Incomplete and inaccurate nursing records and documentation
Pennine Acute Hospitals NHS Trust received 3 coroners' reports about this hazard between 15 Jul 2015 and 28 Nov 2017.
They came from 1 coroner. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 13 specific actions.
The story, report by report
Spacing grows with the time between reports.
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
Original on judiciary.uk ↗ Pennine Acute Hospitals NHS Trust responded, stating 6 specific actions.Response (PDF) ↗
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
Stated timescale: July 2015
“¢ Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently - this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools”
Stated timescale: January 2015
4 more stated actions in the Promises tab.
- 1 year laterClosely relatedConfidence 0.90 · high
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
Original on judiciary.uk ↗ Pennine Acute Hospitals NHS Trust responded, stating 7 specific actions.Response (PDF) ↗Response (PDF) ↗
“the RCPCH is unable to comment on the specifics of the case and the Pennine Acute Hospitals NHS Trust has been asked to respond directly on local communication, record keeping and policies and procedures.”
“The Division of Women and Children's is undertaking a programme of rolling audits on communication and documentation. The purpose is to ensure compliance with policy standards and to identify areas where there are challenges in order to implement remediating measures.”
5 more stated actions in the Promises tab.
- 1 year 5 months laterClosely relatedConfidence 0.85 · high
“Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased).”
Original on judiciary.uk ↗ The most recent report. A response may not be due or published yet.
- All reports to Pennine Acute Hospitals NHS Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2015 → 2016Dominic Smith1 year after Joyce Hartford · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in nursing/midwifery record keeping and documentation. The earlier report focuses on incomplete/inaccurate nursing tools and assessments, while the later report cites staff not documenting their rationale and inadequate communication/handover.
Joyce Hartford · 15 Jul 2015
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
Original on judiciary.uk ↗ Dominic Smith · 30 Jun 2016
“Staff did not follow the Trust's protocols/guidance and did not document their rationale where - they exercised clinical discretion”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
2015 → 2017John Lea2 years 4 months after Joyce Hartford · same coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports identify deficiencies in clinical documentation and record‑keeping practices across multiple tools and forms.
Joyce Hartford · 15 Jul 2015
“During the course of the inquest hearing it became apparent that the nursing tools (in particular, the 'Purpose T'), assessments, records, associated documentation and nursing discharge summary were incomplete and/or inaccurate.”
Original on judiciary.uk ↗ John Lea · 28 Nov 2017
“Gaps within the documentation/record keeping/missing entries by both doctors and nurses (including fluid balance charts for a patient in heart failure and subject to fluid restriction, risk assessments, care planning, rounding tool and medical attendance upon the deceased).”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
Stated action · timescale: July 2015
“We are undertaking a review of current documentation to ensure it meets all Trust standards and therefore supports improvements in care delivery. On a monthly basis the ward is audited using the nursing metrics which includes the quality of record keeping.”
Stated action · timescale: January 2015
“¢ Since January 2015 Ward T7 has recruited into a number of vacant registered nurse posts; as part of the induction for these new staff we have developed an induction booklet which includes the requirement for a senior member of the nursing team to observe the staff member undertaking various tasks to confirm that these are being performed competently - this includes completion of documentation such as District Nurse referrals, SKIN bundles (for tissue viability) and Rounding Tools”
Stated action · timescale: Ongoing
“There are also weekly audits of documentation undertaken by the Clinical Matron/Unit Manager and the Band 6 Sisters and feedback is given to the relevant member of staff at the time of the audit. These include accurate and timely completion of risk assessments, use of appropriate care plans and timely reassessments.”
Stated action · timescale: Ongoing
“SKIN bundle training has also been provided by the Equipment Co-ordinator who is a member of the Tissue Viability team.”
Stated action · timescale: Ongoing
“For early detection and management of pressure ulcers the use of scenario training on the completion of the PurposeT tool is now in place.”
Stated action · timescale: August 2015
“Since February 2015, the Unit has achieved 90% and above in the Nursing Care Indicators Audit except for May when the results reduced to 84% and this reduction was responded to immediately recognising that this was related to a trial of incorporating nursing documentation within the medical records. This was addressed and results improved to 92% in June, 95% in July and 93% in August.”
Stated action
“the RCPCH is unable to comment on the specifics of the case and the Pennine Acute Hospitals NHS Trust has been asked to respond directly on local communication, record keeping and policies and procedures.”
Stated action
“The Division of Women and Children's is undertaking a programme of rolling audits on communication and documentation. The purpose is to ensure compliance with policy standards and to identify areas where there are challenges in order to implement remediating measures.”
Stated action
“The division has commissioned an improvement programme of work focusing on these three areas in order to fully embed effective and reliable processes into clinical practice.”
Stated action
“There has been guidance issued to all practitioners to reiterate the need to obtain a thorough, probing history from the patients to ensure questioning covers the potential rupture of membranes in line with policy and carry out an appropriate speculum examination.”
Stated action
“Undertaking correct acute monitoring of patients condition, through using early warning scores is currently a Trust wide project to improve practice.”
Stated action
“The neonatal services has developed a module of training entitled Care of the Compromised Infant, which now forms part of each midwife's mandatory training; the .....”
Stated action
“The Division have developed a programme of training to emphasise recognition of signs and symptoms or deviations from normal physiological observations.”
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Pennine Acute Hospitals NHS Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2015 → 2016 | 0.70 | 0.07 | Closely related · 0.90 | same |
| 2015 → 2017 | 0.71 | 0.08 | Closely related · 0.85 | same |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.