Inaccurate and inconsistent care plan entries and record keeping
Care Quality Commission received 10 coroners' reports about this hazard between 8 May 2017 and 26 Jun 2026.
They came from 9 different coroners in 9 coroner areas. A similar concern was raised again 9 times after the first warning.
A published response was found for 9 of the 9 earlier reports, stating 7 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”
Web search (Tavily): No evidence found either way
[PDF] Choking Incident Report Checklist - NJ.gov ↗- 2 months later
“Records of routine checks on residents are not made. Therefore whilst it was asserted that Mr [name redacted] was checked hourly throughout following the fall there is no evidence that the checks were carried out”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and”
Web search (Tavily): No evidence found either way
- 5 months later
“Failed to keep accurate records.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
Stated timescale: December 2017
Web search (Tavily): No evidence found either way
Opinion Paper: “So what if ChatGPT wrote it?” Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy ↗“we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”
Web search (Tavily): No evidence found either way
New platform for AsureQuality Auditing Services ↗ - 1 year 11 months laterClosely relatedConfidence 0.85 · higha different coroner
“Furthermore, the general quality of record keeping was poor.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“Council's considerations and investigation: Following Mr [name redacted] death, several monitoring and support visits took place at Barely Brook. We considered a sample of referrals that had been made in respect of current residents. Wigan Council can confirm that the recording of referrals of any kind (including dietician and falls team, and referrals to the Later Life and Memory Team) has improved. Barley Brook has demonstrated they are now keeping contemporaneous records and documentation.”
Stated timescale: 24th June 2019 to present
Web search (Tavily): No evidence found either way
Improving Referral and Continuity of Care Through Structured Outpatient Disposition Planning Enabled by Electronic Referrals: A Quality Improvement Study ↗“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
Stated timescale: 12 months
Web search (Tavily): No evidence found either way
CQC's 2026 Overhaul: New Leadership, Cleared Backlogs, New Rules — Team Care Compliance ↗ - 1 year later
“The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff who were monitoring him.”
Original on judiciary.uk ↗ Care Quality Commission responded.Response (PDF) ↗
- 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ Care Quality Commission responded, stating 1 specific action.Response (PDF) ↗
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Web search (Tavily): No evidence found either way
Documentation That Protects: How Clear Record-Keeping ... ↗ - 1 year 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeeping
Care Quality Commission responded.Response (PDF) ↗
- 1 year 10 months laterIdentical hazardConfidence 0.90 · high
“Overall documentation at the home was limited and lacked detail”
Original on judiciary.uk ↗ Repeated from the earlier report:documentationhomelimiteddetail
Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗
- 1 year 4 months laterIdentical hazardConfidence 0.90 · higha different coroner
“That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeeping
Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗
- 5 months laterIdentical hazardConfidence 0.95 · higha different coroner
“(1) The record keeping in the home appeasers to be inaccurate and inconsistent”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeeping
Care Quality Commission responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Care Quality Commission
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.
2017 → 2019Sidney Baker1 year 11 months after Ronald Farrington · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight failures in maintaining accurate patient records within care settings.
Ronald Farrington · 22 Dec 2017
“Failed to keep accurate records.”
Original on judiciary.uk ↗ Sidney Baker · 2 Dec 2019
“Furthermore, the general quality of record keeping was poor.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
2017 → 2021John Dickinson3 years 7 months after Ronald Farrington · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the accuracy and completeness of patient records.
Ronald Farrington · 22 Dec 2017
“Failed to keep accurate records.”
Original on judiciary.uk ↗ John Dickinson · 22 Jul 2021
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
2019 → 2021John Dickinson1 year 8 months after Sidney Baker · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with the quality and completeness of resident record keeping. The earlier report cites incorrect entries and missing referrals, while the later report notes inconsistent and insufficient detail in records.
Sidney Baker · 2 Dec 2019
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
Original on judiciary.uk ↗ John Dickinson · 22 Jul 2021
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
2017 → 2021John Dickinson4 years 2 months after David Sheppard · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports identify problems with record keeping that hinder proper assessment and reconstruction of care. The earlier report focuses on missing timely notes of events, while the later report highlights inconsistent records lacking detail on general wellbeing.
David Sheppard · 8 May 2017
“Staff failed to keep an acute and contemporaneous note of the events that occurred with timings.”
Original on judiciary.uk ↗ John Dickinson · 22 Jul 2021
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ 2021 → 2022Frederick King1 year 4 months after John Dickinson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight problems with record keeping that omitted key details about food, fluid intake and general wellbeing. The later report describes the same kind of incomplete records affecting fluid provision and other observations.
John Dickinson · 22 Jul 2021
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ Frederick King · 15 Nov 2022
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
2017 → 2022Frederick King5 years 4 months after James Harris · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports identify shortcomings in the documentation of care activities, pointing to inadequate record‑keeping practices. The earlier report notes missing routine‑check logs, while the later report highlights incomplete fluid and pad records that hindered the investigation.
James Harris · 21 Jul 2017
“Records of routine checks on residents are not made. Therefore whilst it was asserted that Mr [name redacted] was checked hourly throughout following the fall there is no evidence that the checks were carried out”
Original on judiciary.uk ↗ Frederick King · 15 Nov 2022
“Inadequate record keeping in the Birchwood Care made it difficult to obtain the relevant records for the Inquest and the records obtained were incomplete”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Read and sign sheets have been implemented so that staff read and sign care plans individually when residents are admitted to the home. The aim is that these are completed in a timely manner within 72 hours of a service user arriving, and staff will read and sign them the expectation being within one week. On point of admittance information is given at handover three times a day so that staff are aware of needs of a new resident.”
2020 → 2024James Astley3 years 9 months after Anthony Slack · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that the care home's documentation was limited and lacked detail, making it hard to assess care provided. The core issue is inadequate record‑keeping.
Anthony Slack · 1 Dec 2020
“The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff who were monitoring him.”
Original on judiciary.uk ↗ James Astley · 10 Sept 2024
“Overall documentation at the home was limited and lacked detail”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Care Home confirmed that; 1. The Provider/Registered Manager is speaking to staff individually to reiterate the need for thorough record keeping in relation to falls but also generally. A documentation awareness training offer has been made to the Provider/Registered Manager by Tameside and Glossop CCG Quality Improvement Team. This has been accepted and sessions will take place in February via Microsoft Teams. The Local Authority require all providers to comply with good record keeping”
2021 → 2024James Astley3 years 2 months after John Dickinson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight inadequate documentation that fails to capture residents' wellbeing and nutrition needs. This shortcoming delays recognition of deterioration and risks to health.
John Dickinson · 22 Jul 2021
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ James Astley · 10 Sept 2024
“Overall documentation at the home was limited and lacked detail”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
2021 → 2026Ronald Nelson4 years 6 months after John Dickinson · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight problems with record keeping, specifically inconsistency and lack of detail in documenting residents' wellbeing and care.
John Dickinson · 22 Jul 2021
“(1) The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ Ronald Nelson · 15 Jan 2026
“That there remain potential issues of poor record keeping. ii) There are concerns over the level of compliance of care plans”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
2019 → 2026Ronald Nelson6 years 1 month after Sidney Baker · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight problems with inaccurate or incomplete care‑plan records and overall poor record‑keeping practices.
Sidney Baker · 2 Dec 2019
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
Original on judiciary.uk ↗ Ronald Nelson · 15 Jan 2026
“That there remain potential issues of poor record keeping.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
2019 → 2026Susan Dale6 years 7 months after Sidney Baker · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight problems with inaccurate and inconsistent record‑keeping in care homes.
Sidney Baker · 2 Dec 2019
“There were concerns that entries contained in Mr [name redacted] care plan were incorrect, including vital information contained on his weight monitoring sheet. Furthermore, the general quality of record keeping was poor.”
Original on judiciary.uk ↗ Susan Dale · 26 Jun 2026
“(1) The record keeping in the home appeasers to be inaccurate and inconsistent”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
2021 → 2026Susan Dale4 years 11 months after John Dickinson · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with record keeping being inconsistent and lacking detail. The earlier report focuses on general wellbeing records, while the later report concerns inaccuracies in incident and handover records.
John Dickinson · 22 Jul 2021
“The record keeping was inconsistent and lacked detail on general wellbeing.”
Original on judiciary.uk ↗ Susan Dale · 26 Jun 2026
“The record keeping in the home appeasers to be inaccurate and inconsistent”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
Stated action
“the provider has taken a number of measures to address concerns including, but not limited to, the provision of training with first aid, CPR and choking prioritised in the induction process, as well as documentation training sessions and the introduction of an incident reporting questionnaire”
What happened next: No evidence found either way
The organisation's promised measures are described in a checklist and training resources, but no source confirms they were implemented.
“Utilize the checklist below to complete your initial incident report.”
“FirstAidTraining can teach you to: ✓Identify and treat a choking incident”
No evidence found does not mean the action did not happen.
Stated action
“The Registered Provider is responsible for ensuring care staff are competent, skilled and experienced and that they are appropriately trained as is necessary to enable them to carry out their duties, (Regulation 12 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014).The Registered Provider has the responsibility to ensure care staff follow service users care plans, and to make staff aware of the importance of knowing how to effectively and safely support service users and”
What happened next: No evidence found either way
The Care Quality Commission provides guidance on staffing and training requirements but does not specify a completion timeframe for staff training.
No evidence found does not mean the action did not happen.
Stated action · timescale: December 2017
“We have improved our systems to identify long running adult safeguarding enquiries and take actions to bring them to a satisfactory conclusion. In December 2016 15% of our adult safeguarding enquiries had been in progress for over 12 months. By December 2017 we had reduced this to 4%, despite the number of adult safeguarding enquiries we are undertaking having more than doubled over that period.”
What happened next: No evidence found either way
The organisation's statement about reducing long-term adult safeguarding enquiries to 4% by December 2017 is not addressed in any of the provided sources.
“Multidisciplinary perspectives on opportunities, challenges and implications of generative conversational AI for research, practice and policy”
“Streamlining supervision, safeguarding resilience: the ECB's agenda for more effective, efficient and risk-based European banking supervision”
No evidence found does not mean the action did not happen.
Stated action
“we have put in place a new auditing system with close support from the local quality development team from East Surrey, this has been developed over the past year and has been met with positive feedback from the local team. The”
What happened next: No evidence found either way
The organisation announced plans to implement a new auditing system with support from the local quality development team, but no source confirms the system was fully operational or delivered as promised.
“To advance the digitalisation of our auditing and certification services and to support the future of food assurance, AsureQuality is partnering with Intact - a market leader in quality assurance software solutions for food industry certification, to implement a new Audit Management System.”
No evidence found does not mean the action did not happen.
Stated action · timescale: 24th June 2019 to present
“Council's considerations and investigation: Following Mr [name redacted] death, several monitoring and support visits took place at Barely Brook. We considered a sample of referrals that had been made in respect of current residents. Wigan Council can confirm that the recording of referrals of any kind (including dietician and falls team, and referrals to the Later Life and Memory Team) has improved. Barley Brook has demonstrated they are now keeping contemporaneous records and documentation.”
What happened next: No evidence found either way
The organisation's statement about improved referral recording at Barley Brook is not supported by evidence from the provided sources.
“Baseline referral documentation averaged fewer than two referrals per w”
No evidence found does not mean the action did not happen.
Stated action · timescale: 12 months
“We will carry out a further comprehensive inspection within 12 months, to ensure action has been taken and the provider is no longer in breach.”
What happened next: No evidence found either way
The Care Quality Commission announced plans to overhaul its processes and increase inspections by September 2026, targeting 9,000 inspections. No specific commitment to conduct a further comprehensive inspection within 12 months of a promise was identified in the provided sources.
“The Care Quality Commission is overhauling how it works. After a rough couple of years - inspection backlogs, mounting criticism, internal problems - the regulator has new leadership and a plan to fix things by the end of 2026. If you run a care service, these changes will affect how you're assessed.”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
Stated action
“The provider has indicated they have also reviewed the quality of their own documentation and care records. In relation to food records, in addition to improved documentation, staff have also received additional training.”
What happened next: No evidence found either way
The provider mentions reviewing documentation and training staff regarding food records, but no source confirms this action was completed.
“Documentation represents far more than administrative paperwork. Clear, accurate record-keeping forms the backbone of quality care delivery, protecting both residents and the professionals who serve them. When direct care staff understand documentation's vital role and receive proper training in record-keeping practices, they gain confidence in their professional capabilities while creating”
No evidence found does not mean the action did not happen.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- 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 Care Quality Commission 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 |
|---|---|---|---|---|
| 2017 → 2019 | 0.72 | 0.17 | Closely related · 0.85 | different |
| 2017 → 2021 | 0.74 | 0.24 | Closely related · 0.90 | different |
| 2019 → 2021 | 0.73 | 0.20 | Closely related · 0.90 | different |
| 2017 → 2021 | 0.68 | 0.24 | Closely related · 0.90 | different |
| 2021 → 2022 | 0.73 | 0.16 | Identical · 0.90 | different |
| 2017 → 2022 | 0.71 | 0.21 | Closely related · 0.85 | different |
| 2020 → 2024 | 0.78 | 0.25 | Identical · 0.90 | same |
| 2021 → 2024 | 0.80 | 0.10 | Identical · 0.90 | different |
| 2021 → 2026 | 0.77 | 0.33 | Identical · 0.90 | different |
| 2019 → 2026 | 0.75 | 0.33 | Identical · 0.90 | different |
| 2019 → 2026 | 0.73 | 0.23 | Identical · 0.95 | different |
| 2021 → 2026 | 0.71 | 0.36 | Closely related · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Care Quality Commission
- Ambulance handover delays at hospitals reduce availability3 reports · 2015–2026
- Non‑compliance with care plans and insufficient incident review5 reports · 2016–2026
- Inadequate repositioning and monitoring of at-risk patients2 reports · 2013–2025
- Missing falls prevention equipment in resident care2 reports · 2018–2025
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.