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. East Sussex

    AI-generated summary

    Finlay Stuart Ian FINLAYSON · 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

    Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.

    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 reliably transfer key medical information between incompatible systems

    Wider context from the report

    “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison. Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems. I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand. I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient. ”

    Source location

    Finlay Stuart Ian FINLAYSON · 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

    Undertake an internal review of EMIS Web interoperability and medical-record transfer issues raised in the report.

    Verbatim wording from the response

    “We have undertaken an internal review of EMIS Web, focussing on the issues raised as areas of concern in the Report in relation to EMIS Web, namely a potential lack of interaction between clinical systems in prisons (predominantly SystmOne) and other clinical systems in community GP surgeries, and the evidence you heard that notes have to be printed and scanned on to SystmOne, with key information inputted manually, if an individual’s GP practice uses a clinical system other than SystmOne.”

    Source location

    Response from EMIS
    Page 1 · response
    Published 25 March 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

    Maintain compliance with the latest NHS England GP2GP specifications and associated processes for electronic medical-record transfers.

    Verbatim wording from the response

    “EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 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

    Continue reviewing EMIS solutions to identify potential performance improvements affecting medical-record transfers.

    Verbatim wording from the response

    “As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 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

    Enable functionality supporting automatic electronic transfer of prisoners’ full community GP records to prison GPs and back on release.

    Verbatim wording from the response

    “Since the time of Mr Finlayson’s death, more has been done to improve matters. Full GP registration (‘GMS’) has been introduced into prisons in the last two years as a result of policy change by NHS England. Functionality was enabled by TPP to enact this policy change. As a result, prisoners can now opt to have their community GP registration (and their community GP record) transferred to the prison GP. This involves the automatic electronic transfer of the full community GP record to the prison GP, which is then transferred out again on release of the prisoner to the community GP practice. This is an enormous improvement. This change applies regardless of whether the community GP practice uses SystmOne or EMIS.”

    Source location

    Response from TPP
    Page 1 · response
    Published 25 March 2024

    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 GP2GP functionality and NHS England specification compliance sufficiently mitigate the identified medical-record transfer risks; no further software development is required.

    Verbatim wording from the response

    “As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 2024

    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

    EMIS cannot control whether prisons request medical records through GP2GP or a manual process.

    Verbatim wording from the response

    “EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 2024

    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

    GP data controllers are responsible for permitting data sharing and enabling the relevant reciprocal controls under data protection legislation.

    Verbatim wording from the response

    “Your report highlights that information was not freely shared between the GP (using SystmOne) and the prison service. Functionality to allow seamless sharing of data is available within SystmOne, and this functionality was available to the detained estate (including prisons) from well before 2019. However, as is still the case, the sharing of data is dependent on the data controller (in this case the GP) permitting the data to be made available to other healthcare organisations. This responsibility is set out in UK Data Protection Legislation. Without the control in SystmOne being turned on by the GP data controller (and a reciprocal control on the receiving side being enabled) the data is not visible. Dame Fiona Caldicott and other data champions have tried to make information sharing ‘the norm’ but there is still resistance in many areas.”

    Source location

    Response from TPP
    Page 1 · response
    Published 25 March 2024

    Open published response
  2. East Riding and Hull

    AI-generated summary

    Ethel Doreen Reed · 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

    Ethel Doreen Reed fell at home, sustaining rib fractures that caused a pneumothorax and chest infection, and later developed pneumonia and Covid-19 while in hospital. She was discharged to a community rehabilitation centre while described as not medically fit for discharge and died there on 2 March 2023. The report raises concerns about staffing, continuity of care, personal care, leadership and escalation arrangements on a winter-pressure ward, as well as an electronic record system issue affecting identification of authors of discharge-letter changes.

    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 electronic patient record system to identify authors of changes to finalised discharge letters

    Wider context from the report

    “(2) An issue with the Lorenzo electronic patient record keeping system has been identified in respect of the system not auto populating the identification of the author of any changes made in the immediate discharge letter (IDL) after it has been finalised. This could lead to miscommunication of critical issues and difficulties in establishing who made what decisions which could lead to delays in treatment in the next post discharge setting which in turn could lead to future deaths. ”

    Source location

    Ethel Doreen Reed · 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

    Complete an internal review and consult other Lorenzo users about the Immediate Discharge Summary author-identification process.

    Verbatim wording from the response

    “However, we have completed an internal review of the current process and consulted with other Lorenzo users. The outcome of these discussions is that the Trust is now looking to change the current process of completing the IDS as detailed below:”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 4 · response
    Published 21 February 2024

    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

    A single remedy to identify all authors of Immediate Discharge Summary changes cannot yet be identified because non-clinical staff manage summaries before finalisation.

    Verbatim wording from the response

    “We have not yet been able to identify a single remedy to the issue raised around the identification of all authors making changes to the Immediate Discharge Summary (IDS). The primary barrier to a simple solution to this issue is that there are often non-clinical staff involved in the management of the IDS before it is finalised.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 4 · response
    Published 21 February 2024

    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 proposed Immediate Discharge Summary process change cannot begin fully until required project, system and stakeholder resources become available and internal approval is completed.

    Verbatim wording from the response

    “This piece of work will require resources of Project Management, Change Management, CDC Form Developer, System Support and Information and reporting. There will also be significant stakeholder engagement required including the pharmacy team. Due to this and other similar concerns raised recently, it has been recommended that this piece of work be given a priority 1 and resources allocated as soon as they become available. The timescales for deployment will depend on the approach, but would likely begin with those areas with a significant number of IDS templates set up currently.”

    Source location

    Response from Humber Health Partnership Hull Royal Infirmary
    Page 4 · response
    Published 21 February 2024

    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

    Responsibility for the Lorenzo system relationship sits directly with trusts and the supplier because NHS England has no contract.

    Verbatim wording from the response

    “Your Report also raised a concern around the Lorenzo electronic patient record keeping system not auto-populating the identification of the author of any changes made in the immediate discharge letter after it has been finalised. NHS England no longer has a contract with Dedalus (Lorenzo system) and therefore the relationship sits directly with the Trust(s) and supplier.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 21 February 2024

    Open published response
  3. Exeter and Greater Devon

    AI-generated summary

    Samuel Thomas Jordan · 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

    Samuel Thomas Jordan, aged 25, was imprisoned at HMP Exeter and was found hanging in a single-occupancy cell after an incident with his cell mate on 26 March 2020. The inquest concluded that he died by suicide while suffering from mental illness. The jury identified the lack of access to records from a temporary GP practice, including information about his mental health and current medication, as a contributory factor in 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

    Lack of access to temporary GP practice records through the NHS Spine

    Wider context from the report

    “During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death. The inquest heard that prisoners coming to prison frequently were nomadic and frequently had registered with GP practices on a temporary basis and records from such practices not coming to the notice of prison healthcare as such records are not accessible through the NHS spine. Lack of access through the NHS Spine to the records of the practice where Samuel was registered as a temporary patient was, the jury found, a contributory factor in Samuel’s death. ”

    Source location

    Samuel Thomas Jordan · 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

    Improve information sharing between the detained estate and wider NHS by enabling access to Spine-connected services, including PDS, eRS and GP2GP Transfer.

    Verbatim wording from the response

    “NHS England has been working to improve the processes around information sharing between the detained estate and the wider NHS. This includes enabling access to a range of Spine connected services including Personal Demographics Service (PDS), Electronic Referral Service (eRS) and GP2GP Transfer. As a result of these changes, some patients transferring into the detained estate will have a GP2GP transfer whereby the patient’s electronic GP record is sent from their previously registered GP Practice to the new GP Practice that they register with within the detained estate. Further details are available via the links below:”

    Source location

    Response from NHS England
    Page 1 · response
    Published 12 February 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

    Provide GP2GP electronic transfer of community GP records into and out of healthcare systems across the adult male and children’s secure estate.

    Verbatim wording from the response

    “Patients within the adult male and children and young people’s secure estate (adult male prisons, young offender institutions and secure training centres) have the opportunity to register with healthcare at their place of detention. This means a GP2GP transfer can now take place, electronically transferring the patient’s community GP record into the clinical system in place across the secure estate, and then back out to the community when the patient registers with a GP on release. The ability for a GP2GP transfer of a community GP record into the prison healthcare system was rolled out to the male prison estate between February and July 2022, so this option was not available at the time of Samuel’s death, but I hope provides assurance around current practice.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 12 February 2024

    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 temporary-registration and detained-estate information-sharing processes are considered sufficient, subject to consent and direct contact where necessary.

    Verbatim wording from the response

    “In summary, there are existing processes around the management of temporary resident patients. These support GP Practices to take over the management of patients by registering them permanently at the new practice where this is appropriate. Where care continues to be provided on a temporary basis, there are existing information flows to send information about the care episode back to the patients’ registered GP Practice via the GMS3 form, where the patient has consented, and for this information to then be integrated into the patients’ registered GP record so that”

    Source location

    Response from NHS England
    Page 2 · response
    Published 12 February 2024

    Open published response
  4. Manchester South

    AI-generated summary

    Shahzadi Khan · 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

    Shahzadi Khan was detained under the Mental Health Act after a manic episode with psychotic symptoms and was discharged from an out-of-area private hospital to her family home. Following inadequate discharge planning, communication problems and a failure to arrange the appropriate community care pathway, she deteriorated and took a fatal overdose of prescribed zopiclone at home. The concerns included the effects of out-of-area placements, poor coordination of local care pathways, and insufficient awareness of menopause as a possible factor in mental health deterioration.

    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 share clinical notes across different electronic systems

    Wider context from the report

    “1. The inquest heard evidence that a shortage of mental health beds nationally meant that the situation that arose here of a placement out of area many miles from home was not unusual and that private beds were being used on a regular basis due to a shortage of NHS beds. The inquest heard that this meant that there were a number of consequences as a result of all of such placements which could as in Ms Khan’s case impact on a patient and increase the risk they presented. In particular: • A family could not easily stay in contact and visiting was almost impossible. This meant a patient felt more isolated and their family could not provide information effectively to the treating clinicians. • Where a non-NHS bed was being used or an out of trust bed was being used notes were not easily shared as different electronic systems were used. • Out of area trusts/private providers would not be familiar with local arrangements to support discharge and had to rely on local trust teams to put plans in place which could as in this case lead to less effective communication ”

    Source location

    Shahzadi Khan · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Essex

    AI-generated summary

    Amanda Hitch · 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

    Amanda Hitch died on 12 February 2022 after deliberately jumping in front of a train intending to die. She was receiving community mental health treatment. Concerns included important clinical information not being visible to the care team, structured risk-management tools not being specifically considered, and railway-station attendances not being reliably passed to her care coordinator under a multi-agency support plan.

    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 clinical record to present information as a continuous chronological running record

    Wider context from the report

    “(1) During the inquest, it became clear that one significant entry in the clinical notes made by someone in a separate service commissioned by the Essex Partnership University Trust, and which expressed a very specific and imminent intention from the deceased to end her life, was not seen by others in the clinical team. This was almost certainly because the clinical record does not present on computer screens as a continuous chronological running record, but is instead viewed thematically. That means that readers are likely to look at entries made within their particular clinical team, rather than see what others have recorded more recently. There is an obvious risk that critical and important information garnered by others and put into the medical records will not be seen, and that those making clinical decisions on risk management will thus be unaware of potentially very significant information. ”

    Source location

    Amanda Hitch · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  6. Manchester South

    AI-generated summary

    Lauren Elizabeth Bridges · 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

    Lauren Elizabeth Bridges, who was detained under the Mental Health Act and treated in out-of-area mental health placements, died on 26 February 2022 after a ligaturing incident two days earlier. The report identified concerns about delayed discharge and repatriation, the distance from home, missed opportunities to move her closer to home, and inadequate communication between relevant organisations. It also identified wider concerns about shortages of local mental health beds and reliance on independent providers.

    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 record-keeping systems to support direct transfer and sharing of clinical information

    Wider context from the report

    “The jury identified inadequate and insufficient communication between Dorset Healthcare NHS Trust, The Priory and relevant parties. I heard evidence that Dorset Healthcare NHS Trust have appointed a designated Care Co-ordinator for its Out-of-Area patients. Having a single point of contact will alleviate some of the communication issues identified. I heard evidence from The Priory as to some of the challenges it faces when dealing with the NHS commissioning bodies, be they Hospital Trusts or Integrated Care Boards. The Priory is just one of the several independent providers of mental health care. 1. The Priory deals with 42 NHS separate commissioning bodies. 2. There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible. 3. These bodies have varying processes and requests for communication. 4. There is no national standard process for referrals into the independent sector nor for discharge/repatriation to the ‘home team’. ”

    Source location

    Lauren Elizabeth Bridges · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Avon

    AI-generated summary

    Stephen William Cassidy · 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 William Cassidy fractured his hip and was admitted to Southmead Hospital, where he was given intravenous Ceftriaxone during anaesthetic induction despite a recorded Ceftriaxone allergy. He suffered a severe anaphylactic reaction and died shortly afterwards. The principal concern was that hospital staff could not routinely or easily access or automatically receive Summary Care Record information, including allergies, creating a risk of avoidable patient harm and 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 integrate the Summary Care Record with SMH and primary care electronic patient records for automatic transfer of clinical information

    Wider context from the report

    “a) There is no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily; b) This is despite provision existing for SWAS clinical staff to do so before a patient arrives at hospital; c) There is no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (known as EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appears in SMH’s electronic patient record; d) As a result hospital doctors are ignorant of important clinical information on the patients they are treating; e) This can lead to avoidable patient harm including death. ”

    Source location

    Stephen William Cassidy · 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

    Implement the National Care Records Service to provide integration with local clinical systems and alternative authentication methods.

    Verbatim wording from the response

    “The implementation of National Care Records Service (NCRS) will address two of these points:”

    Source location

    Response from NHS England
    Page 2 · response
    Published 22 September 2023

    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

    Deliver programmes such as GP Connect and MIG that convey allergy information end to end in machine-processable form.

    Verbatim wording from the response

    “NHS England is committed to other programs of work (e.g., GP Connect / MIG) which are currently delivering solutions that convey allergy information end to end in a machine processable way.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 22 September 2023

    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 in-context NCRS integration with Careflow through coordinated NHSE, NBT and System C work.

    Verbatim wording from the response

    “2. One-click/in-context access to NCRS: The ability to access the SCR (and its follower NCRS) in context unfortunately could not be deployed in 2022 at the time of the move to Careflow owing to technical incompatibilities. Following discussions, the IT teams of NHSE, NBT, and System C (producers of Careflow) have had a meeting on the 6th of November to agree a way forward on integration, and the Director of IT at NBT has communicated the requirement to System C so”

    Source location

    Response from NHS North Bristol NHS Trust
    Page 1 · response
    Published 22 September 2023

    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

    Current SCR viewing requirements prevent clinical systems from machine-processing allergy information for automatic insertion into local patient records.

    Verbatim wording from the response

    “The SCR viewing requirements require clinical systems and organisations that consume the SCR to only present the information as human readable and not machine processed i.e., a human must read the information, assimilate this, and transcribe relevant content in the correct way, into their local patient record.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 22 September 2023

    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

    NHSE is best placed to address seamless integration of electronic patient record systems across England.

    Verbatim wording from the response

    “We have addressed the progress towards integration of SCR/NCRS in-context in a) 2. The ability to populate alerts across systems was discussed in meetings with NHSE in October, however these poses significant logistical challenges in definition of data points and creation a ‘single source of truth’ across systems. NHSE are aware of the challenges faced and will be best placed to address the specific question of ‘seamless integration’ of EPR systems across England spanning primary and secondary care.”

    Source location

    Response from NHS North Bristol NHS Trust
    Page 2 · response
    Published 22 September 2023

    Open published response
  8. Manchester South

    AI-generated summary

    Corinne Haslam · 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

    Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.

    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 systems to support transfer of clinical information between mental health and physical health specialists

    Wider context from the report

    “2. It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems. The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa), with an inherent risk to patient safety arising from such information being held in silos. ”

    Source location

    Corinne Haslam · 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

    Issues concerning Pennine Care NHS Foundation Trust should be addressed in the Trust’s response.

    Verbatim wording from the response

    “I note that you have also addressed matters of concern to the Chief Executive of Pennine Care NHS Foundation Trust and I would expect the Trust’s response to address those issues.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 28 July 2023

    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

    Shared care records are considered a safe and secure way to bring together separate records from different health and care organisations.

    Verbatim wording from the response

    “With regard to the compatibility of electronic patient records, a shared care record joins up information based on an individual rather than an organisation, and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 28 July 2023

    Open published response
  9. North West Wales

    AI-generated summary

    Eifion Wyn Huws · 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

    Eifion Wyn Huws, aged 63, died by suicide at his daughter’s home on 10 June 2022 after being found suspended by a ligature. Concerns included the Emergency Department not having access to a very urgent mental-health referral held in hard-copy notes, and delays in completing and sharing the Health Board’s investigation and implementing resulting actions.

    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

    Unavailability of all relevant notes electronically for fully informed treatment and care decisions

    Wider context from the report

    “1. a. During the Inquest evidence was heard that Eifion’s GP had made a ‘very urgent’ referral to the Single Point of Access and Allocation (SPOAA) on 13 May 2022 indicating that on the background of attempts at ending his life, he was extremely concerned that Eifion was experiencing deterioration in his mental state. This document was contained within the hard copy set of notes held by the Psychiatric Liaison Team. When Eifion attended the Emergency Department the following day, on 14 May 2022, the Emergency department staff were not aware of this ‘very urgent’ referral as they only had access to the electronic notes and not the hard copy notes. Had they been aware it is likely to have further informed their decision making. It is concerning that the process of ensuring electronic notes to allow for fully informed decisions around treatment and care based on all available records, is not available to staff. It was not clear at Inquest whether the transition from paper-based notes to electronic notes was a Health Board initiative or a nationally followed initiative. Either way, any delay in ensuring all notes are available electronically is potentially harmful to patients. b. During the evidence it was accepted that ‘a’ above was not a consideration for improvement as part of the Health Board’s investigation and so was not an action within the Action Plan upon which it could make improvements or plan to make improvements. It is surprising that the Health Board did not consider this as an issue which required further consideration and improvements in its learning and improvement. ”

    Source location

    Eifion Wyn Huws · 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 Health Board engagement in WCCIS implementation, including reviewing functionality and supporting required development work.

    Verbatim wording from the response

    “The Welsh Government have advocated the use of an information technology (IT) system that links health and social care through the use of an integrated care platform. The Welsh Community Care Information System (WCCIS) will enable a single integrated health and social care record. This system will help social services (adults & children) and a range of community health services (including mental health, therapies and community nursing) to ensure that care and support for individuals, families and communities are more effectively planned, co-ordinated and delivered. It will support information sharing requirements, case management and workflow for health and social care organisations across Wales. It will show where a patient is within their treatment journey and alert health professionals to key data, which will support the delivery of effective treatment.”

    Source location

    Response from Betsi Cadwaladr University Local Health Board
    Page 1 · response
    Published 12 June 2023

    Open published response
  10. Mid Kent and Medway

    AI-generated summary

    Sally-Ann Few · 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

    Sally-Ann Few was found dead at home on 12 March 2022, after being discharged from hospital the previous day with both slow-release and faster-acting morphine; a post-mortem found that she died as a consequence of morphine toxicity. Concerns included the GP prescribing system not showing that Oromorph had been stopped, a discrepancy between inpatient morphine prescriptions that was not reviewed, and poor medical record keeping that did not document decision-making, discussions, or advice.

    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

    Absence of electronic-record alerts for required medication discrepancy reviews

    Wider context from the report

    “(2) Evidence was heard that Mrs. Few whilst an inpatient was prescribed Oromorph and not Zoromorph the drug she had been using at 20mg twice a day. The effect of which may have impacted upon her pain control but the evidence did not show she had high pain scores. A pharmacist recognised this discrepancy on 8th March and asked for this to be reviewed. No such review took place and it was difficult to see on the electronic records system that such a review needed to take place as apparently there were no highlights or flags to alert the doctors that such a review needed to take place. ”

    Source location

    Sally-Ann Few · 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

    Develop auditable electronic prescribing functionality that alerts doctors when pharmacists identify issues requiring review.

    Verbatim wording from the response

    “The EPMA system is being continuously developed and enhanced to improve patient safety, and whilst there is a section now included for Pharmacists to add notes to electronic prescriptions, the Trust is seeking to develop”

    Source location

    Response from Medway NHS Foundation Trust
    Page 2 · response
    Published 21 November 2022

    Open published response
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Data last updated 7 September 2026