Inadequate documentation of patient observations and assessments

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. ?Every quote shown was checked by code to appear word for word in the original report.

• 2018 → 2024Robert Fuller6 years 1 month after James Quinton · different coronerClosely relatedConfidence 0.92 · high

  Closely relatedConfidence 0.92 · high

  Both reports highlight inadequate record‑keeping practices that hinder clinical review and patient safety. The earlier report focuses on nursing notes and observation charts in resuscitation, while the later report concerns ward‑based charts and documentation of professional input.

  James Quinton · 22 Feb 2018

  “During the course of the evidence it became clear that the poor quality nursing notes and the lack of information of the observation chart made it difficult for the reviewing Consultants to get a clear picture of events that had been occurring.”

  Check it in the source

  Robert Fuller · 2 Apr 2024

  “There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”

  Check it in the source

  Stated action in the response to the earlier report

  “1. The Emergency Department has considered the use of scribes in the course of resuscitation within the emergency department. The Matron, has discussed this with the Care Group Educator and work has commenced on training individuals as scribes in such situations and to ensure that observations are accurately collated and recorded in the course of the”

  Earlier report in the app · Later report in the app

• 2024 → 2025Lee Stammers1 year 5 months after Robert Fuller · different coronerClosely relatedConfidence 0.86 · high

  Closely relatedConfidence 0.86 · high

  Both reports highlight inadequate documentation and communication leading to unsafe care. The earlier focuses on general record‑keeping gaps affecting behavior monitoring; the later specifies missing test results and system flaws allowing untracked cancellations.

  Robert Fuller · 2 Apr 2024

  “There was evidence of poor record keeping on the ward. This included behaviour charts, enhanced patient supervision records and daily evaluation charts not being consistently recorded.”

  Check it in the source

  Lee Stammers · 22 Aug 2025

  “Poor documentation, Communication, and systems- There were no clear communication, documentation, or systems in place, to identify if investigations had been performed as requested.”

  Check it in the source

  Stated action in the response to the earlier report

  “We have taken the opportunity to review and refine our Enhanced Care Policy and this is proceeding through our governance process for sign off over the coming weeks. One of the changes has been to separate our Falls Risk Assessment and Confusion Risk Assessment to support easier recognition of patients who are either a falls risk or those patients who need a designated level of supervision due to behaviours of concern.”

  Earlier report in the app · Later report in the app