Inaccurate and inaccessible patient records
Failure to maintain easily accessible, up-to-date, and accurate information about patients/service users in care settings.
1,708 items
16 sources
10 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
87match
F244 - Common information practices shared data and electronic records
There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter...
Matched on
terms: patient, record
Committee recommendation
84match
#6 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
Missing or inaccurate telephone numbers in NHS patient records undermined government’s efforts to contact 375,000 people. The contact centre relied on telephone numbers in NHS patient records when calling people to check their needs. Over 20% of the 1.8 million telephone numbers passed to the contact centre from NHS records, for roughly 375,000 people, were missing or found...
Matched on
terms: inaccurate, patient, record
PHSO casework decision
84match
P-001489 - An Inpatient Service in the Darlington area
Mr I complains that the Inpatient Service shared his medical information with his employer without consent, and that some of his medical records are inaccurate.
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
82match
R15 - CDI patient observations records
Health Boards should ensure that nursing staff caring for a patient with CDI keep accurate records of patient observations including temperature, pulse, respiration.
Matched on
terms: patient, record
Inquiry recommendation
82match
R38 - Medical record keeping
Health Boards should ensure that clear, accurate and legible patient records are kept by doctors, that records are seen as integral to good patient care.
Matched on
terms: patient, record
PFD report
81match
Lee Hollman
The practice had inadequate systems for maintaining accurate medical records, removing outdated repeat prescriptions, and reviewing patients' medication within guidelines.
Matched on
terms: patient, record
LGO / SPSO decision
80match
201508104 - Grampian NHS Board
Mr C complained that an incorrect entry had been placed in his GP records which he had asked the practice to remove or mark 'to be disregarded'. He also complained that the board did not deal with his subsequent complaint in a timely manner. Following investigation, we were of the view that the practice had taken reasonable action...
Matched on
terms: inaccurate, patient, record
Inquiry recommendation
78match
R20 - Stool records for CDI patients
Health Boards should ensure that where a patient has, or is suspected of having, C.difficile diarrhoea a proper record of the patient's stools is kept.
Matched on
terms: patient, record
Inquiry recommendation
78match
R14 - Patient records compliance audit
Health Boards should ensure that the nurse in charge of each ward audits compliance with the duty to keep clear and contemporaneous patient records.
Matched on
terms: patient, record
Inquiry recommendation
78match
IBI-4d - Patient Records Audit
Patient Records: Before the end of 2027 there should be a formal audit, publicly reported, of the extent of success of digitisation of patient records in each of the four health jurisdictions of the UK, measuring at least the levels of patient access to their personal records, their ability to identify and correct apparent errors in them, their...
Matched on
terms: patient, record
Committee recommendation
78match
#1 - Ensure urgent and full implementation of IMMDS review recommendations 6 and 7 on patient records
Without records of which patient has undergone which procedure, or been prescribed which drug, the health system will continue to, in the words of the IMMDS review team, “fly blind”. We recommend that the Government urgently ensures that the accepted recommendations 6 and 7 of the IMMDS review are fully implemented.
Matched on
terms: patient, record
PFD report
77match
Peter Pattinson
Care home staff failed to act on family requests for bed rail use and repairs, did not conduct risk assessments, and maintained inadequate, unpaginated patient records.
Matched on
terms: patient, record
PFD report
77match
Afifa Qaisar
Critical issues included inaccurate drug administration records, missing emergency equipment, delays in urgent platelet transfusions, and a failure to properly monitor fluid balance, indicating systemic clinical procedural shortcomings.
Matched on
terms: inaccurate, record
PFD report
77match
Thomas Maher
Missing medical records, unupdated risk assessments, non-functioning falls alarms, systemic delays in patient transfers, and incompatible paper/electronic record systems severely hampered patient care and safety.
Matched on
terms: patient, record
CQC action
77match
Cygnet Bury Hudson
The service must ensure that care records are contemporaneous and complete. Patient risk assessments must be updated following incidents and without delay.
Matched on
terms: patient, record
Committee recommendation
76match
#24 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
The DWP contact centre relied on telephone numbers in NHS patient records to call clinically vulnerable people who had not yet registered their needs. In some 375,000 cases out of the 800,000 people that the contact centre could not get hold of, or over 20% of the 1.8 million people the centre attempted to contact, it was because...
Matched on
terms: inaccurate, patient, record
Committee recommendation
75match
#13 - Thirteenth Report - Initial lessons from the government’s response to the COVID-19 pandemic
The pandemic has again highlighted the role of high-quality data in enabling effective service delivery, monitoring and improvement. For example, due to missing or inaccurate telephone numbers within NHS patient records, the shielding programme was unable to follow-up letters to 375,000 vulnerable people with phone calls. Local authorities, which were passed the details of individuals who could not...
Matched on
terms: inaccurate, patient, record
PFD report
73match
Stuart Aaron Collins
Inadequate patient assessment and a complete failure to conduct hourly observations or maintain accurate nursing notes for an epileptic patient. Furthermore, a hazardous item was left accessible to the patient.
Matched on
terms: patient
PFD report
73match
Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Matched on
terms: patient, record
PFD report
73match
Zeeyad Hamadi
Inadequate patient weighing and poor medical record-keeping within the prison were noted. There was limited liaison between prison and hospital staff, confusion over prisoner private healthcare policies, and delays in securing bed watch cover.
Matched on
terms: patient, record
PFD report
73match
Desrae Tucker
Inadequate recording of anti-embolic stocking use, no consideration for discharging the patient with them, and failure to prescribe anti-coagulant medication upon discharge were issues.
Matched on
terms: patient, record
PFD report
73match
Charles Bradley
Inadequate record-keeping and communication failures at Arrowe Park Hospital led to the patient not being expected upon transfer and unclear documentation of a significant fall.
Matched on
terms: patient, record
PFD report
73match
David Chatburn
The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Matched on
terms: patient, record
PFD report
73match
Frederick Hall
Widespread deficiencies included poor staff training for NG tube insertion, erratic patient monitoring, failure to follow consultant instructions, and significant communication breakdowns. Additionally, poor record-keeping and inadequate staffing compounded risks.
Matched on
terms: patient, record
PFD report
73match
Linda Fisher
Inaccurate medication dosages resulted from doctors relying on patient-reported weight, and critical family medical history was not obtained or effectively communicated among staff.
Matched on
terms: inaccurate, patient
PFD report
73match
Daniel McCallum Keane
The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Matched on
terms: patient, record
Inquiry recommendation
73match
COVID-M3.4 - Data Systems for High-Risk Individuals
The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient...
Matched on
terms: patient, record
CQC action
73match
Cheshire Hair Transplant Clinic Limited
The service must ensure staff keep complete and accurate patient records and store them safely.
Matched on
terms: patient, record
LGO / SPSO decision
72match
21-018-569c - The Coach House Residential Home (21 018 569c)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: patient, record
LGO / SPSO decision
72match
21-018-569a - Norfolk & Suffolk NHS Foundation Trust (21 018 569a)
Summary: We found fault with the Care Home who did not keep accurate or up-to-date records. We also found fault with the Integrated Care Board who do not keep a register of patients receiving s117 aftercare in its area. We found no fault with the actions of the Council or the Trust. The identified faults caused avoidable distress...
Matched on
terms: patient, record
CQC action
71match
Snowdrop Place Care Home
The registered person must maintain accurate, complete and contemporaneous records in respect of each service user.
Matched on
terms: record
CQC action
71match
Forge House Services Limited
The registered manager should work with staff to improve staff recording, ensuring all care records display people's names, are dated and show who had written them, as not all care records displayed this information, making it difficult to accurately identify when people's needs had changed and who had recorded the change.
Matched on
terms: record
CQC action
71match
Applegarth Care Home
The provider must ensure that accurate, complete and up to date records are maintained in respect of people who use the service.
Matched on
terms: record
CQC action
71match
St.Theresa's Nursing Home
The provider must ensure that care and treatment is provided in a safe way for service users, including ensuring care records are consistently completed, accurate, and updated to provide clear information on people's needs, including wound care and repositioning, and that appropriate specialist advice is sought in a timely manner.
Matched on
terms: record
CQC action
71match
St Paul's Lodge
The registered person must maintain accurate, complete and contemporaneous records in respect of each service user, including a record of the care and treatment provided to the service user and decisions taken in relation to the care and treatment provided.
Matched on
terms: record
PFD report
69match
Felix Cembrowicz
The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Matched on
terms: patient, record
PFD report
69match
John Lansdowne
Unclear observation records and inconsistent staff understanding of patient observation protocols during bathing, coupled with the use of baths instead of safer walk-in showers, posed risks.
Matched on
terms: patient, record
PFD report
69match
John William Wright
A patient fall was not investigated as a Serious Untoward Incident, and there was unclear training for doctors on fall policy and incident recording.
Matched on
terms: patient, record
PFD report
69match
Yuki Ivy Norman-Knight
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.
Matched on
terms: patient, record
PFD report
69match
Rosemary Oladejo
A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Matched on
terms: patient, record
Inquiry recommendation
69match
R19 - ICN instructions recorded
Health Boards should ensure that where Infection Control Nurses provide instructions on the management of patients those instructions are recorded in patient notes.
Matched on
terms: patient, record
CQC action
69match
Haisthorpe House
The provider must ensure people who used services are protected from receiving unsafe care and treatment by maintaining accurate records about the care needs of each person living there.
Matched on
terms: record
CQC action
69match
The Peter Gidney Neurodisability Centre
There was a failure to maintain accurate records of people's care.
Matched on
terms: record
CQC action
69match
St John's Home
The provider must ensure that accurate and contemporaneous records are maintained in respect of service users.
Matched on
terms: record
CQC action
69match
Private Ultrasound Scan
The service must ensure staff maintain accurate and complete record in respect of each service user.
Matched on
terms: record
CQC action
69match
Newland House
Records relating to the care and treatment of people using the service were not complete, accurate or up to date.
Matched on
terms: record
CQC action
69match
Tregertha Court Care Home
The provider must ensure that accurate, complete, and contemporaneous records are kept in respect of each service user, specifically regarding food and fluid intake, including totals and assessed levels, to enable accurate monitoring of nutritional needs.
Matched on
terms: record
CQC action
69match
JDK Limited (Glenholme Care)
There were no processes in place to maintain records in an accessible and secure way. Information was not protected and was not accessible in emergency situations.
Matched on
terms: record
Inquiry recommendation
69match
R24 - TVN instructions recorded
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.
Matched on
terms: patient, record
Inquiry recommendation
69match
R22 - Relative discussions recorded
Health Boards should ensure that any discussion between a member of nursing staff and a relative about a patient which is relevant to the patient's continuing care is recorded.
Matched on
terms: patient, record