Recurring concern

Electronic patient records failing to make relevant clinical information available and actionable

First to latest report 12 Sep 2013 — 16 Jun 2026

Reports that mention this concern
67
Times this concern has been raised
75
Stated actions linked to this concern
102

What this concern includes

Includes failures of electronic patient-record systems or their dedicated workflows that prevent relevant information from being reliably accessed, displayed, preserved, shared, handed over or acted upon across clinical care.

What is not included
  • Excludes failures concerning paper-only records or information sharing with no explicit electronic patient-record connection.
  • Excludes generic failures of clinical attention, staffing, training or communication unless the report directly ties them to the electronic patient-record system or its dedicated workflow.
  • Excludes concerns about the clinical decision itself where the electronic patient-record system did not contribute to the information-access or action failure.
  • Excludes unrelated information systems that are not electronic patient-record systems or directly integrated clinical-record workflows.

Reports and published responses 67 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Philip Jones · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Philip Jones developed difficulty swallowing in February 2021, lost significant weight, and was diagnosed with Motor Neurone Disease after hospital admission in September 2021. He developed bronchopneumonia, deteriorated, was discharged home, and died there on 9 October 2021. Concerns included backlogs for neurology appointments, incompatible IT systems affecting information sharing, and delays in communications from consultants to other clinicians and patients.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of IT systems across healthcare organisations to support shared access to complete patient information

    Wider context from the report

    “2. The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult. This impacted the holistic view that clinicians needed of an individual patient. Whilst images could be shared there was no ability for notes for one Trust to be visible to a clinician at another Trust; ”

    Source location

    Philip Jones · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Build digital infrastructure using artificial intelligence, automation and video-call technologies to support NHS services.

    Verbatim wording from the response

    “I also note your concern that incompatible IT systems between the hospitals in question made communication and information sharing in relation to Mr Jones’s treatment more difficult, as did the delay in the consultants communicating with other clinicians, including GPs, and as well as the patients themselves. I recognise that there needs to be adequate administrative support and greater use of digital technology to assist healthcare workers in completing non-clinical tasks, and that could increase the time they can spend caring for patients. This would provide a better patient experience and, ultimately, improve health outcomes.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 October 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Publish a plan for digital health and social care to modernise digital technology and improve data use and care pathways.

    Verbatim wording from the response

    “You may wish to note that the Spending Review, announced in Autumn 2021, included £2.1 billion to modernise digital technology on the frontline to improve cyber security, improve the NHS’s use of data, and redesign care pathways. As well as a funding”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 October 2022

    Open published response

  2. Dorset

    AI-generated summary

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Gaia Kima Pope-Sutherland, who had epilepsy and mental health conditions, left her aunt’s address in a psychotic state on 7 November 2017 and was later found deceased on 18 November 2017. The jury concluded that she probably died from hypothermia between 15.59 on 7 November and 10.00 on 8 November 2017. Principal concerns included under-resourcing and poor communication between epilepsy, neurology and mental health services, as well as issues concerning police training, missing-person policies and record keeping, and communication and information sharing within mental health services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to flag key information on DHUFT RiO records

    Wider context from the report

    “viii. As per paragraph 1(xi) above, information could be lost on lengthy RiO records held by DHUFT if there is a significant number of records, and I therefore request that consideration is given to a guidance document dealing with how and what information should be flagged on RiO which could be provided to all staff at DHUFT. I would further request consideration is given to training staff how to record information, so it is flagged on the record. ”

    Source location

    Gaia Kima Pope-Sutherland · Prevention of Future Deaths report
    Page 7 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop and publish RiO guidance explaining how to view, add and remove alerts.

    Verbatim wording from the response

    “In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-learning and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31st October 2022. This training will also be available as a standalone e-learning module, which will be available to all existing RiO users in the Trust. The e-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31st October 2022.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Update RiO training and provide a standalone e-learning module on using the alerts system, promoting it to existing users and staff.

    Verbatim wording from the response

    “In response to this concern, the Trust will develop a guidance document on viewing, adding and removing alerts on RiO and upload this to the Trust intranet by 30th September 2022. The existing RiO e-learning and classroom-based learning courses, which are a mandatory requirement for new staff who will be using RiO as part of their role, will also be updated to orientate staff to the existence of the guidance and to demonstrate how and when to use the alerts system on RiO. This will be updated by 31st October 2022. This training will also be available as a standalone e-learning module, which will be available to all existing RiO users in the Trust. The e-learning module will be promoted to staff via email and via dissemination at the CMHT Team Leaders workshop. This will be available and disseminated by 31st October 2022.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    No further action is identified for RiO significant-event flags because their use already forms part of the Trust’s training programme.

    Verbatim wording from the response

    “Please note we have focused our action on the alerts system on RiO. As outlined in the evidence given to you by ████████, there is also a separate function on RiO of flagging a progress note as a significant event, so that it informs the risk assessment. We have not identified any further actions for this function, as this already forms part of our RiO training programme.”

    Source location

    Response from NHS Dorset Healthcare University
    Page 3 · response
    Published 28 September 2022

    Open published response

  3. North East Kent

    AI-generated summary

    Hayley Smith · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Hayley Smith developed severe and enduring anorexia nervosa and died on 29 December 2019 after an out-of-hospital cardiac arrest caused by severe hypoglycaemia. The inquest identified inadequate communication and information-sharing between the organisations involved in her care, including failures to share information about her Community Treatment Order.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of separate clinical record systems to provide cross-organisational access to crucial information

    Wider context from the report

    “(1) Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes: I. South London and the Maudsley NHS Foundation Trust (SLAM) II. North East London NHS Foundation Trust (NELFT locally known as the Kent and Medway Eating Disorders Team) III. The White House IV. Kings College NHS Foundation Trust (Kings) V. General Practitioner (GP) VI. East Kent Hospitals NHS Trust (EKHT for Queen Elizabeth the Queen Mother) VII. South East Coast Ambulance Service (2) The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others. The White House were not sent copies of clinical correspondence and at the time did not have access to GP records although since Hayley’s death do now have access to GP records. The mental health team at NELFT were responsible for managing Hayley’s CTO despite the fact that she was placed out of their geographical area but were not aware she had been seen by either the ambulance service or by Queen Elizabeth the Queen Mother hospital. (3) The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial information which could have made a difference ultimately meaning Hayley may not have died when she did. It is highly likely that the paramedic at South East Coast Ambulance Trust who attended Hayley on 23rd December or the emergency department nurse who saw her at Queen Elizabeth the Queen Mother hospital on 24th December 2019 been aware that Hayley was on a CTO they or her treating mental health team would have been able to take steps which would have saved her life. (4) Evidence was given at the inquest that locally some steps have been taken to try to share key data between acute hospitals but there have been significant hurdles which have impeded the process namely, the different information technology systems used, licensing issues for the software, Data Protection requirements, confidentiality and consent issues as well as training and funding. (5) Hayley died following an out of hospital cardiac arrest on Christmas day 2019. If information been shared between different health care organisations particularly crucial information about Hayley’s CTO it is highly likely she would still be alive today. ”

    Source location

    Hayley Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Milton Keynes

    AI-generated summary

    Brooke MARTIN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Brooke Martin was detained under the Mental Health Act at Isla House, where she was found hanging in her room on 11 June 2019 after earlier ligature-related incidents and concerns about observation and risk assessment. She died at Milton Keynes University Hospital. A principal concern was that incompatible NHS record systems prevented healthcare providers from accessing complete patient records, including information from an out-of-area hospital.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of healthcare information systems to provide providers with access to complete patient records

    Wider context from the report

    “During the course of the evidence it was explained to me that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient. This situation should be reviewed to see how access across the NHS can be gained to patient records when required. I was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history. This would not be the case if he had direct access to the records. ”

    Source location

    Brooke MARTIN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The receiving provider was given comprehensive referral information, which it considered sufficient to proceed with admission.

    Verbatim wording from the response

    “In preparing this response, my officials made enquiries with NHS England and NHS Improvement and its South East region. I am advised that as part of the referral process, comprehensive information relating to Miss Martin was shared by the Surrey and Borders Partnership NHS Foundation Trust, which Elysium Healthcare considered sufficient to proceed with Miss Martin’s admission. This included care plans, incident log, risk assessment and clinical information. In addition, I am informed that Miss Martin’s referral to Elysium Healthcare was discussed over a number of weeks between Trust and Elysium Healthcare staff, with continuing communication, including the submission of monthly reports, during Miss Martin’s admission to Chadwick Lodge.”

    Source location

    2021-0299-Response-from-Department-of-Health-and-Social-Care_Published
    Page 2 · response
    Published 9 September 2021

    Open published response

  5. County Durham and Darlington

    AI-generated summary

    Mina TOPLEY-BIRD · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to upload PDF medical records and important information promptly in original form to the electronic notes system

    Wider context from the report

    “1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form. This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them. ”

    Source location

    Mina TOPLEY-BIRD · Prevention of Future Deaths report
    Page 5 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Implement Cito electronic records functionality for scanning, uploading and viewing documents.

    Verbatim wording from the response

    “This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.”

    Source location

    2021-0100-Response-from-West-Park-Hospital-Redacted
    Page 2 · response
    Published 13 April 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.

    Verbatim wording from the response

    “Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services.”

    Source location

    2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
    Page 2 · response
    Published 13 April 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.

    Verbatim wording from the response

    “My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required.”

    Source location

    2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
    Page 3 · response
    Published 13 April 2021

    Open published response

  6. South Yorkshire (Western)

    AI-generated summary

    Thomas Rawnsley · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Thomas Rawnsley, a residential nursing home resident, developed a chest infection, later collapsed at the home and died in hospital on 4 February 2015. Concerns included the quality of safety-netting advice, the risks of telephone consultations and incomplete information during clinical triage, and inaccuracies or omissions when paramedic advice was transferred to patient information leaflets.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure of EPR records to accurately reflect information given to patients

    Wider context from the report

    “(3) The information which appears on the EPR is not accurately recorded on the patient information leaflet where pressures of time mean that paramedics are rushing to summarise the instructions on the EPR on the patient information leaflet. This could lead to incorrect information being provided to patients or incomplete information being provided to patients along with the EPR not properly reflecting the information which has actually been given to the patient. ”

    Source location

    Thomas Rawnsley · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Audit sampled patients treated at home to assess the information and advice provided, including clinician records and patient understanding.

    Verbatim wording from the response

    “The Trust has carefully considered the mechanism of the audit suggested in the Regulation 28 Report and has determined an alternative process. I am aware that you invited this at the inquest hearing and no disrespect is intended. We consider that a different approach is required due to anticipated practical difficulties with recording of the PIL and concerns that this method would result in an ‘on notice’ audit and results may therefore be skewed against the true position.”

    Source location

    2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Spot-audit EPR care plans for recorded leaflet completion and the quality of non-conveyance advice.

    Verbatim wording from the response

    “Additionally, and as an interim phase, the Trust will undertake the following:”

    Source location

    2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Re-audit care-plan documentation after the intervention.

    Verbatim wording from the response

    “Additionally, and as an interim phase, the Trust will undertake the following:”

    Source location

    2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Develop EPR tick-box indicators to record information left with patients.

    Verbatim wording from the response

    “Additionally, and as an interim phase, the Trust will undertake the following:”

    Source location

    2020-0283-Response-from-Yorkshire-Ambulance-Service-NHS-Trust-Redacted
    Page 2 · response
    Published 6 January 2021

    Open published response

  7. Warwickshire

    AI-generated summary

    Eleanor Emily SHERMAN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Eleanor Emily SHERMAN died at Warwick Hospital on 20 August 2020 after collapsing at home; a CT scan confirmed a subarachnoid haemorrhage. The report identified two misdiagnoses, failure to read the GP referral letter, and systemic problems with access to the GP’s electronic records and the scanning of notes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Inability of the GP team to access the electronic record

    Wider context from the report

    “(1) Two misdiagnoses at Warwick Hospital notwithstanding the GP specifically stating in writing that Mrs Sherman should be treated as a SAH unless a CT scan showed to the contrary (2) Systemic errors regarding the inability of the GP team at Warwick Hospital to access the electronic record and the slowness of notes being scanned on to the system. ”

    Source location

    Eleanor Emily SHERMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Delays in scanning clinical notes onto the electronic system

    Wider context from the report

    “(1) Two misdiagnoses at Warwick Hospital notwithstanding the GP specifically stating in writing that Mrs Sherman should be treated as a SAH unless a CT scan showed to the contrary (2) Systemic errors regarding the inability of the GP team at Warwick Hospital to access the electronic record and the slowness of notes being scanned on to the system. ”

    Source location

    Eleanor Emily SHERMAN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Provide ED GPs with access to Evolve and Lorenzo electronic records and require completion of related e-learning.

    Verbatim wording from the response

    “Action ref | Action | Action Lead(s) | Due date | Current status | Done date 10675 | 1. Grant Access to GPs in ED to e-records (Evolve) and Lorenzo - D/W IT, GPs complete e-learning module on e-records (Evolve) and Lorenzo software | ████████ | 01/12/2020 | Completed | 11/01/2021 10676 | 2. Subarachnoid haemorrhage to be discussed as part of the Junior doctors teaching program with this case to be incorporated into Junior doctors teaching and handbook to share learning | ████████ | 31/01/2021 | Completed | 04/11/2020 10678 | 3. Junior doctors to reflect on the case and review NICE guidelines on headache. Junior staff to discuss it with their educational supervisor noting it on their Form R and appraisal. | ████████ | 31/01/2021 | Completed | 25/11/2020 10679 | 4. Learning from incident to be shared with staff working in AEC and ED via team meetings and newsletters.”

    Source location

    2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
    Page 2 · response
    Published 30 December 2020

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Improve ED staff access to AEC notes and inform them where notes are located for patients who re-present.

    Verbatim wording from the response

    “| ████████ | 30/11/2020 | Completed | 11/11/2020 10680 | 5. Amendment of the ACP Triage Form to include GP concerns and re-design of the form used by MNPs in AEC to take down GP referrals Consideration to be given to whether this form part of the medical record and to ensure it is included where appropriate. | ████████ | 30/11/2020 | Completed | 13/10/2020 10682 | 6. Review processes within AEC to ensure referral letters are available and seen by Doctors prior to seeing the patient. | ████████ | 30/11/2020 | Completed | 15/10/2020 10681 | 7. Medical team to review processes to ensure improved access to AEC notes for ED staff, including considering real time scanning and making ED aware of AEC note location for re-presenters | ████████ | 31/01/2021 | Completed | 20/11/2020 10683 | 8.”

    Source location

    2020-0254-Response-from-South-Warwickshire-NHS-Foundation-Trust-Redacted.pdf
    Page 2 · response
    Published 30 December 2020

    Open published response

  8. Suffolk

    AI-generated summary

    Karen Jane Winn · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Karen ‘Jane’ Winn died at West Suffolk Hospital after developing bilateral pulmonary emboli and deep venous thromboses in the context of haemolytic anaemia. Although prophylactic anticoagulation was identified as necessary, it was not administered during most of her admission, and the report states that this contributed to her death. Concerns included a lack of early haematology consultant involvement, repeated manual overriding of the automated VTE assessment warnings, and inadequate electronic flagging of the anticoagulation decision.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to clearly flag decisions to administer prophylactic anticoagulation in the patient electronic record

    Wider context from the report

    “3. I am further concerned that if a consultant at an early review has decided that prophylactic anticoagulation medication needs to be administered (even in the situation when a INR test is still awaited) that this is not clearly flagged on the patient electronic record in the Smart Zone, to act as a prompt for clinicians taking over that patients care. ”

    Source location

    Karen Jane Winn · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The suggested Smart Zone prompt cannot currently be provided because narrative care plans cannot be pulled into the system, which only flags assessment omissions.

    Verbatim wording from the response

    “The narrative aspect of a clinician’s plan cannot be ‘pulled through’ into the smart zone. However, the actions described in section 2 will ensure that an in-completed VTE assessment is recognised. Furthermore, the addition of the haemolytic anaemia prompting within the VTE assessment tool should aid ensuring that the clinicians are aware that this condition requires VTE prophylaxis consideration.”

    Source location

    2020-0213-Response-from-West-Suffolk-Hospital-REDACTED.pdf
    Page 4 · response
    Published 4 December 2020

    Open published response

  9. Derby and Derbyshire

    AI-generated summary

    Mr Edward Cowey · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Edward Cowey was admitted to Royal Derby Hospital on 22 January 2020, suffered a fall with a head injury on 23 January, and died on 28 January 2020 from a subdural haematoma, with anticoagulation recorded as a contributing factor. Concerns included fragmented patient information across electronic and paper systems, inconsistent local and national guidance on head injuries, gaps in anticoagulation guidance, and a falls form that did not direct doctors to relevant head-injury guidance.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to keep patient transfer information on one database

    Wider context from the report

    “1. That patient electronic and paper based transfer information is not kept on one database. Mr Coweys’ handover notes were kept on extra Med, his neurological observations on Patient Track and the falls form on his hard copy notes; ”

    Source location

    Mr Edward Cowey · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  10. County Durham and Darlington

    AI-generated summary

    Laura Eve PARSONS · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Laura Eve Parsons was found dead at home on 5 November 2019, after consuming a fatal amount of liquid morphine prescribed for breakthrough cancer pain. She had previously been admitted to hospital following an accidental morphine overdose, but a repeat prescription was later issued without the electronic prescribing system directing the prescriber to review the prominent medical-record information about that overdose.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section

    Wider context from the report

    “Ms Parsons was prescribed liquid morphine to treat ‘break through’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from hospital. The remainder of the prescribed morphine was discarded. On 31st October 2019 Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine. At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records. It was explained at inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section. ”

    Source location

    Laura Eve PARSONS · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026