First reported 12 Sep 2013•Latest report 22 Jun 2026
Definition
What this concern includes
Includes failures to retrieve, locate, present or provide access to relevant existing records for assessment, treatment and care decisions.
Not included
Excludes absent or inaccurate information that was never reliably recorded.
Excludes failures to transfer otherwise available information to another service or recipient.
Excludes failure to review records that were already available unless access or retrieval was also deficient.
Reports
122
Distinct published reports
Individual concerns
129
A report can raise multiple concerns
Date range
2013–2026
First to latest report issue date
Stated actions
192
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 Care23
NHS England22
Care Quality Commission6
Barts Health NHS Trust5
Betsi Cadwaladr University LHB5
HM Prison and Probation Service5
Cwm Taf Morgannwg University Local Health Board4
Manchester University NHS Foundation Trust4
Recipient name withheld4
Swansea Bay University Local Health Board4
Leicestershire Partnership NHS Trust3
North London NHS Foundation Trust3
Nottinghamshire Healthcare NHS Foundation Trust3
Royal London Hospital3
Tameside and Glossop Integrated Care NHS Foundation Trust3
NHS trust67
Ministerial department26
Executive non-departmental public body25
Local health board14
Healthcare site11
Multi-service care provider11
Integrated care board8
Health and social care service regulator6
Prison or young offender institution6
Type not available6
Company limited by guarantee5
Executive agency5
Police force4
Devolved government3
Health-system partnership3
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.
Devon, Plymouth and Torbay
Concerns raised1
Failure to prevent or clearly identify automatic deactivation of an active SystmOne patient record by access from a previously involved organisation
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Share the investigation findings and learning with relevant health and justice organisations, highlighting the need to avoid inappropriate record re-registration.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 21 August 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
The events were attributed to human error rather than a systemic SystmOne issue.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Record movement does not affect patients’ clinical care or treatment plans.
Stated by NHS EnglandDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Manchester South
Concerns raised1
Failure to provide drug and alcohol service professionals with access to relevant mental health records
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Work with NHS England and sector partners to overcome barriers to data sharing between services.
Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 25 June 2026.
Action
Introduce the Single Patient Record to enable sharing of patient information across relevant health and social care providers.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 25 June 2026.
Gateshead and South Tyneside
Concerns raised1
Failure to provide prompt access to patient medical records across NHS Trusts
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Develop the Red Tape Challenge to improve primary-secondary care communication, interface working, prescribing, records access, interoperability, and process standardisation.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 19 June 2026.
Action
Introduce a Single Patient Record across England to enable consistent sharing of patient information among relevant health and social care providers from 2028.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 June 2026.
Cheshire
Concerns raised1
Fragmented storage of clinical records without a central access point
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Implement a structured Disclosure Control Toolkit and governance process for mapping, searching, collating, reviewing and disclosing records.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Action
Require relevant patient information, including externally generated clinical documents, to be recorded, stored and uploaded through the expected DSR process.
Stated by Alternative Futures Group LimitedStated completedThe respondent said that this action was complete when they made their response on 12 March 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Medical information may legitimately remain across multiple appropriate sources; a structured collation and disclosure process can address this without a single central record.
Stated by Alternative Futures Group LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
South Wales Central
Concerns raised1
Limited access for community pharmacists to patients’ drug histories and recent test results
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
Action
Write to pharmacy owners, pharmacists and pharmacy technicians with patient-safety concerns, recommended safeguards and supporting resources.
Stated by General Pharmaceutical CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Digital Health and Care Wales is responsible for explaining pharmacy access requirements and planned changes to patient records in Wales.
Stated by General Pharmaceutical CouncilRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Northamptonshire
Concerns raised1
Lack of hospital doctors’ electronic access to detailed primary care medical notes
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.11
Action
Implement the Single Patient Record to unify patient data from multiple sources and provide clinicians access through existing clinical systems.
Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 January 2026.
Action
Lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Implement the Frontline Productivity Programme to improve access to patient information and develop digital workflow capabilities.
Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 29 January 2026.
Action
Work across the health system to support greater integration and awareness of medical-record sharing between providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Action
Work with the Summary Care Record Programme to support wider access to relevant patient information.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Action
Provide clinicians with Northamptonshire Care Record access containing expanded primary care information, with Summary Care Record information migrated into it.
Stated by University Hospitals of Northamptonshire NHS GroupStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Provide clinicians with GP Connect access to structured primary care data, including medications and allergies.
Stated by University Hospitals of Northamptonshire NHS GroupStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
Action
Complete single-sign-on integration from Nervecentre into the Northamptonshire Care Record to remove separate logins.
Stated by University Hospitals of Northamptonshire NHS GroupStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Action
Raise the requirement for GP free-text access with the National Record Locator and Shared Patient Record Programme Boards.
Stated by University Hospitals of Northamptonshire NHS GroupStated plannedThe respondent said that this action was planned when they made their response on 29 January 2026.
Action
Work with Northamptonshire Integrated Care Board to explore enhanced primary-care data-sharing options.
Stated by University Hospitals of Northamptonshire NHS GroupStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Action
Continue advocating for access to full GP consultation notes through appropriate national forums.
Stated by University Hospitals of Northamptonshire NHS GroupStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.4
Position
Access to the Northamptonshire Care Record is determined locally and falls outside NHS England’s remit to comment on.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
Position
The Trust is responsible for, and better placed to answer, questions about local EPR integration and hospital information access.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Full GP free-text consultation notes cannot currently be accessed because they are outside the scope of national shared-care-record programmes.
Stated by University Hospitals of Northamptonshire NHS GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Direct access to GP systems is constrained by the need for agreements with numerous practices, including cross-boundary practices, and previous negotiations did not progress.
Stated by University Hospitals of Northamptonshire NHS GroupUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
East Riding and Hull
Concerns raised1
Lack of access to important mental health records from partner NHS mental health institutions
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Work across the health system to support greater integration and awareness of record sharing between providers.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Action
Work with the Summary Care Record Programme to support wider access to relevant patient information.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 20 January 2026.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Individual NHS trusts are responsible for procuring, implementing and locally converging their electronic patient record systems.
Stated by NHS EnglandRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Derby and Derbyshire
Concerns raised1
Lack of a single electronic patient record accessible to all services
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.9
Action
Share identified non-SystmOne GP practices with Perinatal CMHT clinicians and administrators.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Add alerts to patient records identifying GP practices that do not use SystmOne.
Stated by The TrustStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Draft an information leaflet explaining different electronic records, their impact, and risk mitigation.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Send the electronic-record information leaflet to GPs when referring patients from practices using different systems.
Stated by The TrustStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Add contextual-information-sharing guidance to the electronic referral document for professionals.
Stated by The TrustStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Provide team training on using EMIS interoperability to view SystemOne within two months.
Stated by Sett Valley Medical CentreStated plannedThe respondent said that this action was planned when they made their response on 15 December 2025.
Action
Provide £20 million investment to connect care records across England by March 2026.
Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 15 December 2025.
Action
Develop the Single Patient Record to provide unified access to patient information across care settings.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Action
Work with the Summary Care Record Programme to support wider access to relevant patient information.
Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 15 December 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.7
Position
Configuration and interoperability of clinical record systems across NHS providers and GP practices fall outside the Trust’s direct control and remit.
Stated by Derbyshire Community Health Services NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
Position
Resolving the absence of a unified patient record requires system-wide and national action overseen by NHS England, rather than action by an individual Trust.
Stated by Derbyshire Community Health Services NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
Existing universal health visiting, professional communication, GP liaison and record-access arrangements address local information-sharing needs despite the absence of a single record.
Stated by Derbyshire Community Health Services NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Position
Changing from EMIS to SystmOne would significantly increase risk across integrated primary-care and community services.
Stated by Sett Valley Medical CentreDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
Interoperability specifications and related information-technology due diligence are outside the Practice’s authority and control.
Stated by Sett Valley Medical CentreOutside remitThe respondent said that this matter was outside its role or authority.
Position
Developing interoperability between EMIS and SystmOne is the responsibility of the NHS Derby and Derbyshire Integrated Care Board as service commissioner.
Stated by Sett Valley Medical CentreRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Position
NHS England does not mandate IT infrastructure, so it cannot require a single electronic patient record across providers.
Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.
West Sussex, Brighton and Hove
Concerns raised1
Overreliance on self-declaration questionnaires without further enquiry or access to previous medical history
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
Action
Include immersion pulmonary oedema in the diving medical screening declaration.
Stated by Sub-Aqua AssociationStated completedThe respondent said that this action was complete when they made their response on 19 November 2025.
Action
Remind members at renewal and through periodic newsletters to complete medical declarations accurately.
Stated by Sub-Aqua AssociationStated plannedThe respondent said that this action was planned when they made their response on 19 November 2025.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Position
Revised medical screening forms and existing training changes are considered sufficient to mitigate the risk of immersion pulmonary oedema in diving.
Stated by Sub-Aqua AssociationExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Essex
Concerns raised1
Inability to navigate System One records to find previous incidents of self-harm in prison
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5
Action
Deliver structured SystmOne training through induction, refresher training, and equivalent training for long-term agency staff.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
Action
Require agency staff to confirm in writing that they understand how to navigate SystmOne clinical records and record confirmations.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Reinforce through clinical governance that practitioners consider risk-related history, including information beyond the default summary record view.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Expand monthly clinical-note audits to check access to relevant historic information during risk assessments and report findings through governance and quality monitoring.
Stated by HCRG Care GroupStated plannedThe respondent said that this action was planned when they made their response on 28 October 2025.
Action
Embed SystmOne training into governance and supervision processes to support consistent and safe use of the platform.
Stated by HCRG Care GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 October 2025.
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Includes failures to retrieve, locate, present or provide access to relevant existing records for assessment, treatment and care decisions.
