HSJ's investigation into missing patient records has prompted calls for enforceable standards on their availability.

Royal College of Physicians director of health informatics Professor John Williams told HSJ not having the full patient record at the time of the appointment was dangerous. "There may be issues about the patient you are not aware of," he said.

"It becomes a self-perpetuating and escalating problem because once the notes go missing you end up creating multiple duplicate records."

The Healthcare Commission does not scrutinise record availability, but Professor Williams said the incoming Care Quality Commission should introduce a national standard requiring all records to be available, with targets to monitor trust performance.

Institute of Health Record and Information Management chair Stuart Green agreed nationally enforced standards were needed.

He highlighted the low status of records clerks, whose "pay is very poor", and said their low morale and numbers, coupled with a lack of space in records libraries and split hospital sites, created a situation where it was not unusual for hospitals to have 20 per cent of records unavailable when needed. A full electronic health record would solve many of these problems, but would require the scanning of mountains of patient files and was a "million miles away".

HSJ's investigation into more than two million outpatient appointments at 49 hospital trusts found that trusts reported on average that 2.6 per cent of records were not available when needed, ranging from 19 per cent to 0.05 per cent. But Mr Green said it was too easy for trusts to manipulate their figures to under-report the problem.

The real state of some hospital records libraries is made clear in an audit report from Northern Lincolnshire and Goole trust released to HSJ under the Freedom of Information Act. "Staff [are] now struggling to access the large mobiles [shelves] due to the weight of records on top - most of the misfiles are in this area," the report states. "This appears to be caused by records falling over to the other side of the racking and ending up completely out of sync."

Further problems highlighted in the report include medical secretaries hanging on to records for up to three weeks after they have been used, staff not signing records out of the library and a batch of misfiles attributed to a period when students were drafted in to help the understaffed service.

The trust audited the location of 91 patient records. Seventeen records were either misfiled or not in the location they had been signed out to. It took records staff 245 minutes to locate those files alone.

The vulnerability of records service to staff absences is also clear in other audits released to HSJ. For example, Sandwell and West Birmingham Hospitals trust reported a very low unavailability rate of 0.6 per cent. But in some parts of the trust, this rose to 9 per cent during the August summer holiday.

Most trusts now have electronic tracking systems that require staff to swipe a barcode attached to the file so its location can be tracked. But many audits found these were not being properly used. This was the case with over half of all missing records at St George's Healthcare trust.

A further problem for that trust was that older records were filed off site. These records could be provided within two hours but that would cost£80 per record in office hours and£227 out of hours.

Some trusts also provided HSJ with the details of their patient record availability audits for inpatients and patients admitted through accident and emergency. These were harder to collate as trusts categorised patient type differently. But the figures suggest that in both cases the rate of unavailable notes is higher than for outpatients. Leeds Teaching Hospitals trust, for example, reported a below average percentage of missing outpatient records of 2.2 per cent. But its inpatient unavailability was 24 per cent.

National Patient Safety Agency medical director Dr Kevin Cleary said: "The NPSA has received a number of reports of patient safety incidents reported by frontline NHS staff resulting from patient records being unavailable. It is essential that clinical staff have all the relevant information readily available when making decisions about diagnosis and treatment."

Last year, 39,323 breaches of patient safety relating to patient documentation were reported to the NPSA.

See Missing: the notes of more than a million outpatients for more coverage.