Recurring concern

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

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First reported 12 Sep 2013•Latest report 16 Jun 2026

Definition

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.

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
67

Distinct published reports

Individual concerns
75

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
102

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care19
NHS England19
Care Quality Commission5
Avon and Wiltshire Mental Health Partnership NHS Trust3
University Hospitals of Derby and Burton NHS Foundation Trust3
Essex Partnership University NHS Foundation Trust2
Greater Manchester Health and Social Care Partnership2
Ministry of Justice2
NHS Derby and Derbyshire Integrated Care Board2
Appello Careline Limited1
Association of Ambulance Chief Executives1
Association Of British Neurologists1
Barts Health NHS Trust1
Betsi Cadwaladr University LHB1
Birmingham Women'S and Children'S NHS Foundation Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    David John Buttriss · 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

    David John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health teams.

    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 access to relevant records across healthcare providers

    Wider context from the report

    “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that • There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis • The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May. • It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision. ”

    Source location

    David John Buttriss · 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

    Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.

    Verbatim wording from the response

    “We recognise that there are many challenges across the NHS to support secure data and record sharing, and we are actively leading a number of initiatives to address this. For example, the Global Digital Exemplar (“GDE”) programme, led”

    Source location

    2018-0010-Response-by-NHS-England
    Page 1 · response
    Published 7 March 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

    Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.

    Verbatim wording from the response

    “In addition, NHS England is working with a number of Local Health and Care Record Exemplars to support the provision of safe integrated care across health and care settings. The aim will be to establish a local record for authorised staff in different organisations to access permitted information about a patient’s history of contact with the NHS and related care services. This may include information from ‘physical health checks’ for people with serious mental illness which NHS England is encouraging a greater take up of. We have made progress on this with around 60 local information sharing initiatives underway, each aiming to share information across organisations – such as GP, Acute and Social Care settings – and across geographies as the patient moves.”

    Source location

    2018-0010-Response-by-NHS-England
    Page 2 · response
    Published 7 March 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

    Existing secure RiO access arrangements are considered sufficient for sharing health records with other agencies.

    Verbatim wording from the response

    “The Trust already works with other agencies to allow secure health record sharing. Agencies are requested to complete an application form for access to RiO, the Trust’s electronic health record system. The application form is a standard form which requires specific information detailing the individual, their role, employing organisation and the legal basis for access as well as confirmation of Information Governance training. The Trust has allowed access to RiO to a number of agencies including Cornwall Council, acute hospitals and GPs.”

    Source location

    2018-0010-Response-by-Cornwall-NHS-Trust
    Page 2 · response
    Published 7 March 2018

    Open published response
  2. Isle of Wight

    AI-generated summary

    Joseph Peter Dunne · 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

    Joseph Peter Dunne, aged 58, was discharged from hospital on 14 July 2015 after presenting with pain and feeling unwell, and was later found collapsed at home on 16 July 2015. He became unresponsive while using the toilet and was pronounced dead at 3.20 p.m.; the medical cause of death was peritonitis due to a perforated duodenal ulcer. The report raises concerns about Information Governance breaches that allowed clinical records, including an abnormal D-dimer result, to be deleted or altered and not seen by treating clinicians.

    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 make medical-record edits visible to treating clinicians

    Wider context from the report

    “1. I am concerned that there are clear breaches in Information Governance protocols. It is clear that there are IG issues which allow one Clinician to make entries or delete information from a patient’s medical records, when they are not correctly logged in to the database, or are doing so under a colleague’s log-in (which remains live after they've walked away from the computer terminal). Matters are compounded inasmuch as these edits are then found to be invisible to those clinicians who are actually treating the patient, and are only ascertainable when an IT audit trail is undertaken. It should not be possible for Doctor A to be able to access records made by Doctor B and to alter those medical records. ”

    Source location

    Joseph Peter Dunne · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  3. Preston and West Lancashire

    AI-generated summary

    Stephen McDermott · 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

    Stephen McDermott was found deceased at home on 25 May 2015, having died sometime earlier as a result of the intentional application of a ligature; the inquest recorded the medical cause of death as hanging and concluded suicide. In the preceding months, he had presented repeatedly after overdoses and being recovered from train tracks, but was discharged without mental health follow-up. The principal concerns included fragmented and poorly used records, incomplete assessments and record keeping, insufficient consideration of overlapping mental health and substance misuse issues, missed opportunities for face-to-face assessment, limited information sharing between services, and an incomplete incident review.

    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 a shared electronic mental health record system across teams

    Wider context from the report

    “1) The electronic record system is not the same across all mental health teams (Single Point of Access, Crisis Team, Mindsmatter) meaning that not all relevant records were available at each point of assessment of Mr McDermott – Mindsmatter use ‘IAPTS’ and the other teams use ‘ECR Blue’ as opposed to there being one record system for all to use and to ensure mental health records are in one place. Although ████████ gave evidence that Mindsmatter now has access to ECR Blue and the other teams have access to IAPTS, his evidence was that the system remains “clunky.” His evidence was that a new electronic system has been commissioned, but he did not know whether it was one system for all teams to have access to and/or whether the problems highlighted in this case would remain. In addition, the system is not due to be implemented for a further 18 months. He agreed that having one electronic system used by all teams would be of benefit; ”

    Source location

    Stephen McDermott · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. South Yorkshire (Eastern)

    AI-generated summary

    Jason Derek Vaughan · 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

    Jason Derek Vaughan died by suicide by hanging at his home on 23 September 2015. The principal concerns were limitations in the IAPT electronic clinical records, a risk assessment tool that did not capture deterioration below its highest-risk level, and insufficient recognition of factors associated with suicide among middle-aged men and socio-economic groups.

    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

    Insufficient written narrative detail accompanying coded clinical record entries

    Wider context from the report

    “(1) The effectiveness of the IAPT electronic patient clinical records system (SystemOne) may be limited, in some instances, by there being insufficient written narrative detail (eg. As to medication commencement dates, doses, changes etc.) to accompany the coded data entries in the drop down box selection ”

    Source location

    Jason Derek Vaughan · Prevention of Future Deaths report
    Page 1 · 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 SystmOne system does not have a systemic defect preventing staff from recording important medication-management information.

    Verbatim wording from the response

    “Electronic systems can support adequate record keeping but ultimately it still depends upon a staff member to input data. In your Regulation 28 report you gave examples regarding medications management. Recording adequate data regarding medication management is absolutely key in healthcare. This is because it is an essential part of the management of the majority of patients with severe mental disorder, and often plays a part in those with less severe mental health conditions. All medications have side effects, some of them serious. It is for this reason that I would agree with you wholeheartedly that recording adequate data regarding medications management is essential. However there does not appear to be a systemic issue with the SystmOne tool which prevents the recording of invaluable data.”

    Source location

    2016-0105-Response-by-Rotherham-Doncaster-and-South-Humber-NHS-Trust
    Page 2 · response
    Published 11 March 2016

    Open published response
  5. Liverpool and the Wirral

    AI-generated summary

    Amy Rose COOPER · 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

    Amy was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between 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

    Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services

    Wider context from the report

    “It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area. Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care. This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information. This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place. Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome. ”

    Source location

    Amy Rose COOPER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Nottinghamshire

    AI-generated summary

    Philip Anthony Denning · 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 Anthony Denning, who had a history of substance misuse and mental health problems, died from diamorphine intoxication on 23 July 2015 after using heroin. The report raised concerns about fragmented services, limited psychology provision, poor information-sharing between organisations, and a lack of clarity in primary care about accessing appropriate support for people with both substance misuse and mental health needs.

    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 CRI access to Nottinghamshire Healthcare electronic patient records

    Wider context from the report

    “4. The CRI is an entirely separate entity from Nottinghamshire Healthcare and has no access to RiO, Nottingham Healthcare’s electronic record-keeping system. If, for instance, one of their patients had been seen regularly by Nottinghamshire Healthcare following overdoses, they would not be aware of this unless their patient told them about this. ”

    Source location

    Philip Anthony Denning · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Cumbria

    AI-generated summary

    Richard Scott Green · 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

    Richard Scott Green was found hanged in his cell at Haverigg Prison on 9 May 2014, using a ligature made from a torn bed sheet. The jury found that bullying and debt had contributed to his death but was not satisfied that he intended to kill himself. The report raised concerns that his documented history of self-harm and apparent suicide attempts was not recognised or acted upon by prison medical professionals, with missed opportunities to assess and manage the risk he presented.

    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 SystmOne to provide usable search and clear flagging of important historical information

    Wider context from the report

    “I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ”

    Source location

    Richard Scott Green · Prevention of Future Deaths report
    Page 1 · 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

    Re-procure the electronic healthcare system with improved sharing of risk indicators between healthcare services and NOMS.

    Verbatim wording from the response

    “In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

    Source location

    2015-0456 - Response from NHS England
    Page 2 · response
    Published 2 November 2015

    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

    Implement an interface between healthcare services and NOMS to share risk indicators and support proactive risk management.

    Verbatim wording from the response

    “In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

    Source location

    2015-0456 - Response from NHS England
    Page 2 · response
    Published 2 November 2015

    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

    Provide full training and regular training updates for the new electronic healthcare system.

    Verbatim wording from the response

    “In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

    Source location

    2015-0456 - Response from NHS England
    Page 2 · response
    Published 2 November 2015

    Open published response
  8. Manchester South

    AI-generated summary

    David Baddeley · 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

    David Baddeley, who had a history of schizophrenia, died at home on 23 June 2015 after tying a ligature around his neck; the cause of death was recorded as hanging, with schizophrenia also noted. Concerns included delays and gaps in transferring and reviewing medical records, incompatibility between electronic systems, and the failure to identify his psychiatric illness and lack of antipsychotic medication during primary-care handovers and checks.

    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 record transfer systems to highlight key information

    Wider context from the report

    “That the transfer of 4 patients electronic records between medical practices can mean that key information is not highlighted due to the incompatibility of the systems. ”

    Source location

    David Baddeley · 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

    Remind practices to check, highlight and correctly code significant diagnoses when patients transfer to another practice.

    Verbatim wording from the response

    “18. Practices will be reminded to ensure that when a patient deregisters and transfers to another practice, that the patient record, both electronic and paper, should be checked to ensure that significant diagnoses are recorded, highlighted and correctly coded.”

    Source location

    2015-0451-Response
    Page 2 · response
    Published 21 October 2015

    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

    Receiving practices must establish patients’ clinical needs from transferred records, while sending practices remain responsible for record accuracy.

    Verbatim wording from the response

    “3. Where records are transferred electronically, the READ codes are to be used by the recipient practice to establish for themselves, in conjunction with any medical records summary, the clinical needs and concerns relating to that patient. The sending practice has a data governance obligation in ensuring accuracy.”

    Source location

    2015-0451-Response
    Page 1 · response
    Published 21 October 2015

    Open published response
  9. Worcestershire

    AI-generated summary

    Liam 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

    Liam Smith was admitted to HMP Hewell on 7 August 2014 and died after taking a combination of prescribed and illicitly obtained medication in his cell. The concerns included possible failures to follow mandatory ACCT procedures, inadequate dissemination and recording of medical information, and limited healthcare interaction with high-risk drug users, potentially resulting in warning signs being missed.

    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 the System 1 summary page to display relevant important information

    Wider context from the report

    “(3) Healthcare Staff indicated that they do not always read relevant sections of the System 1 notes and that the "summary page" of System 1 does not always "pull through" relevant important information with a result that staff may be unaware of that information. ”

    Source location

    Liam SMITH · Prevention of Future Deaths report
    Page 1 · 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

    Take the SystmOne summary-page information issue forward through the West Midlands Regional SystmOne User Group.

    Verbatim wording from the response

    “The concerns you have raised regarding healthcare staff not reading relevant sections of the records have been taken very seriously. All registered clinical staff have a professional obligation to review relevant parts of the notes; this message has been reiterated and addressed with all clinical staff. The second part of the concern relates to information being ‘pulled through’ onto the summary page. This matter is being taken forward with the West Midlands Regional SystmOne User Group so that the learning generated through Mr Smith’s death can be shared much wider than one prison. In the meantime, this issue has been raised with clinical staff in a staff meeting at HMP Hewell and the learning is being disseminated across the three prisons in which the Trust provides healthcare.”

    Source location

    2015-0382-Response-by-NOMS
    Page 2 · response
    Published 18 September 2015

    Open published response
  10. Avon

    AI-generated summary

    Simon Peter REYNOLDS · 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

    Simon Peter REYNOLDS was admitted to Mason Unit at Southmead Hospital on 10 November 2014 after being detained under section 136 of the Mental Health Act. While left alone in his room, he forced a fist-sized ball of paper into his throat, causing him to choke; he later died in hospital on 21 November 2014. Concerns included the absence of a documented admission risk assessment, no computerised admission note by the nurse in charge, and the need to consider guidance or training on observation levels, suicide and self-harm risk assessment, risk management, and communication of risk.

    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 admission information in computerised Rio notes

    Wider context from the report

    “(2) During the investigation I heard evidence that the nurse in charge made no record on the computerised Rio notes in relation to the admission. I would ask that you look into the appropriateness of this. ”

    Source location

    Simon Peter REYNOLDS · 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

    Review Place of Safety staffing levels through the Safer Staffing initiative to support timely observations and information recording.

    Verbatim wording from the response

    “• Reviewing staffing levels on the Place of Safety suite as part of the wider national Safer Staffing initiative, to ensure optimal staffing levels at all times, which will in turn support timely observations and recording of information.”

    Source location

    2015-0296-Avon-and-Wiltshire-NHS-Trust
    Page 2 · response
    Published 24 July 2015

    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

    The RIO entry was made shortly after the incident, although documentation was delayed while staff managed the traumatic incident and debrief.

    Verbatim wording from the response

    “Record on Rio The nurse-in-charge should have made an entry on the RIO record. Staff are encouraged to make their written record in as close a proximity to any assessment or event taking place as possible. Since the inquest, we have examined the audit trail of entries on RIO and determined that the entry was made on RIO at 00:11 hours, which was not long after staff had finished dealing with the incident and participating in the debrief. The day-time nurse in charge did not go off duty until 23.00 hours (one and a half hours beyond the end of her shift) in order to handover all necessary information and support staff.”

    Source location

    2015-0296-Avon-and-Wiltshire-NHS-Trust
    Page 1 · response
    Published 24 July 2015

    Open published response
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Data last updated 7 September 2026