Inadequate clinical records hinder investigations
Barking received 5 coroners' reports about this hazard between 4 Nov 2022 and 25 Oct 2024.
They came from 1 coroner. A similar concern was raised again 4 times after the first warning.
A published response was found for 4 of the 4 earlier reports, stating 15 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Original on judiciary.uk ↗ Barking responded, stating 1 specific action.Response (PDF) ↗
“has completed all the actions assigned to the department within the Trust's SI recommendations and subsequent Action Plan. If any scan is mis- reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr [name redacted] scans through its Governance process.”
Web search (Tavily): No evidence found either way
Standards for radiology events and learning meetings ↗- 3 months later
“Clinical records were poorly maintained , resulting in an unclear picture of fluid administration.”
Original on judiciary.uk ↗ Barking responded, stating 1 specific action.Response (PDF) ↗
“Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”
Stated timescale: completed
Web search (Tavily): No evidence found either way
CLINICAL ↗ - 8 months laterClosely relatedConfidence 0.90 · high
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
Original on judiciary.uk ↗ Repeated from the earlier report:clinicalrecords
Barking responded, stating 6 specific actions.Response (PDF) ↗
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
Stated timescale: 9 November 2023
Web search (Tavily): No evidence found either way
Set Barking Alert – Furbo Help Center ↗“A video has been developed and was placed on the Trust intranet 27 November 2023 which shows - Medical Director (Patient Safety and Patient Experience), explaining the importance of good record keeping.”
Stated timescale: 27 November 2023
Web search (Tavily): No evidence found either way
Do business records management affect business growth? ↗4 more stated actions in the Promises tab.
- 8 months laterClosely relatedConfidence 0.90 · high
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Original on judiciary.uk ↗ Repeated from the earlier report:clinicalrecords
Barking responded, stating 5 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“The CQC has confirmed that they are reviewing this case, and will consider what further action should be taken, and whether any monitoring of the trust, or regulatory response, is required.”
“be able to check the wording in their specific product information to ensure the appropriate advice on checking for leaks is present.”
3 more stated actions in the Promises tab.
- 4 months laterClosely relatedConfidence 0.90 · high
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment.”
Original on judiciary.uk ↗ Repeated from the earlier report:investigationinquest
Barking responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“the Trust has put mitigations in place. The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability.”
“BHRUT plan to recruit more learning disability nurses in 2025. They have created pathways to encourage and upskill existing staff due to the shortage of nurses going into learning disability training (RNLD).”
Stated timescale: 2025
- All reports to Barking
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.
2022 → 2023Thomas Doyle11 months after Peter Ross · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify poor maintenance of clinical records as a problem. The earlier report links this to communication lapses in patient care, while the later report links it to hindered governance and inquest investigations.
Peter Ross · 4 Nov 2022
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Original on judiciary.uk ↗ Thomas Doyle · 20 Oct 2023
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
Original on judiciary.uk ↗ 2022 → 2024David Morris1 year 8 months after Peter Ross · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the quality of clinical records. The earlier report links poor record‑keeping to communication lapses, while the later report links it to impeded investigations.
Peter Ross · 4 Nov 2022
“Clinical records were poorly maintained, exacerbating the lapses in communication between those treating Mr [name redacted].”
Original on judiciary.uk ↗ David Morris · 4 Jul 2024
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“has completed all the actions assigned to the department within the Trust's SI recommendations and subsequent Action Plan. If any scan is mis- reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr [name redacted] scans through its Governance process.”
2023 → 2024David Morris1 year 5 months after George Kearsey · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with inadequate clinical record‑keeping that obscured patient care details. The earlier case concerned fluid balance documentation; the later case concerned overall record quality hindering death investigation.
George Kearsey · 9 Feb 2023
“Clinical records were poorly maintained , resulting in an unclear picture of fluid administration.”
Original on judiciary.uk ↗ David Morris · 4 Jul 2024
“During Mr [name redacted] ward-based treatment on 3 & 4th May 2022 clinical records were either of a poor standard or were non-existent.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”
2023 → 2024Chloe Every1 year after Thomas Doyle · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight deficiencies in the Trust's clinical documentation that hinder investigations and decision‑making.
Thomas Doyle · 20 Oct 2023
“The trust's clinical records were of a particularly poor standard which impeded the Trust's governance investigation and the inquest investigation in determining what, if any consideration was given to the possibility that Mr [name redacted] was suffering from an infection.”
Original on judiciary.uk ↗ Chloe Every · 25 Oct 2024
“The investigation of this inquest was prejudiced by the absence of contemporary nursing and medical notes from various stages of [the deceased]'s treatment.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
Stated action
“has completed all the actions assigned to the department within the Trust's SI recommendations and subsequent Action Plan. If any scan is mis- reported, the Department uses it as a learning opportunity, and it is reviewed at the Departmental Radiology Event and Learning Meeting (REALM) and undertakes a process of peer review. The Radiology Department has reviewed Mr [name redacted] scans through its Governance process.”
What happened next: No evidence found either way
The organisation states it reviews scans through its governance process and uses REALM meetings for learning, but no source confirms completion of all assigned actions or a specific timeline.
“A positive culture to develop learning is vital to improve outcomes and comply with the recommendations of the Francis Report.1 As radiologists, we are constantly striving to improve the standards of service we provide to patients with a culture of learning, self-reflection and personal development. Humans will always make errors and radiologists are no different. They will also have moments of brilliance”
No evidence found does not mean the action did not happen.
Stated action · timescale: completed
“Cross site audits have been completed on COTE (Care of the Elderly) wards on a random basis to understand a cross section of compliance with fluid management with no notice given to the ward in advance of the audit. The audits capture patients who are on fluid restriction, patients requiring oral and intravenous hydration, parenteral nutrition and output monitoring, whether the intake and output is entered on Careflow Vitals and appropriate action taken as necessary. The audits were completed by”
What happened next: No evidence found either way
The promised cross-site audits on COTE wards were not confirmed to have been completed.
“The proportion of prescriptions which met the IV fluid prescribing bundle of care increased (3.8% to 22.9% [p=0.004]) and the legibility of the IV fluid prescription increased (28.3% to 56.3% [p=0.004]).”
“## Keywords colloids, crystalloids, fluid management, overhydration, underhydration”
“## Abstract Intravenous (IV) fluids are commonly prescribed drugs in healthcare. However, inappropriate fluid administration is associated with higher morbidity and mortality. *Fluid stewardship* is defined as a series of coordinated interventions for judicious IV fluid administration, with a primary goal of limiting the deleterious effects of inappropriate fluid prescription and fluid overload or”
No evidence found does not mean the action did not happen.
Stated action · timescale: 9 November 2023
“An Internal Alert has been shared with staff via email, Alert reference Issued Date 9 November 2023 which details good record keeping standards that should be adhered to by all staff.”
What happened next: No evidence found either way
No source confirms an internal alert was shared with staff on 9 November 2023 regarding good record keeping standards.
“This article covers how to enable, disable, and customize the Barking Alert notifications for your Furbo Dog Camera 360. It is intended for Furbo owners who want to manage how often they receive pet alerts on their smartphones, or troubleshoot alerts that are not working.”
“Bark alerts are not sent in real time. It may take some time to receive notifications as we analyze context, not just keywords.”
“Bark provides alerts to administrators on bullying, drug and alcohol-related content, weapons, self-harm, and much more.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 27 November 2023
“A video has been developed and was placed on the Trust intranet 27 November 2023 which shows - Medical Director (Patient Safety and Patient Experience), explaining the importance of good record keeping.”
What happened next: No evidence found either way
No source confirms the video was published on 27 November 2023 or placed on the Trust intranet.
“Do business records management affect business growth? Clement Mintah, [name redacted], Felicia Aloo, [name redacted] · 2022-03-10 · 17(3):e0264135 · DOI: 10.1371/journal.pone.0264135 · PMID: 35271595 · PMCID: PMC8912245 ## Abstract The implementation of a records management plan is an excellent approach to ensure small and medium-sized enterprises (SMEs) are sustained and continue to expand into huge or multi-national corporations.”
No evidence found does not mean the action did not happen.
Stated action · timescale: week commencing 4 December 2023
“A screen saver was agreed and appeared on all Trust computer screens week commencing 4 December 2023”
What happened next: No evidence found either way
No source confirms a screen saver was displayed on all Trust computer screens during the week commencing 4 December 2023.
“The purpose of this standard is to set a minimum standard for protecting our computers with password protected screen savers. The screen saver logs out an active user after a set amount of time with no activity. By requiring a user to sign in when they return, it minimizes the risk of an unauthorized person using an active session while the authorized user is away. A password-enabled screen saver”
“A HIPAA screensaver is basically a screensaver that automatically turns on after a computer is left unattended for a period of time. HIPAA screensaver compliance is discussed below.”
No evidence found does not mean the action did not happen.
Stated action · timescale: on first day working at the Trust
“All medical staff must complete a record keeping module on the Trust BEST learning management system that allows staff to undertake e learning module on their first day working at the Trust.”
What happened next: No evidence found either way
No source confirms that medical staff are required to complete a record keeping module on the Trust's BEST learning management system on their first day.
“Complete the online learning modules series, Foundations for Medical Record Keeping. 3. Apply medical record requirements to your record keeping for one month.”
“GBS Medical Record Keeping Policy Approved April 2020 Page 1 of 8 GBS Medical Record Keeping Policy GBS Medical Record Keeping Policy Approved April 2020 Page 2 of 8 Contents Definitions 3 1. Introduction 4 Aims 4 Scope 4 2. Governance 5 3. Guidance and Standards 5 4. Responsibility and Practitioner Accountability 7 5. Medical Records Audit 7”
No evidence found does not mean the action did not happen.
Stated action · timescale: recently
“The Trust sepsis education programme is essential for all clinical staff and has recently been updated. This is supported by additional face to face training for doctors and nurses.”
What happened next: No evidence found either way
No source confirms the promised sepsis education programme was recently updated or supported by face-to-face training for doctors and nurses.
“Hospital Sepsis Program Core Elements are essential to optimize patient care and help clinicians, hospitals, and health systems in efforts to improve the hospital management and outcomes of sepsis.”
“Provide educational materials to staff about sepsis emphasizing the importance of preventing sepsis through proper infection control and expressing concerns when an individual/patient demonstrates a change in health status.”
“Trust Board papers 7th September 2011 - Barking Havering and ... # Trust Board papers 7th September 2011 - Barking Havering and ...”
No evidence found does not mean the action did not happen.
Stated action · timescale: ongoing
“The Trust has adopted the UK Sepsis Trust`s adult screening tool and the use of this is audited by the Lead Nurse for Sepsis. Audits include patients who have scored over 5 on the National Early Warning Score to ensure that Sepsis was considered. In addition, all positive blood culture cases are audited to ensure compliance with the Sepsis 6.”
What happened next: Evidence found that the action was carried out
The Trust's policy states it uses the UK Sepsis Trust adult screening tool and audits its use, including for patients with a National Early Warning Score over 5 and all positive blood cultures.
“Sepsis screening is facilitated via Nervecentre. Clinical staff must undertake Nervecentre training to obtain an account. These accounts must not be shared because the electronic signature is applied to all actions in the system. Nervecentre training is available via the CITS portal.”
“The sepsis six care bundle has been adopted by hospitals in England and Wales for the management of patients with sepsis, with the aim of increasing survival when all elements of the bundle are achieved.”
“Screening tools and automated alerts are available but are not in widespread use. Where clinical information is stored electronically, software systems can detect sepsis before the clinical team has suspected it.”
Stated action
“The CQC has confirmed that they are reviewing this case, and will consider what further action should be taken, and whether any monitoring of the trust, or regulatory response, is required.”
Stated action
“be able to check the wording in their specific product information to ensure the appropriate advice on checking for leaks is present.”
Stated action · timescale: 30 September 2024
“no patients that are currently on a Patient Tracker List for any cancer diagnosis can be removed or deferred without approval of the responsible consultant”
Stated action · timescale: April 2024
“Critical Care Outreach Team (CCOT) model since April 2024.”
Stated action · timescale: October 2023
“Patient Safety Investigation Response Framework (PSIRF) which uses multidisciplinary investigations and reviews with multiple responsible authors.”
Stated action
“the Trust has put mitigations in place. The Trust provides mandatory training for all staff including both nursing and medical staff related to the care of patients with a Learning Disability.”
Stated action · timescale: 2025
“BHRUT plan to recruit more learning disability nurses in 2025. They have created pathways to encourage and upskill existing staff due to the shortage of nurses going into learning disability training (RNLD).”
- 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 Barking 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 |
|---|---|---|---|---|
| 2022 → 2023 | 0.72 | 0.12 | Closely related · 0.90 | same |
| 2022 → 2024 | 0.74 | 0.14 | Closely related · 0.90 | same |
| 2023 → 2024 | 0.73 | 0.14 | Closely related · 0.90 | same |
| 2023 → 2024 | 0.66 | 0.01 | Closely related · 0.90 | 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.