Inconsistent and incomplete medical records
Medway NHS Foundation Trust received 4 coroners' reports about this hazard between 16 May 2016 and 15 Nov 2022.
They came from 4 different coroners. A similar concern was raised again 3 times after the first warning.
A published response was found for 1 of the 3 earlier reports, stating 3 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan.”
Original on judiciary.uk ↗ No published response from Medway NHS Foundation Trust was found for this report.
- 4 years 9 months laterClosely relatedConfidence 0.90 · higha different coroner
“The next of kin was incorrectly recorded on Mr [name redacted] medical records”
Original on judiciary.uk ↗ Repeated from the earlier report:medicalrecords
No published response from Medway NHS Foundation Trust was found for this report.
- 1 year 3 months later
“Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs [name redacted] medical records”
Original on judiciary.uk ↗ Medway NHS Foundation Trust responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed. Since the recipient of this letter, the team has again sent out safety message to all nursing staff as a reminder of the expected standard. Compliance with expected practice will be audited monthly, and monitored”
Stated timescale: monthly
“Changing the set up of the clinical team on the ward will allow the hierarchical tree with Change the 'Ward based structure to team based.”
Stated timescale: Nov-22
- 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“At the inquest it was clear that the standard of record keeping by the medical staff was poor”
Original on judiciary.uk ↗ Medway NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Trust Pharmacy team has contacted representatives of the Kent & Medway ICB Medicines Optimisation team that cover Medway & Swale. They are currently investigating the review process by the pharmacist to understand how the dose and product changes made were recorded and communicated to the GP practice. They are also investigating why these changes did not appear in the Kent Summary of Care Record.”
- All reports to Medway NHS Foundation 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.
2016 → 2021Christopher Smith4 years 9 months after Jonathan Fry · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the accuracy and completeness of patient medical records. The earlier report cites inconsistent/incomplete records affecting care plans, while the later report notes incorrect recording of next‑of‑kin and other documentation errors.
Jonathan Fry · 16 May 2016
“Medical records were inconsistent and / or incomplete”
Original on judiciary.uk ↗ Christopher Smith · 3 Feb 2021
“The next of kin was incorrectly recorded on Mr [name redacted] medical records”
Original on judiciary.uk ↗ 2016 → 2022Sally-Ann Few6 years 6 months after Jonathan Fry · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight inadequate medical record documentation that obscures reviews, care plans, and decision‑making. The later report describes the same problem of poor record keeping leading to reliance on oral testimony.
Jonathan Fry · 16 May 2016
“Medical records were inconsistent and / or incomplete leading to a lack of clarity as to reviews and care plan.”
Original on judiciary.uk ↗ Sally-Ann Few · 15 Nov 2022
“At the inquest it was clear that the standard of record keeping by the medical staff was poor”
Original on judiciary.uk ↗ 2022 → 2022Sally-Ann Few7 months after Kathryn Millard · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight failures in medical record documentation, noting that important clinical information was not recorded or was missing from patient notes.
Kathryn Millard · 25 Apr 2022
“Whomever attended (if they anybody did in fact attend), did not make any entry into Mrs [name redacted] medical records”
Original on judiciary.uk ↗ Sally-Ann Few · 15 Nov 2022
“At the inquest it was clear that the standard of record keeping by the medical staff was poor and it was only by hearing from witnesses via statements and orally, including from her family, that the decision making around her care and plans for her management became clear, as there was very little written in the notes.”
Original on judiciary.uk ↗
No published response from Medway NHS Foundation Trust was found for this report.
No published response from Medway NHS Foundation Trust was found for this report.
Stated action · timescale: monthly
“The Trust has also taken action to ensure that Anti-Embolic Stocking (AES) are prescribed and applied when indicated by the medical team. Safety messages and local teaching have occurred to ensure that nurses escalate incidents where an appliance has been indicated, but not prescribed. Since the recipient of this letter, the team has again sent out safety message to all nursing staff as a reminder of the expected standard. Compliance with expected practice will be audited monthly, and monitored”
Stated action · timescale: Nov-22
“Changing the set up of the clinical team on the ward will allow the hierarchical tree with Change the 'Ward based structure to team based.”
Stated action
“The Trust Pharmacy team has contacted representatives of the Kent & Medway ICB Medicines Optimisation team that cover Medway & Swale. They are currently investigating the review process by the pharmacist to understand how the dose and product changes made were recorded and communicated to the GP practice. They are also investigating why these changes did not appear in the Kent Summary of Care Record.”
- 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 Medway NHS Foundation 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 |
|---|---|---|---|---|
| 2016 → 2021 | 0.65 | 0.09 | Closely related · 0.90 | different |
| 2016 → 2022 | 0.71 | 0.06 | Identical · 0.90 | different |
| 2022 → 2022 | 0.67 | 0.02 | Identical · 0.90 | different |
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.