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. West Sussex

    AI-generated summary

    John Ashley · 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

    John Ashley took his own life while suffering a deterioration in his mental illness, according to the inquest conclusion. The report identified concerns about failures to update his care and treatment plan, record and share key information, review his deterioration and medication non-compliance, and provide adequate clinical oversight and cover arrangements.

    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 record and compile key patient information in CareNotes

    Wider context from the report

    “2. Staff were not recording interactions with Mr Ashley in the CareNotes system and often emails were not copied into these notes. Therefore there was a lack of compilation of key information relating to Mr Ashley. ”

    Source location

    John Ashley · 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

    Continue monitoring compliance with care plans, risk assessments and supervision through performance reporting and audits.

    Verbatim wording from the response

    “The Trust monitors performance in each of these areas and there are individual performance dashboards for each team within the Carenotes system that allow clinicians to monitor their own performance when they log onto the system. Team Leaders and other managers also have access to team/service based reports through our "Report Manager" performance system and these provide an audit function and allow managers to have an overview of team performance.”

    Source location

    2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
    Page 2 · response
    Published 8 April 2020

    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

    Not all email correspondence is routinely uploaded; recording the substance of relevant contact is considered sufficient.

    Verbatim wording from the response

    “It is standard practice for all interactions with patients to be recorded on the Carenotes system and these records are available and accessible to clinicians in all parts of our service to review. In the case of Mr Ashley, it was evident that our acute and community services used his health records to share information, make clinical decisions and review his care. However, I understand that you had specific concerns that email correspondence from Mr Ashley's sister, was not uploaded to his record. I would advise that it is not customary practice to upload all email correspondence. However, the Trust would expect a record and detail of ████████ contact to be recorded on the system.”

    Source location

    2020-0071-Sussex-Partnership-NHS-Foundation-Trust_Redacted
    Page 3 · response
    Published 8 April 2020

    Open published response

  2. Manchester South

    AI-generated summary

    Julie Helen Taylor · 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

    Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.

    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 digital information access between acute and community trusts

    Wider context from the report

    “8. The IT constraints meant that the acute trust could not access the community trusts records. The community trust itself had not fully digitised meaning not all professionals could see each other's notes. The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial. ”

    Source location

    Julie Helen Taylor · Prevention of Future Deaths report
    Page 3 · 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 local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.

    Verbatim wording from the response

    “I am advised by NHS England and NHS Improvement that Ms Taylor’s death is currently being reviewed under the LeDeR process and I expect the local NHS to reflect on the findings of the review and take action to address any failings in the care provided locally for people with a learning disability. I have also asked officials to bring your report to the attention of the National Director for Learning Disabilities, Ray James, who is leading work nationally to improve services for people with learning disabilities and/or autism.”

    Source location

    2019-0454-Response-from-the-Department-of-Health-and-Social-Care
    Page 2 · response
    Published 7 January 2020

    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

    Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.

    Verbatim wording from the response

    “You have also identified a number of areas regarding community care in Derbyshire. As Derbyshire does not fall under the remit of the Greater Manchester Health and Social Care Partnership we are unable to provide a response to those issues.”

    Source location

    2019-0454-Response-from-Greater-Manchester-Health-and-social-Care-Partnership-Redacted
    Page 2 · response
    Published 7 January 2020

    Open published response

  3. Mid Kent and Medway

    AI-generated summary

    Dorothy June MACEY · 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

    Dorothy June MACEY sustained leg injuries when her legs went through a glass door and was later discharged home with district nurse dressing care. Antibiotics prescribed in September were not received promptly, and concerns were raised about wound assessment, information sharing, record-keeping, sepsis checks, medication monitoring, care planning and a missed visit. She was admitted to hospital for sepsis on 28 September 2018, developed gangrene in her left lower leg, and died at Medway Maritime Hospital on 7 October 2018.

    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

    Incomplete recording in district nurse electronic care and treatment records

    Wider context from the report

    “(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”

    Source location

    Dorothy June MACEY · 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

    Failure of electronic care records to provide remote access to shared clinical information

    Wider context from the report

    “(1) Protocol required district nurses to photograph the leg wounds to assist in the assessment and this was not done on any of the visits. I heard evidence that photographs on the patient electronic record cannot be accessed remotely on home visits limiting the shared information that should be available to conduct an assessment. (2) District nurses did not share information with the GP when it was established that there had been a delay in the prescribed antibiotic treatment regime, and this was not escalated within the team. (3) Incomplete recording- The district nurse electronic care and treatment records on iNurse were: a) very brief and did not contain information necessary to have a comprehensive assessment or understanding of deterioration or improvement in her condition b) difficult to access remotely and showed limited information, therefore the previous nurse attendance could not be seen on particular visits. Evidence was that the record was not accessed prior to the visit on 24th September and the delay in the treatment regime was not understood when antibiotics were requested on that day. (4) A sepsis pathway check was completed on 20th September. This was not completed when antibiotics were requested on 24th September. There is a concern that developing sepsis may be missed in a deteriorating patient. (5) There was no updated care plan in place for her leg dressings. District nurse support staff changed the type of leg dressings without approval of the qualified nurses, evidence was heard that this should not be done without discussion. (6) Medication administration charts completed by carers were incomplete. The antibiotic administration was not checked despite previous issues with the delay in the treatment regime becoming known to district nurses on 20th September. This record was shared with or escalated to the GP for advice when there was a lack of improvement in her condition. (7) A visit required for 28th September was incorrectly scheduled for 1st October and was not picked up within the Missed Visit protocol in place. ”

    Source location

    Dorothy June MACEY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Nottinghamshire

    AI-generated summary

    Alexander James Davidson · 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

    Alexander James Davidson became suddenly unwell with abdominal pain, vomiting and diarrhoea, and died at the Queens Medical Centre on 26 February 2018 after developing an infected and necrotic pancreatic pseudocyst caused by gallstone pancreatitis. The report raised concerns about NHS 111 telephone triage for young or vulnerable patients, the clarity and transfer of triage information, testing for pancreatitis in young people, and the management of unscheduled returns to emergency departments.

    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

    Delays in updating electronic patient records with NHS 111 triage documents

    Wider context from the report

    “(3) The NHS 111 telephone triage service provides an electronic copy of the patient triage notes to the patient’s GP within minutes of the call ending. There was a delay of 7 days in the GP surgery uploading the 111 triage document to Alex’s patient record. This prevented Alex’s GP from reviewing the triage note prior to his consultation with the patient. There is no guidance as to expected practise with regards to the timely updating of electronic patient records, and as a result delays are all too frequent. ”

    Source location

    Alexander James Davidson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Avon

    AI-generated summary

    Christopher Michael SEAL · 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

    Christopher Michael Seal died by suicide on 30 November 2017 at playing fields at Bath Spa University, having been found suspended from rugby posts. In the five days before his death, he was assessed as high risk by mental health services, but concerns included underestimation of his condition, failures to escalate after missed contact and a police welfare check, inadequate information sharing with his family, and weaknesses in records, policies and staff 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

    RIO records system displaying an older information-sharing form as the most recent

    Wider context from the report

    “2. On the RIO records system I was advised that it put the first information sharing form as the most recent when it wasn’t, in this case there was a more recent form, this misled the staff, although both forms were clearly completed and on the RIO system – is this a technical matter with IT or is this a training matter for the staff using the system? ”

    Source location

    Christopher Michael SEAL · 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

    Amend and disseminate RiO guidance on editing or creating information-sharing forms.

    Verbatim wording from the response

    “The Trust recognises the confusion this caused staff and indeed the Court and we welcome the fact that this has been highlighted for improvement. The training and guidance for staff has consequently been amended. The RiO clinical support now states that it is acceptable to either edit the most recent RiO form, or to create a new form. It is not acceptable to edit forms other than the most recent. This has been disseminated to clinical staff through team meetings and is being circulated to staff via an internal ‘Red Top Alert’.”

    Source location

    2019-0013-Response-by-Avon-and-Wiltshire-Mental-Health-NHS-Trust
    Page 2 · response
    Published 24 May 2019

    Open published response

  6. Shropshire, Telford and Wrekin

    AI-generated summary

    Name not published · 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

    The deceased had a history of mental health issues, self-harm and two suicide attempts, and was in contact with mental health services until the evening of 30 April 2018 before taking her own life the next morning. Concerns included a prolonged delay in accessing IAPT counselling and difficulties with the electronic recording, risk assessment and progress-note systems.

    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 electronic records to preserve and clearly display original entries

    Wider context from the report

    “2. Risk assessment and progress notes. a) The electronic records were hard for a lay person to follow or understand particularly when said to have been updated or validated with the potential for original entries to have been overwritten (as opposed to amended or deleted). If the user of the system understands it then that does not make it unfit for purpose but it was not clear how a user would readily see what had originally been written. b) This is distinct from progress notes and/or risk assessments being accurately recorded. It was not clear when and how often risk assessments should be updated and how and when they would be read in conjunction with the progress notes. Were risk assessments intended to be summaries if a user did not have time to read all the progress notes? What function were they intended to serve? Consideration should be given as to whether the system can be improved. ”

    Source location

    Name not published · 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

    Update Rio form guidance to show staff how to find the history of electronic record entries.

    Verbatim wording from the response

    “The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 31 May 2024

    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 the Rio system further to make exact changes between versions of electronic records identifiable.

    Verbatim wording from the response

    “The Trust uses the Rio system for electronic patient records. It is impossible for clinical staff to overwrite fields in Rio forms to change or delete an entry once it has been made without the system recording this. Records of all changes can be viewed by the clinician through clicking on the “history” tab. When a Subject Access Request is made, our Health Records department print out the most up to date record. The “how to guides for the forms in Rio are currently being updated to instruct staff how to find the history of an entry. Where the previous versions are requested, these are printed out as secondary notes which include the dates the changes were made unfortunately, at present the only way to identify what the exact change was, is to compare the 2 sets of notes. We are currently looking at further developing the system to address this issue.”

    Source location

    Response from Midlands Partnership NHS Foundation Trust
    Page 2 · response
    Published 31 May 2024

    Open published response

  7. Manchester North

    AI-generated summary

    Mr Bradley Fraser Brown · 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 Bradley Fraser Brown was a serving prisoner who died in prison on 14 August 2017 after being found suspended by a ligature from a cell light fitting. The report identifies concerns about his late weekend transfer, limited access to healthcare records and assessments, reduced weekend healthcare provision, and the absence of national guidance on late prison transfers.

    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 provide clinicians with access to transferring prisoners’ full healthcare records

    Wider context from the report

    “1. Late transfer of Prisoners between Prisons - on Fridays/at a weekend puts Prisoners at increased risk of death as adequate mental health/risk assessments cannot be conducted. There are no mental health nurses available to assess/monitor prisoners over the weekend, thus making late transfers unsafe. The same concern applies, in principle, to public/bank holidays. There are different levels of healthcare at the weekends as compared to weekdays. This gives cause for concern given the inherent susceptibilities with which prisoners frequently present. Transfer itself creates vulnerability that requires additional support, intervention and care and is of particular concern where the transferring prisoner is being held in isolation within the Care and Separation Unit (CSU or ‘Seg’ as it is colloquially known). By virtue of the very different prison regime at the weekends (increased lock up periods/isolation in cells, fewer staff on duty, reduced activities) timely risk assessment is critical in the prevention of self-harm leading to death. Late transfer also risks inadequate assessment where the clinician concerned cannot access the prisoner’s full healthcare record, thus substantially reducing the amount of key information available to them. Where the transferring prisoner has not been seen by Healthcare, other clinicians such as mental health nurses cannot access the healthcare record database. There is no national guidance in relation to late transfers/cut-off points etc. 2. Commissioning of Mental Health/Healthcare Services: As commissioners for healthcare services within prisons, the above concerns are also being brought to the attention of NHS England, for action. These issues are not unique to the Prison involved in Mr Brown’s case. ”

    Source location

    Mr Bradley Fraser Brown · 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

    Issue HMP Haverigg staff a reminder to confirm transfers with Healthcare so medical records are promptly reassigned and available on arrival.

    Verbatim wording from the response

    “Prior to any transfer there is a requirement for Healthcare staff at the sending establishment to assess each prisoner to ensure that any health concerns are recorded and communicated to the receiving prison and to confirm that the prisoner is medically fit to be moved. A notice has been issued to all staff at HMP Haverigg, which was the transferring prison in Mr Brown’s case, reminding them to confirm to Healthcare staff any transfer, so that medical records are reassigned promptly in order that they are immediately available when the prisoner arrives at the new establishment.”

    Source location

    2018-0374-Response-by-HM-Prison-and-Probation-Service
    Page 2 · response
    Published 10 May 2019

    Open published response

  8. Manchester West

    AI-generated summary

    John Waite · 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

    John Waite died in hospital after suffering a haemorrhage following removal of a femoral dialysis line, alongside pneumonia and acute kidney injury after a fall and prolonged time on the floor. The principal concerns were that patients may require constant visual observation for up to one hour after catheter removal because of the potential for rapid blood loss, and that electronic systems allowed author times of clinical notes to be changed.

    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 clinical notes permitting alteration of author times

    Wider context from the report

    “4. I request the Salford Royal Hospital to review their information technology systems to prevent the changing of author times of notes on the electronic system because the author times can represent an important time in relation to the treatment and care given to a patient and may be relied upon by healthcare professionals who give treatment and care after the time of a note. The review should also consider whether both the time of the author of the report and the time that appropriate action is taken should be included in the note so that healthcare professionals would have to record both times when completing notes to ensure that there is unequivocal clarity as to the time the action was taken and the time the note was authored. ”

    Source location

    John Waite · 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

    Appraise available electronic-record functionality and discuss it with users.

    Verbatim wording from the response

    “The Trust will appraise the functions available at the outset to discuss the functionality of EPR to all users. Staff already do not have the in-depth knowledge required to discuss the function available but the functionality is not routinely taught to our teams so many users are not aware of it. If the feedback from practitioners is that they believe this is the correct way to do it, the documents appeared at the times they had the patient, and this practice had spread through good intentions which were incorrectly applied.”

    Source location

    John-Waite-Response2
    Page 3 · response
    Published 26 September 2018

    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

    Incorporate a “date and time seen” field into new electronic-record documents.

    Verbatim wording from the response

    “We are already incorporating a “date and time seen” field into our new documents so that they are authored at the correct time, but with a field to show if the time seen differed from the documented time.”

    Source location

    John-Waite-Response2
    Page 3 · response
    Published 26 September 2018

    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

    Issue all electronic-record users guidance for recording retrospective notes without changing authored times.

    Verbatim wording from the response

    “We have issued an urgent bulletin to all EPR users with guidance on how retrospective notes should be made (i.e. authored time not to be changed but captured as time written and annotated notes then to incorporate ‘written in retrospect, at 9.15am’).”

    Source location

    John-Waite-Response2
    Page 4 · response
    Published 26 September 2018

    Open published response

  9. West Yorkshire Eastern

    AI-generated summary

    Michael John Drewell · 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

    Michael John Drewell fell from his bike while travelling to work on 16 November 2017, sustained a hip fracture, and underwent surgery. He later suffered a cardiac arrest at home and died on 22 December 2017 from a pulmonary thromboembolism, likely a complication of the hip surgery. The concerns were that a Senior Clinician’s advice for six weeks of Tinzaparin was not followed and was not recorded in the electronic notes, resulting in a four-week prescription that ended two days before his death.

    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 record senior clinician advice in electronic notes

    Wider context from the report

    “The treating Consultant advised that Mr Drewell, because of his height and weight, be given anti-coagulant Tinzaparin for six weeks rather than four weeks as was usual. He recorded his advice on the handwritten records at hospital following a ward round the day after surgery. When the Junior Doctor came to prescribe Tinzaparin several days later he likely did not consult the handwritten notes and only prescribed four weeks Tinzaparin immediately before Mr Drewell’s discharge from hospital. Evidence was heard that Junior Doctors would not be expected to consult the handwritten notes when prescribing drugs in accordance with NICE Guidelines. It is of concern that the advice of a Senior Clinician was not followed and, further, that his advice was not placed upon the electronic notes. ”

    Source location

    Michael John Drewell · 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

    Record post-discharge Tinzaparin instructions on electronic drug charts and transfer them automatically to electronic discharge advice notes for eligible patients.

    Verbatim wording from the response

    “I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

    Source location

    2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
    Page 2 · response
    Published 26 September 2018

    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

    Add electronic notes recording discharge medication advice after multidisciplinary team meetings with treating clinicians.

    Verbatim wording from the response

    “I can reassure you that good practice is already embedded within many clinical areas throughout the Trust. For example, Elderly Medicine patients with pelvic fractures who are being discharged to care in the community (CIC) beds have Tinzaparin continued until they are weight bearing after discharge. An instruction to this effect is added to the electronic drug chart and this information is then pulled through automatically to the EDAN. In addition, our pharmacists will also add electronic notes regarding discharge medication advice following multi-disciplinary team meetings with treating clinicians.”

    Source location

    2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
    Page 2 · response
    Published 26 September 2018

    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

    Comprehensively reviewing the entire medical record before electronic discharge prescribing is considered impractical for junior doctors.

    Verbatim wording from the response

    “In your Regulation 28 Report you highlight the fact that the junior doctor did not consult the hand-written medical records before prescribing the anticoagulant medication. I am sure that you will agree that it is impractical for junior doctors to comprehensively review the medical record in its entirety when completing the electronic discharge advice note (EDAN) and prescription. It is therefore imperative that if individual clinicians decide to prescribe ‘off protocol’ they either action this themselves personally, or leave clear unambiguous instructions within the electronic record. This can be done in two ways; either the eMeds electronic prescribing chart can be annotated or the EDAN can be pre-populated with specific discharge advice.”

    Source location

    2018-0259-Response-by-Leeds-Teaching-Hospitals-NHS-Trust
    Page 2 · response
    Published 26 September 2018

    Open published response

  10. London (East)

    AI-generated summary

    Caliel Arlington SMITH-KWAMI · 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

    Caliel Arlington Smith-Kwami suffered a profound hypoglycaemic episode around 28 hours after birth and later died on 17 August 2016 from persistent neonatal hyperinsulinaemic hypoglycaemia. He was discharged before key test results were obtained, and concerns included failures to notify clinicians that results were delayed or available, unclear responsibility for chasing results, and a missed opportunity to involve community midwives.

    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

    Lack of electronic record alerts to clinical staff when results are ready

    Wider context from the report

    “(3)The results of the amino acid profile, which raised the possibility of hyperinsulinism were sent through to the electronic record system on the 9 August 2016. It does not appear that any clinician was aware of this result prior to Caliel’s death. The Consultant in Charge of Caliel’s care stated there is no system in place with the electronic record system for highlighting to clinical staff that results are ready. He stated that when paper records were in place, clinicians would result the paper result, but this notification has now been lost. ”

    Source location

    Caliel Arlington SMITH-KWAMI · 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