
When GP surgeries change their IT systems they must ensure that the medical records of current and previous patients are transferred from the old system to the new or that the records on the old system are archived in a way that makes them readily available.
NHS England
NHS England
St Helens — recommendation 10
When creating and indexing Niche logs or records, the perpetual abuse of alcohol by any of the parties involved should be highlighted on their Niche record as a warning sign, even if the person is a victim
Merseyside Police
Merseyside Police
Leeds — recommendation LYPFT2
For Domestic violence (where any past or present incidents are known) to be routinely noted within the FACE risk document.
Leeds and York Partnership NHS Trust
Leeds and York Partnership …
Cornwall — recommendation 11b
That there is a requirement for relevant early history, such as fostering, to be included as an integral part of GP records.
NHS England
NHS England
Cornwall — recommendation 9d
Consideration of how to tighten documentation regarding any referrals, outcomes or follow up?
Safer Cornwall
Cornwall — recommendation 9c
Paper record search to ensure that all relevant information is included on electronic record
Safer Cornwall
Barnet — recommendation 15
Following a Mental Health Act Assessment at least one of the medical assessors should make written entry of their findings that is transferred to the RiO record as soon as practicable whether or not the patient has been detained. If the patient is not detained, the reasons for the decision …
Barnet, Enfield & Haringey Mental Health …
North London NHS Foundation …
CQC enforcement actions(8)
Warning Notice: Royal United Hospital Bath NHS Trust
The Care Quality Commission issued a formal warning notice to Royal United Hospital Bath NHS Trust. This action followed an unannounced inspection in June, which found the hospital was failing to meet five national standards, including those related to patient …
Oct 2013
Warning Notice: Essex Partnership University NHS Foundation Trust
The Care Quality Commission (CQC) carried out unannounced focused inspections of Finchingfield Ward in October and November 2020 due to concerning information regarding safety incidents. Inspectors found that some staff did not follow required actions to maintain patient safety, including …
inpatient mental health wards
Jan 2021
Warning Notice: South Tyneside NHS Foundation Trust
The Care Quality Commission told South Tyneside NHS Foundation Trust that it must make further improvements to protect children and young people who may be at risk of harm. A focused inspection found limitations within the patient recording system in …
Oct 2016
Warning Notice: Peterborough and Stamford Hospitals NHS Foundation Trust
The Care Quality Commission told Peterborough and Stamford Hospitals NHS Foundation Trust that it must take action to improve services at Peterborough City Hospital. Following a review of compliance, inspectors found the trust was not meeting five essential standards of …
Peterborough City Hospital
Mar 2011
Warning Notice: Lewisham and Greenwich NHS Trust
The Care Quality Commission (CQC) carried out an unannounced, focused inspection at Queen Elizabeth Hospital in December after receiving information that triggered concerns about the safety and quality of services relating to DNACPR orders. CQC told Lewisham and Greenwich NHS …
Queen Elizabeth Hospital
Jan 2021
Warning Notice: Croydon Health Services NHS Trust
CQC served the trust a warning notice due to concerns about triage, staff training and appraisal, risk assessments and record keeping, equipment and environment checks, and leadership and governance. Staff didn’t always complete risk assessments and records to the required …
Croydon University Hospital
Nov 2025
Warning Notice: County Durham and Darlington NHS Foundation Trust
CQC identified significant and serious safety concerns during the surgery inspection. These related to safe staffing, escalation when people were deteriorating, record keeping and learning from incidents. Due to these issues, the trust has been told to make significant improvements …
Bishop Auckland Hospital, Darlington Memorial Hos…
Nov 2025
Conditions Imposed: The Dudley Group NHS Foundation Trust
The Care Quality Commission varied conditions on The Dudley Group NHS Foundation Trust's registration following an inspection at Russells Hall Hospital. Inspectors found concerns regarding the triage, assessment, and tracking of patients in the emergency department, especially concerning suspected sepsis. …
Russells Hall Hospital
Sep 2018