23 Sep 2025 Tony Buengo Jackson · Prevention of Future Deaths report East London
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Concerns raised 1
Unavailability of notes for the 24th November admission View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Tony Buengo Jackson · 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
Tony Buengo-Jackson, who had progressive multiple sclerosis and lived in a nursing home, died after a PEG tube inserted on 19 November 2024 passed through his transverse colon, causing bowel perforation, peritonitis and sepsis. The report raises concerns that the injury was not detected until 3 December despite an earlier admission, CT scan and surgical consultation, and that poor records and inadequate Trust governance impeded investigation and learning.
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× 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 notes for the 24th November admission
Wider context from the report “3. The Trust could not provide notes of the 24th November admission .
” Source location Tony Buengo Jackson · Prevention of Future Deaths report
Open source report
18 Sep 2025 Kwabena Amoateng · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Kwabena Amoateng · 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
Kwabena Amoateng, a 17-year-old boy with congenital central hypoventilation syndrome, became ill on 16 September 2024 and died in hospital on 23 September 2024 after developing severe respiratory complications. A Paediatric Respiratory Action Plan for his condition was mislabelled and misfiled, so it was unavailable to emergency healthcare professionals assessing him. The report identified the absence of a coordinated process for producing and storing such documents in online clinical records as a substantive concern.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure prominent and accurate filing of critical respiratory action plans in online clinical records
Wider context from the report “1. The inquest found that a critically important document had been produced by his specialist respiratory doctors to assist emergency healthcare professionals in understanding his rare and potentially dangerous condition - CCHS. The document, A Paediatric Respiratory Action Plan (‘PRAP’) set out the necessary steps to be considered should Kwabena fall ill.
2. During Kwabena’s final illness, those assessing him from 16ᵗʰ-21ˢᵗ September 2024 were unaware of this vital document as it had been mislabelled and misfiled within the online records available to them .
3. Had the PRAP been more prominently filed it is likely that those assessing Kwabena would have escalated his treatment to admission to hospital far earlier, which may have resulted in Kwabena’s life being saved.
4. An investigation into why the PRAP was not visible to emergency services in this case has highlighted that there is no coordinated process to ensure a consistent approach in producing and storing such documents in online clinical records.
” Source location Kwabena Amoateng · Prevention of Future Deaths report
Open source report
1 Aug 2025 Suzanne EDWARDS · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Unreliable access to patients' primary care records in Emergency Departments View source
Linked responses
Bedfordshire Hospitals NHS Foundation Trust Buckinghamshire Healthcare NHS Trust Milton Keynes University Hospital NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
Bedfordshire Hospitals NHS Foundation Trust
Provide Emergency Department clinicians access to Shared Care Records, GP Connect and Summary Care Records for patient care.
View source
Bedfordshire Hospitals NHS Foundation Trust
Continue working with healthcare partners to ensure necessary patient data sharing occurs for effective treatment.
View source
Milton Keynes University Hospital NHS Foundation Trust
Optimise the eCare record for sharing through the Health Information Exchange.
View source
Milton Keynes University Hospital NHS Foundation Trust
Establish Health Information Exchange links with providers serving significant numbers of common patients.
View source
Milton Keynes University Hospital NHS Foundation Trust
Encourage other providers to share more pertinent record content through the Health Information Exchange.
View source
Buckinghamshire Healthcare NHS Trust
Link Summary Care Record visibility into the Acute Electronic Patient Record front screen when it launches.
View source See 3 more actions
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AI-generated summary
Suzanne EDWARDS · 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
Suzanne EDWARDS became unwell on 29 November 2024, was assessed by her GP and at Milton Keynes Hospital, admitted to Bedford Hospital for surgery to insert a kidney stent, and died there of sepsis on 1 December 2024. The principal concern was that emergency departments lacked reliable access to patients’ primary care records, and the inquest identified a failure to recognise signs of urinary tract obstruction, resulting in a lost opportunity to treat the condition before sepsis developed.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unreliable access to patients' primary care records in Emergency Departments
Wider context from the report “Emergency Departments at hospitals in this and surrounding jurisdictions do not have reliable access to patients' primary care records, including recent GP consultations, investigations or concerns. This means that clinicians are frequently treating acutely unwell patients without full access to their recent medical history , which can delay or misdirect diagnosis and undermine patient safety and continuity of care and lead to avoidable deaths.
Without access to a patients full records further lives may be put at risk.
” Source location Suzanne EDWARDS · Prevention of Future Deaths report
Open source report
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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 Emergency Department clinicians access to Shared Care Records, GP Connect and Summary Care Records for patient care.
Verbatim wording from the response “I do of course recognise the risk you have identified that can result when primary and secondary healthcare providers cannot access each other's medical records. I welcome the opportunity to explain what access to Shared Care Records (including GP records) our A&E clinicians have at both the Bedford and Luton & Dunstable hospital sites. I hope this will assure you that Bedfordshire Hospitals NHS Foundation Trust clinicians do, as far as is possible, have access to primary care records to assist them in the diagnosis of conditions thus reducing the overall risk to patient safety and further mitigating the risk of future deaths.” Source location Response from Bedfordshire Hospitals NHS Trust
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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 working with healthcare partners to ensure necessary patient data sharing occurs for effective treatment.
Verbatim wording from the response “Thank you for bringing this important patient safety concern to my attention. As a Trust we are committed to working closely with our healthcare partners to ensure that data sharing happens, we all recognise the vital information sharing that is needed to effectively treat our patients.” Source location Response from Bedfordshire Hospitals NHS Trust
Open published response
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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 Optimise the eCare record for sharing through the Health Information Exchange.
Verbatim wording from the response “At MKUH, we continue to:” Source location Response from Milton Keynes University Hospital
Open published response
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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 Establish Health Information Exchange links with providers serving significant numbers of common patients.
Verbatim wording from the response “MKUH has developed HIE linkages with many other providers.” Source location Response from Milton Keynes University Hospital
Open published response
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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 Encourage other providers to share more pertinent record content through the Health Information Exchange.
Verbatim wording from the response “At MKUH, we continue to:” Source location Response from Milton Keynes University Hospital
Open published response
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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 Link Summary Care Record visibility into the Acute Electronic Patient Record front screen when it launches.
Verbatim wording from the response “In Buckinghamshire we are fortunate to have a Summary Care Record which contains a record of encounters with all health services. This includes primary care diagnosis codes and lists, medication lists and brief summaries of primary care appointment outcomes. The Summary Care Record is visible to all hospital colleagues and access will be linked into our Acute Electronic Patient Record front screen when this launches in September / October 2025. This visibility would I believe mitigate against the issues noted in the Report although at the moment some patients have opted out across the system as a matter of personal choice.” Source location Response from Buckinghamshire Healthcare NHS Trust
Open published response
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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 Expanding the patient information shared through existing records is outside the Trust’s control.
Verbatim wording from the response “It is not within the Trust's control to expand upon what patient information is shared on the services outlined above as the record is taken from the Summary Care Record and GP Connect. The extent of what is contained in the Summary Care Record is regulated by NHS Digital which forms part of NHS England.” Source location Response from Bedfordshire Hospitals NHS Trust
Open published response
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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 NHS England regulates the extent of information contained in the Summary Care Record.
Verbatim wording from the response “It is not within the Trust's control to expand upon what patient information is shared on the services outlined above as the record is taken from the Summary Care Record and GP Connect. The extent of what is contained in the Summary Care Record is regulated by NHS Digital which forms part of NHS England.” Source location Response from Bedfordshire Hospitals NHS Trust
Open published response
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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 Summary Care Record visibility and some EMIS access are considered sufficient to mitigate concerns about hospital clinicians’ visibility of primary care records.
Verbatim wording from the response “In Buckinghamshire we are fortunate to have a Summary Care Record which contains a record of encounters with all health services. This includes primary care diagnosis codes and lists, medication lists and brief summaries of primary care appointment outcomes. The Summary Care Record is visible to all hospital colleagues and access will be linked into our Acute Electronic Patient Record front screen when this launches in September / October 2025. This visibility would I believe mitigate against the issues noted in the Report although at the moment some patients have opted out across the system as a matter of personal choice.” Source location Response from Buckinghamshire Healthcare NHS Trust
Open published response
23 Jun 2025 REDACTED Deceased · Prevention of Future Deaths report Northumberland
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Concerns raised 1
Lack of one accessible system for weights, heights and BMI View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
49 Marine Avenue GP Surgery (NPC Surgery Department of Health and Social Care Northumbria Healthcare NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 5
49 Marine Avenue GP Surgery (NPC Surgery
Develop improved information-sharing strategies across primary care, secondary care, schools, mental health services and social care, including exploring monthly multidisciplinary meetings.
View source
Department of Health and Social Care
Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.
View source
Department of Health and Social Care
Deliver a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.
View source
Northumbria Healthcare NHS Foundation Trust
Implement SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.
View source
Northumbria Healthcare NHS Foundation Trust
Continue reviewing clinical systems and digital platforms to streamline central reporting and interoperability of height and weight measurements.
View source See 2 more actions
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AI-generated summary
REDACTED Deceased · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
The deceased was a 17-year-old girl with autism, anxiety, significant weight loss and extreme malnutrition who died in hospital on 5 May 2024 after cardiac output was lost following vomiting during preparation for insertion of a central venous line. The principal concerns included inadequate monitoring of her weight, lack of face-to-face assessments, failure to refer or escalate care appropriately, discharge from CAMHS without direct assessment, poor communication and unclear oversight of outpatient care.
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× 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 one accessible system for weights, heights and BMI
Wider context from the report “6.One records system - weights, heights and Body Mass Index (BMI)
I heard that patient care records are held on different care record systems within the NHS which are not universally accessible to healthcare organisations, healthcare professionals or patients. I heard good examples of accessible records such as the Great North Care Record (GNCR) and SystmOne operated by some in Primary Care.
I am concerned there is not one accessible system for weights, heights and BMI .
” Source location REDACTED Deceased · Prevention of Future Deaths report
Open source report
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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 improved information-sharing strategies across primary care, secondary care, schools, mental health services and social care, including exploring monthly multidisciplinary meetings.
Verbatim wording from the response “3. Communication and Information Sharing: The report highlights concerns regarding the flow of information from other agencies, including the school and mental health services. We concur that a more robust system for sharing relevant clinical and safeguarding information is essential. We are committed to improving multidisciplinary communication, including liaising more proactively with schools, mental health services, and social care teams involved with patients at risk.” Source location 2025-0314 - Response from 49 Marine Avenue Surgery
Open published response
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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 Execute a programme to improve interoperability and sharing of patient records, including medical history, investigations, height, weight and other vital measurements.
Verbatim wording from the response “It is recognised by NHS England that the joining up of records to achieve easy access to all the information by clinicians and 'patients/their guardians' remains a challenge and NHS England with the Department of Health and Social Care is currently executing a substantial programme of work to increase the interoperability and sharing of all patient records, including medical history, investigations and vital patient measurements (Blood pressure, Height and Weight etc) and would include centile charts in paediatric services. This has been outlined in the Governments 10 Year Plan and the ambition to develop a ‘Single Patient Record’.” Source location Response from Department for Health and Social Care
Open published response
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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 a Single Patient Record bringing patients’ medical records together in one comprehensive digital record, targeted to begin processing information by 2028.
Verbatim wording from the response “The Government’s 10 Year Health Plan commits to the delivery of a SPR. This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place which will help prevent unfortunate incidents where fragmented and disjointed information prevents treatment from being provided on time.” Source location Response from Department for Health and Social Care
Open published response
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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 SystmOne electronic records for Nutrition and Dietetics outpatient consultations, including visibility, communication, measurement tracking and auditable triage.
Verbatim wording from the response “3. Introduction of SystmOne as a clinical electronic records system for Nutrition and Dietetics outpatient consultations (Go Live of the Nutrition and Dietetics SystmOne unit was August 2024) provides:” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Open published response
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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 clinical systems and digital platforms to streamline central reporting and interoperability of height and weight measurements.
Verbatim wording from the response “12. The Trust are continuing to review all clinical systems and digital platforms to streamline, where possible, the reporting of weight and height and the interoperability of systems to provide assurance that measures are captured and reported centrally by all services.” Source location 2025-0314 - Response from Northumbria Healthcare NHS Foundation Trust
Open published response
13 Mar 2025 Mr Paul Timothy Dunne · Prevention of Future Deaths report South London
View report summary
Concerns raised 1
Lack of shared access to mental health and A&E clinical records View source
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
NHS England
Specify the Core Information Standard and support sharing critical clinical information through local Shared Care Records.
View source
NHS England
Advance national interoperability between Shared Care Records across England.
View source
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AI-generated summary
Mr Paul Timothy 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
Mr Paul Dunne was brought to A&E after a paracetamol overdose and was considered at high risk of suicide, but did not receive continuous 1:1 observation. He absconded several times and was found dead after suspending himself in a nearby children's playground. Concerns included failures in risk assessment, observation, communication, documentation and escalation, as well as separate clinical-record systems used by mental health and A&E staff.
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× 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 shared access to mental health and A&E clinical records
Wider context from the report “3. MH staff and A&E staff write their clinical records in different systems and hospital staff do not have access to MH Rio records . MH staff attending A&E departments are asked to make a double entry in the A&E records as well. Here that was omitted, potentially with fatal risks. Moving to a combined electronic system (now identified as EPIC) has long been the aim of the local health providers, but evidence was heard that the pace of introduction, which is very slow, is in the hands of national NHS leadership.
” Source location Mr Paul Timothy Dunne · Prevention of Future Deaths report
Open source report
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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 Specify the Core Information Standard and support sharing critical clinical information through local Shared Care Records.
Verbatim wording from the response “NHS England is also committed to supporting the sharing of critical clinical information across NHS organisations. Since 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold (known as the core information standard) between providers within their own Integrated Care System” Source location Response from NHS England
Open published response
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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 Advance national interoperability between Shared Care Records across England.
Verbatim wording from the response “footprint, through their local Shared Care Record (ShCR). ShCR supplies must be assured against the Professional Record Standards Body’s (PRSB) Core Information Standard, which has been specified by NHS England. Where local ShCRs are used therefore, the core information standard will be available. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between SHCRs across England. This initiative has been commenced but does not have a defined timeframe as it is dependent on funding which has not yet been confirmed. It aims to enable any authorised health and care professionals to have access to safe, reliable and accurate records, regardless of the patient’s location or where care is provided.” Source location Response from NHS England
Open published response
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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 Individual NHS Trusts are responsible for procuring, implementing and locally converging their chosen electronic patient record systems.
Verbatim wording from the response “NHS England is committed to improving the maturity and quality of Electronic Patient Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts to effectively procure and implement their chosen EPR system, and to agree and progress any convergence of EPR systems within their local systems.” Source location Response from NHS England
Open published response
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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 Local care organisations and NHS Trusts are responsible for agreeing additional shared information and negotiating local data-sharing arrangements.
Verbatim wording from the response “It is, however, up to local care organisations and participating NHS Trusts to agree what information, in addition to the core information standard, is held and shared through the local ShCR. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local ShCR.” Source location Response from NHS England
Open published response
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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 National interoperability between shared care records has no defined timeframe because the required funding has not yet been confirmed.
Verbatim wording from the response “footprint, through their local Shared Care Record (ShCR). ShCR supplies must be assured against the Professional Record Standards Body’s (PRSB) Core Information Standard, which has been specified by NHS England. Where local ShCRs are used therefore, the core information standard will be available. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between SHCRs across England. This initiative has been commenced but does not have a defined timeframe as it is dependent on funding which has not yet been confirmed. It aims to enable any authorised health and care professionals to have access to safe, reliable and accurate records, regardless of the patient’s location or where care is provided.” Source location Response from NHS England
Open published response
17 Feb 2025 DAVID WAYNE BENNETT · Prevention of Future Deaths report Essex
View report summary
Concerns raised 2
Lack of appropriate access by mental health crisis staff to primary care mental health records View source Lack of acute Trust nurse access to mental health and GP records View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Essex Partnership University NHS Foundation Trust Mid and South Essex NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Mid and South Essex NHS Foundation Trust
Develop and expand the Shared Care Record to provide unified access to patient information across partner services.
View source
Mid and South Essex NHS Foundation Trust
Implement the NOVA unified electronic patient record across acute, community and mental health services.
View source
Essex Partnership University NHS Foundation Trust
Develop a unified electronic patient record across EPUT and MSEFT, including bidirectional primary-care integration.
View source
Mid and South Essex NHS Foundation Trust
Disseminate Shared Care Record notifications, guidance and videos to emergency department clinical staff during rollout.
View source See 1 more action
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AI-generated summary
DAVID WAYNE BENNETT · 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 Wayne Bennett died by hanging on 13 June 2023 after being found suspended by a ligature, with cocaine and alcohol ingestion. He had a history of drug-induced psychosis and had sought help for deteriorating mental health, psychosis and lack of sleep before his death. Concerns included inadequate sharing and recording of mental-health and primary-care information, unclear urgent-care pathways, failures to escalate requests for urgent medication review, and insufficient mental-health assessment and liaison at hospital.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of appropriate access by mental health crisis staff to primary care mental health records
Wider context from the report “(1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.
” Source location DAVID WAYNE BENNETT · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of acute Trust nurse access to mental health and GP records
Wider context from the report “(6) Mr Bennett attended the acute hospital Trust for his deteriorating mental health. The acute Trust hospital nurse sought advice from the mental health liaison nurse. The acute Trust nurse did not have access to the mental health or GP records and not all available information was shared with the acute Trust nurse.
” Source location DAVID WAYNE BENNETT · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and expand the Shared Care Record to provide unified access to patient information across partner services.
Verbatim wording from the response “Access to medical records- Shared Care Record
We have several projects under development to improve the sharing of patient information between us, primary care, social care, and NHS colleagues.” Source location Response from Mid & South Essex NHS Trust
Open published response
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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 NOVA unified electronic patient record across acute, community and mental health services.
Verbatim wording from the response “Unified Electronic Patient Record- NOVA
The Nova programme is our long-term plan working to implement a unified electronic patient record (EPR) utilising the Oracle Health platform. This will be a joint platform across acute, community and mental health, enabling a more streamlined, transparent approach to patient care. It will link in with our shared care record (Orion) to allow GPs visibility of information and vice versa, as well as some information being sent to the patient portal, for example discharge letters, results, and questionnaires.” Source location Response from Mid & South Essex NHS Trust
Open published response
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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 a unified electronic patient record across EPUT and MSEFT, including bidirectional primary-care integration.
Verbatim wording from the response “Response: We respectfully advise that MSEFT are best placed to respond to this concern, regarding access to GP records.
With regards to access to the mental health records, the Trust in partnership with MSEFT are currently developing a new unified Electronic Patient record system across EPUT and MSEFT. The strategic ambition to unify care pathways remains at the centre of the programmes commitment including the bidirectional integration with primary care. The new UEPR (NOVA) is expected to go live across the Trust in February 2027.” Source location Response from Essex Partnership University NHS Trust
Open published response
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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 Disseminate Shared Care Record notifications, guidance and videos to emergency department clinical staff during rollout.
Verbatim wording from the response “Notification, training guidance and videos about the Shared Care Record are currently being disseminated to our ED clinical staff as part of the rollout programme. Once the Shared Care Record is embedded, our clinical colleagues will have access to patient records from other agencies themselves, via ACP, enabling them to have a fuller picture of the patient’s clinical background. Staff will have the potential to be alerted to previous mental health interactions or concerns outside of the acute setting, without relying on the patient’s own disclosure. The types of records currently available are set out in the graphic below.” Source location Response from Mid & South Essex NHS Trust
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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 Concerns about care before 6 June 2023 do not relate to the respondent, so it has identified no action concerning them.
Verbatim wording from the response “I understand from my colleagues in attendance at the Inquest hearing, that these matters of concern; points 1 – 5, do not relate to Mid and South Essex NHS Foundation Trust (MSEFT), and we have not identified any action to be taken in respect of these.” Source location Response from Mid & South Essex NHS Trust
Open published response
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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 Mental Health Crisis staff had access to SystmOne records; only the Mental Health Liaison team lacked access at the relevant time.
Verbatim wording from the response “Concern 1) Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health SystmOne records and there is a risk that vital information is not being shared.” Source location Response from Essex Partnership University NHS Trust
Open published response
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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 Mid and South Essex NHS Foundation Trust is best placed to address acute hospital access to GP records.
Verbatim wording from the response “Response: We respectfully advise that MSEFT are best placed to respond to this concern, regarding access to GP records.
With regards to access to the mental health records, the Trust in partnership with MSEFT are currently developing a new unified Electronic Patient record system across EPUT and MSEFT. The strategic ambition to unify care pathways remains at the centre of the programmes commitment including the bidirectional integration with primary care. The new UEPR (NOVA) is expected to go live across the Trust in February 2027.” Source location Response from Essex Partnership University NHS Trust
Open published response
Concerns raised 1
Unavailability of medical records for surgery and post-operative care View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Anne TOWLSON · 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
Anne Towlson was found dead at home on 17 May 2024 after travelling to Turkey for planned tummy tuck and liposuction surgery, and additionally undergoing arm tuck surgery. Her arm wounds had not healed, with open, swollen and weeping wounds noted after her return to the UK; the cause of death was recorded as unascertained. Concerns included the lack of information about the Turkish hospital’s assessment, surgery and postoperative care, uncertainty about whether surgical risks were explained, the consenting process for the additional arm surgery, and limited follow-up after returning to the UK.
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× 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 medical records for surgery and post-operative care
Wider context from the report “1) I am concerned about the fact that the inquest was unable to secure any information from the Turkish Hospital. We have no information about whether any independent enquiries were made either by the company who organised Mrs Towlson’s trip to Turkey for surgery, or the Turkish Hospital itself as to whether Mrs Towlson was fit for surgery. We have not been able to secure her medical records so have no understanding of what exactly the surgery consisted of, or what post-operative care and treatment was provided to Mrs Towlson.
” Source location Anne TOWLSON · Prevention of Future Deaths report
Open source report
6 Feb 2025 Katrina Veronica Francesca Insley · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1
Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Katrina Veronica Francesca Insley · 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
Katrina Insley died on 1 January 2024 at Alexandra Hospital, Redditch, from sepsis due to an infected pressure sore and pneumonia. The report identified concerns about the absence of a formal, documented handover system between hospital and the Neighbourhood Team, limited access to hospital records, and the resulting risk of delayed recognition and treatment of pressure sores, infection and sepsis.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide the Neighbourhood Team with direct access to hospital records for patients with pressure sores
Wider context from the report “(1) The absence of a formal, documented handover system between hospital and Neighbourhood Team and the fact that the NT cannot simply check hospital records of patients with pressure sores to verify their condition without specifically requesting records creates the potential for the NT to fail to appreciate the true condition of a patient’s pressure sores when they are discharged from hospital and follow up to be delayed. This increases the risk of wound infection and consequent sepsis.
(2) I am informed (letter received from HWHT on 31.1.25) that there are established handover procedures and that a statement of practice is being drafted to “formalise” the referral requirements between hospital and NT. I am informed also that an App is being developed which can be used to record and check the condition of pressure sores and that it has the potential to be used across acute and community services. I do not consider that these proposals are sufficiently detailed, precise and concluded to address the concerns that I have expressed.
” Source location Katrina Veronica Francesca Insley · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Obtain electronic patient-record access for two staff members per Neighbourhood Team, including evening and night community nursing teams.
Verbatim wording from the response “The Trusts have further considered the impact of not having a shared records system, and the Health and Care Trust are in the process of obtaining access for 2 members of staff per Neighbourhood team (including Evening and Nights community nursing team) to the Acute Trusts Electronic Patient Record – ‘Sunrise’. The access will be given to staff who sit within Triage hubs in the Neighbourhood Teams and triage new referrals. This will enable them to gain detailed patient information, for example, regarding wounds.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review access uptake after all identified staff receive access and determine whether additional electronic patient-record licences are required.
Verbatim wording from the response “So far, 18 out of the 26 people identified as needing access, have been granted access but are not yet in full operational use. Once all access has been obtained as planned, this will be reviewed quickly to establish whether more licenses are required.” Source location Response from Herefordshire and Worcestershire Health and Care NHS Trust and Worcestershire Acute Hospitals Trust
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24 Jan 2025 Andrew Dominic HEYS · Prevention of Future Deaths report Manchester West
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Concerns raised 1
Failure of health information systems to enable authorised cross-provider access to patient records View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Andrew Dominic HEYS · 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
Andrew Dominic HEYS received a Covid-19 booster vaccination in December 2021 and subsequently suffered from Auto-Immune Encephalopathy. On 12 March 2024, he fell into the Manchester Ship Canal from a bridge, and his body was discovered four days later. Concerns included inadequate training for an out-of-hours GP in following referral pathways and accessing patient records, as well as incompatible health-record IT systems that prevented health professionals from accessing records held elsewhere in the NHS.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of health information systems to enable authorised cross-provider access to patient records
Wider context from the report “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard.
During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional . In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other" . It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS .
” Source location Andrew Dominic HEYS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue rolling out Electronic Patient Records and support trusts to replace, extend, or optimise existing systems.
Verbatim wording from the response “I agree that ensuring health and care professionals have access to a single source of digital information about the patients they are treating and caring for is vitally important to delivering the best care possible. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue.” Source location Response from Department for Health and Social Care
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver a single patient record, beginning its rollout from 2028 with maternity care.
Verbatim wording from the response “Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single patient record (SPR). This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place. We have been engaging with the public to help shape our plans, including what information they would like to see included in a single patient record and we will continue to talk to the public and to health and care professionals as we design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028 and be rolled out first in maternity care.” Source location Response from Department for Health and Social Care
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15 Jan 2025 Tammy Denise Milward · Prevention of Future Deaths report Surrey
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Concerns raised 1
Failure of primary and secondary care providers to access each other’s electronic medical records View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Esher Green Surgery Surrey Heartlands ICB
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 4
Esher Green Surgery
Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.
View source
Esher Green Surgery
Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.
View source
Surrey Heartlands ICB
Provide live GP medication and correspondence feeds with embedded single-sign-on access through the Surrey Care Record.
View source
Surrey Heartlands ICB
Implement a live Surrey Care Record feed displaying complete GP consultation free text, including historic consultations.
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AI-generated summary
Tammy Denise Milward · 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
Tammy Denise Milward, who had severe obsessive compulsive disorder and dependence on prescribed medication, was found unresponsive at home on 1 January 2024 after concerns were raised about her wellbeing. The medical cause of death was mixed drug toxicity, with toxicology showing prescribed medication in excess of prescribed levels and cocaine use shortly before her death. The principal concern was limited coordination and communication between primary and secondary care providers, including poor connectivity between their electronic record systems.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of primary and secondary care providers to access each other’s electronic medical records
Wider context from the report “The Inquest heard evidence that Ms Milward’s case presented treatment challenges which several agencies sought to address but there was limited coordination, in particular that:
a. The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS . As a result, neither the GP practice, nor GPimhs was aware that the other had received messages from or about Ms Milward on 28 December 2023. The coroner heard from SABP that there is ongoing work ongoing to create greater connectivity between the various electronic record systems, but this work is not yet complete .
b. The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs. The coroner was told that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support) but that levels of interaction varied and was sometimes also undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices.
The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death.
” Source location Tammy Denise Milward · Prevention of Future Deaths report
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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 Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.
Verbatim wording from the response “As such in respect of this Concern a., we consider we cannot proactively do anything save bring this to the attention of the ICB as it is a commissioning issue, which we have done, and later react to requests from SABP, subject to approval from the ICB, to facilitate integration of the clinical IT systems which, of course we will do and would expect the other 100 plus practices to do likewise.” Source location Response from Esher Green Surgery
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.
Verbatim wording from the response “(ii) Pending IT integration, which needs to be effected as soon as possible, we will implement any temporary measures recommended by the ICB, alongside the other 100 plus practices. We believe it is important that any changes are effected Surrey-wide and not on an ad hoc basis for an individual practice; and” Source location Response from Esher Green Surgery
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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 live GP medication and correspondence feeds with embedded single-sign-on access through the Surrey Care Record.
Verbatim wording from the response “Currently the Surrey Care Record does share a live feed of the GP medication, all GP held letters and also any letters sent from an acute trust to the GP (live feed again). By mid-April we will have been able to implement a live feed from the GP system which will show the entire consultation free text, including historic consultations. This will effectively give the meat (all clinically relevant) GP record to the health professional treating that patient. Patient/pharmacy messages are stored within the GP record as an administration consultation and as such any messages from the pharmacist to the GP will be fully visible to the GPimhs team. Of note, there is embedded link (single sign on) from within the SABP system so that it requires only one button push from the SABP System One record, in order to automatically open up the Surrey Care Record for that patient.” Source location Response from Surrey Heartlands ICB
Open published response
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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 a live Surrey Care Record feed displaying complete GP consultation free text, including historic consultations.
Verbatim wording from the response “Currently the Surrey Care Record does share a live feed of the GP medication, all GP held letters and also any letters sent from an acute trust to the GP (live feed again). By mid-April we will have been able to implement a live feed from the GP system which will show the entire consultation free text, including historic consultations. This will effectively give the meat (all clinically relevant) GP record to the health professional treating that patient. Patient/pharmacy messages are stored within the GP record as an administration consultation and as such any messages from the pharmacist to the GP will be fully visible to the GPimhs team. Of note, there is embedded link (single sign on) from within the SABP system so that it requires only one button push from the SABP System One record, in order to automatically open up the Surrey Care Record for that patient.” Source location Response from Surrey Heartlands ICB
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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 Electronic record connectivity is a commissioning responsibility for the Surrey-wide ICB, not an individual GP practice.
Verbatim wording from the response “General Practice Integrated Mental Health Service (“GPiMHS”) is a Surrey wide system run by Surrey and Borders Partnership NHS Foundation Trust (“SABP”) and commissioned by Surrey Heartlands Integrated Care Board (“ICB”).” Source location Response from Esher Green Surgery
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice cannot independently improve communication across Surrey; practice-level action will not address the wider issue without a uniform SABP approach.
Verbatim wording from the response “Clinical space in GP practices is usually fully utilised by the practices themselves and this is the case at our Practice. We are currently working with the ICB on finding a solution to our own estate’s challenges but are aware that there is pressure on GP space Surrey wide. As such, we consider that in-person interactions are unlikely to be effected Surrey-wide so email and telephone interactions should be prioritised in our view. This concern b. is not specific to the Practice but is Surrey-wide for all practices and any action taken by the Practice alone will not address the wider community unless SABP seek a uniform approach.” Source location Response from Esher Green Surgery
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Surrey Care Record access is considered sufficient to resolve the risk of GPimhs staff lacking necessary GP record information.
Verbatim wording from the response “Any data is only two mouse clicks away. This should fully resolve the issue of the GPimhs staff not being able to see the GP record to the degree that is required to mitigate this risk.” Source location Response from Surrey Heartlands ICB
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.