Recurring concern

Unreliable access to relevant clinical records for safe care

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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
Individual concerns: 129
Date range: 2013–2026
Stated actions: 192

Reports over time

Reports about this concern issued each year.

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

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

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.

21 Dec2023
Exeter and Greater Devon
Concerns raised1
1. Failure to ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments
This report raised 1 other concern. 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 2
1. Action
  Provide training enabling independent section 12 doctors to access CareNotes.
  Stated by Devon Partnership NHS TrustStated completed
2. Action
  Implement the Devon Shared Care Record to facilitate cross-organisational access to clinical records.
  Stated by Devon Partnership NHS TrustStated in progress
AI-generated summary

NICHOLAS JAMES GLAVIND DYMOND · 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

Nicholas Dymond, who had a history of intermittent drug use, developed paranoia and expressed suicidal thoughts about jumping in front of a train. After a Mental Health Act Assessment following his arrest, he was discharged and ran away when the arranged taxi arrived; less than three hours later, he stepped in front of a train and was pronounced deceased at the scene. The concerns identified included independent doctors potentially conducting assessments without access to patient records and witnesses’ lack of understanding of voluntary admission and the least restrictive option.

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 ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments
Wider context from the report
“(1) The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment. ”
Source location
NICHOLAS JAMES GLAVIND DYMOND · 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
Provide training enabling independent section 12 doctors to access CareNotes.

Verbatim wording from the response
“The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment.”

Source location
Response from Devon Partnership NHS Trust
Page 1 · response
Published 29 December 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
Implement the Devon Shared Care Record to facilitate cross-organisational access to clinical records.

Verbatim wording from the response
“The “Devon Shared Care Record” is also now being implemented. This will facilitate cross organisational access to clinical care records and so further improve availability of relevant information to clinicians.”

Source location
Response from Devon Partnership NHS Trust
Page 2 · response
Published 29 December 2023
Open published response
19 Dec2023
Essex
Concerns raised1
1. Failure of the clinical record to present information as a continuous chronological running record
This report raised 4 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
31 Oct2023
Birmingham and Solihull
Concerns raised1
1. Lack of access to essential patient records before mental health liaison assessment and treatment
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Allocate hospital-record access to bank staff regularly working within the Psychiatric Liaison Team.
  Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS TrustStated planned
2. Action
  Advise agency staff during local induction how to access, review and update hospital records through permanent team members.
  Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS TrustStated planned
Respondent positions 1
1. Position
  Generic logins for agency staff cannot be provided because they would lack traceability, accountability and lawful information processing.
  Stated by Birmingham and Solihull Mental Health NHS Foundation Trust and Sandwell and West Birmingham Hospitals NHS TrustUnable to act
AI-generated summary

Andrew BOWLES · 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 BOWLES was found face down in a canal on 16 May 2023 after leaving Birmingham City Hospital, where he had been assessed following concerns about his mental health. The medical cause of death was drowning. The principal concern was that the mental health liaison nurse did not have direct access to City Hospital records containing information about command hallucinations and thoughts of self-harm, which may have affected the assessment and potential referral for psychiatric admission.

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 essential patient records before mental health liaison assessment and treatment
Wider context from the report
“3. The mental health liaison nurse from Birmingham and Solihull mental health NHS foundation trust did not have a log in to be able to directly access City Hospital records, but rather relied on a colleague to access any notes and provide a verbal handover. Further, she stated in evidence that her assessment may have taken place prior to the A&E notes being put onto the system, as she was unaware that Mr Bowles had been experiencing command hallucinations and had thoughts of self-harm, the same being denied when she saw him less than an hour later. Her evidence was clear, that had she been privy to this information, it would have put a different angle on the assessment and would have led down the route of psychiatric review for potential admission. 4. I am concerned that the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment. I am concerned that there may still be a risk to the life of some patients if the mental health liaison team and Birmingham City Hospital are not ensuring that essential patient records are being appropriately shared and read prior to diagnosis and treatment. The situation may well be the same at University Hospitals Birmingham, given that Birmingham and Solihull Mental Health NHS foundation Trust also run a mental health liaison service in the A&E department. ”
Source location
Andrew BOWLES · 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
Allocate hospital-record access to bank staff regularly working within the Psychiatric Liaison Team.

Verbatim wording from the response
“In the past any “bank staff” (temporary staff) who were on shift would ask a member of the permanent team to access the records, so that they could review them prior to seeing a patient and would also ask permanent staff to update the records, following their review. Following the PFD, a joint meeting has taken place between the two trusts, and we have been able to identify that a number of the bank staff are regularly working bank shifts within the PLT. Therefore these staff will now be allocated access to hospital records. This will improve matters considerably in this area.”

Source location
Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Page 1 · response
Published 6 November 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
Advise agency staff during local induction how to access, review and update hospital records through permanent team members.

Verbatim wording from the response
“There are a small number of staff who may be called in from agencies when there are no other staff available. As these staff may be new to the team and/or to both trusts and only working one shift, it is unlikely that an account is set up immediately for them with the Hospital. In these exceptional circumstance, when the local induction takes place, they will be advised of the processes in place for them to speak with other permanent team members to access the City Hospital notes. They will review them prior to speaking with the patient and also update the records with their assessment after. Now that BSMHFT bank staff also have access to the”

Source location
Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Page 1 · response
Published 6 November 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
Generic logins for agency staff cannot be provided because they would lack traceability, accountability and lawful information processing.

Verbatim wording from the response
“Please be assured, we did explore all possible options including providing a generic log on for agency only staff who may be carrying out one shift. However from an information governance perspective it would not be possible to ascertain who had inputted the information and therefore there would be no traceability or accountability in place, if any problem arose. This is contra to the lawful processing of confidential information. Therefore the only option available was to strengthen the number of PLT staff who have access to the City Hospital records to address any concerns going forward and ensure smooth working.”

Source location
Response from Birmingham and Solihull Mental Health NHS Foundation Trust
Page 2 · response
Published 6 November 2023
Open published response
29 Sep2023
South Wales Central
Concerns raised1
1. Limited access to qualified mental health advice with relevant clinical records
This report raised 5 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Leighton Alan Dickens · 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

Leighton Alan Dickens died by incomplete atypical hanging alone at his home on 14 October 2020, after police encountered him undressed by the roadside while his partner was trying to take him to hospital. The report raised concerns that police did not detain him under section 136 of the Mental Health Act for assessment and that officers had limited access to qualified, clinically informed mental health advice and records when responding to community mental health crises.

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
Limited access to qualified mental health advice with relevant clinical records
Wider context from the report
“This leaves officers with limited sources of qualified mental health advice, with access to relevant clinical records, when responding to the risks posed by those suffering from mental health crisis within the community ”
Source location
Leighton Alan Dickens · Prevention of Future Deaths report
Page 3 · concerns
Open source report
25 Sep2023
Newcastle and North Tyneside
Concerns raised1
1. Lack of radiologist access to patients’ medical notes during imaging assessment
This report raised 4 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 1
1. Action
  Implement digital patient-record access by maintaining Radiology access to Clinica Portal and WebV and extending access to Symphony Paperlite and the new EPR.
  Stated by North Cumbria Integrated Care NHS Foundation TrustStated in progress
Respondent positions 1
1. Position
  Radiologists could not routinely leave the department to review referring-department records because operational pressures made this infeasible.
  Stated by North Cumbria Integrated Care NHS Foundation TrustUnable to act
AI-generated summary

Brian David MORETON · 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

Brian Moreton was admitted with diarrhoea, recurring fever and a distended abdomen; a toxic megacolon present on CT was not reported to those treating him. He was treated for severe colitis, later found to have a perforated bowel, and died from infections following surgery and immunosuppression. The principal concern was poor and misleading communication between clinicians, departments and hospital trusts, including deficiencies in the information provided to radiologists and assumptions about his clinical improvement and surgical referral.

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 radiologist access to patients’ medical notes during imaging assessment
Wider context from the report
“- Evidence was heard that at the time of the inquest radiologists do not have access to patient' medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’S case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient's condition is based on a telephone call referral followed by a summary document which can be at odds with each. - It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient's notes. - The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. - Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’S care was inaccurate and misleading. - Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. - It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. - Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was contemplated - this was not the case. - Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care. ”
Source location
Brian David MORETON · 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 digital patient-record access by maintaining Radiology access to Clinica Portal and WebV and extending access to Symphony Paperlite and the new EPR.

Verbatim wording from the response
“Whilst it would not be commonplace for Radiology staff to access records in the process of triage or whilst interpreting and reporting on imaging, the Trust recognises that in exceptional circumstances, it may be of benefit. Radiology staff have therefore already been granted access to the Clinica Portal, which is an EPR and contains primary care information and past medical history. Access has also been granted to WebV, which is an inpatient EPR and provides access to a patient’s pathology results, vitals/NEWS scoring and nursing assessments. The Trust is in the process of granting Radiology staff access to Symphony Paperlite, and access will also be granted to the new EPR once commissioned. A guideline needs to be produced on which records should be accessed in line with the Royal College of Radiologists.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 5 · response
Published 5 October 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
Radiologists could not routinely leave the department to review referring-department records because operational pressures made this infeasible.

Verbatim wording from the response
“The inquest heard that Radiologists triaging and reporting on Mr Moreton’s imaging on 02/03/2022 did not have access to the relevant records. The Trust has a number of Electronic Patient Records (EPR) across its services. Inpatient, outpatient and community care also utilise paper records. On attendance to the ED on 02/03/2022, Mr Moreton’s records would initially have been in paper format, and later scanned to the ED’s EPR, Symphony. Within the Trust, post-holders are only granted access to systems relevant to their role/service in line with the Trust’s information governance policies. Furthermore, Radiology Departments are not an outlier and it is not common practice nationally within the NHS for Radiology staff to independently obtain information to assist them in the justification and reporting of imaging; the process is reliant on the information provided by the referrer.”

Source location
Response from North Cumbria Integrated Care NHS Foundation Trust
Page 4 · response
Published 5 October 2023
Open published response
19 Sep2023
Avon
Concerns raised1
1. Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff
This report raised 1 other concern. 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 7
1. Action
  Work with North Bristol Trust to identify suitable alternatives to smartcard authentication.
  Stated by NHS EnglandStated in progress
2. Action
  Collaborate with North Bristol Trust to identify suitable options for accessing Summary Care Records.
  Stated by NHS EnglandStated completed
3. Action
  Implement the National Care Records Service to provide integration with local clinical systems and alternative authentication methods.
  Stated by NHS EnglandStated planned
1. Action
  Trial non-smartcard NCRS access with a pilot cohort.
  Stated by Bristol NHS Foundation TrustStated completed
2. Action
  Deploy non-smartcard NCRS access to all Trust staff after limited clinical deployment.
  Stated by Bristol NHS Foundation TrustStated planned
3. Action
  Develop in-context NCRS integration with Careflow through coordinated NHSE, NBT and System C work.
  Stated by Bristol NHS Foundation TrustStated in progress
4. Action
  Work with the ICB and Connecting Care team to provide clearer guidance when Connecting Care cannot display patient information.
  Stated by Bristol NHS Foundation TrustStated completed
Respondent positions 1
1. Position
  Smartcard use remains frequent, making Summary Care Record information visible to clinicians upon request.
  Stated by Bristol NHS Foundation TrustDisputes the concern
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
Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff
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
Work with North Bristol Trust to identify suitable alternatives to smartcard authentication.

Verbatim wording from the response
“Staff require a smartcard to authenticate to Spine services, it is however acknowledged that only a limited number of staff at NBT have and carry a smartcard. NHS England are working with NBT to identify suitable alternative solutions to the use of Smartcards.”

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
Collaborate with North Bristol Trust to identify suitable options for accessing Summary Care Records.

Verbatim wording from the response
“NHS England Summary Care Records team and digital safety experts within the National Patient Safety Team have worked collaboratively with North Bristol Trust to discuss and identify suitable options to access SCR.”

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
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
Trial non-smartcard NCRS access with a pilot cohort.

Verbatim wording from the response
“1. Non-smartcard-based access to NCRS (National Care Record Service): Following discussions with NHSE, NBT IT team have explored access to the new NCRS with existing authentication protocols without having to use Smartcards. This has already been trialled successfully for a pilot cohort, and after a planned limited clinical deployment we would be in a position to make access available to all Trust staff in the first quarter of 2024. This would allow staff to access the NCRS from any browser by using the Microsoft authenticator app and without having to use a Smartcard.”

Source location
Response from NHS North Bristol NHS Trust
Page 1 · 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
Deploy non-smartcard NCRS access to all Trust staff after limited clinical deployment.

Verbatim wording from the response
“1. Non-smartcard-based access to NCRS (National Care Record Service): Following discussions with NHSE, NBT IT team have explored access to the new NCRS with existing authentication protocols without having to use Smartcards. This has already been trialled successfully for a pilot cohort, and after a planned limited clinical deployment we would be in a position to make access available to all Trust staff in the first quarter of 2024. This would allow staff to access the NCRS from any browser by using the Microsoft authenticator app and without having to use a Smartcard.”

Source location
Response from NHS North Bristol NHS Trust
Page 1 · 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 action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Work with the ICB and Connecting Care team to provide clearer guidance when Connecting Care cannot display patient information.

Verbatim wording from the response
“4. We have worked closely with the ICB and the Connecting Care team, they have updated their system to provide clearer advice if Connecting Care is unable to reflect the information contained in the NCRS/SCR/EMIS to "Connecting Care cannot display information on this patient at this time. PLEASE access this information from the National Summary Care Record (NCRS) by accessing the NHS Spine Portal".”

Source location
Response from NHS North Bristol NHS Trust
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
Smartcard use remains frequent, making Summary Care Record information visible to clinicians upon request.

Verbatim wording from the response
“3. Smartcard use in NBT: The majority of NBT staff have active Smartcards even though they are not required for access to Careflow EPR. Following the issue of the Trust safety alert in April 2023 which encouraged staff to access the NCRS/SCR we requested NHSE to investigate access requests and they could confirm that the NCRS was accessed 3,810 times and SCR 2,787 times from NBT since 17th April 2023, with 473 access events for NCRS in the week of 23 October 2023. In the same week the SCR (which can only be accessed with a Smartcard) was accessed 356 times. NHSE were further able to confirm that in the 12 months leading up to October 2023 SCR was accessed from NBT using Smartcards on 30,247 occasions.”

Source location
Response from NHS North Bristol NHS Trust
Page 2 · response
Published 22 September 2023
Open published response
14 Sep2023
North Wales (East and Central)
Concerns raised1
1. Unavailability of electronic mental-health patient notes
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 3
1. Action
  Engage in regional and local-authority discussions to agree a preferred digital patient-records option for North Wales.
  Stated by Betsi Cadwaladr University LHBStated in progress
2. Action
  Develop a Health Board-wide Strategic Outline Case for electronic patient records addressing fragmented care records.
  Stated by Betsi Cadwaladr University LHBStated in progress
3. Action
  Work with the Chief Information Officer to consider options for a more timely MH&LD digital-records solution.
  Stated by Betsi Cadwaladr University LHBStated in progress
Respondent positions 1
1. Position
  National digital patient-record implementation depends on decisions about the national system made by Welsh Government.
  Stated by Betsi Cadwaladr University LHBRedirects responsibility
AI-generated summary

Richard Geraint Griffiths · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Richard Geraint Griffiths moved to the Conwy area in October 2022 to live with his mother, and the transfer of his care from the South Gwynedd Community Mental Health Team did not occur. He was found suspended on 26 March 2023 and was pronounced deceased at the location; the inquest concluded suicide. Concerns included deficiencies in the Health Board’s investigation, an unfinished transfer-of-care process, and delays in implementing electronic mental-health patient notes.

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 electronic mental-health patient notes
Wider context from the report
“c. Patient notes for mental health are still not electronic; they are paper based. I have issued several Prevention of Future Death Reports specifically relating to this. There has been considerable delay in actioning this and yet there is still not anticipated timescale for this to occur. As such, deaths will continue to occur or may occur into the future with the risk that notes are paper based only. The risk relates to only one department or individual having access to them at once when there is wider support for the patient. ”
Source location
Richard Geraint Griffiths · 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
Engage in regional and local-authority discussions to agree a preferred digital patient-records option for North Wales.

Verbatim wording from the response
“Regional meetings are now taking place across Wales to discuss the options that have been presented to them by WG as alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to discuss implications across health and social care services in order to come to an agreement on the preferred option for North Wales.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 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 a Health Board-wide Strategic Outline Case for electronic patient records addressing fragmented care records.

Verbatim wording from the response
“In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024. MH&LD are taking a key role in shaping the outline case to ensure that the Division’s needs are considered as part of the Health Board wide proposal.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 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
Work with the Chief Information Officer to consider options for a more timely MH&LD digital-records solution.

Verbatim wording from the response
“Whilst MH&LD are keen to support and progress the processes outlined above, we are mindful of the scale of the task for agreeing a national solution and are therefore working with BCUHBs Chief Information Officer to consider options which may bring MH&LD a more timely solution. This remains a major priority for the Division and is supported by the Health Board.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 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
National digital patient-record implementation depends on decisions about the national system made by Welsh Government.

Verbatim wording from the response
“Within the notice, you also raised your continued concerns about the implementation of digital patient records for MH&LD. In previous correspondence with you, the Health Board has reported significant delays with the development and implementation of a suitable system at a national level. I understand that you have raised your concerns about the delays with the Health Minister directly. We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected. This has significantly altered MH&LD divisional plans for digital transformation as these were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot having been due to start in September 2023, and the expectation that a wider adoption across all applicable MH&LD services would follow.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 2 · response
Published 18 September 2023
Open published response
8 Sep2023
North West Wales
Concerns raised1
1. Failure of paper-based medical records to provide all relevant care information to involved individuals and organisations
This report raised 4 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 3
1. Action
  Participate in regional and local-authority discussions to assess alternative digital patient-record options for North Wales.
  Stated by Betsi Cadwaladr University LHBStated in progress
2. Action
  Develop a Health Board strategic outline case for electronic patient records, incorporating MHLD requirements to address fragmented care records.
  Stated by Betsi Cadwaladr University LHBStated in progress
3. Action
  Work with the Chief Information Officer to consider options for a more timely MHLD digital-record solution.
  Stated by Betsi Cadwaladr University LHBStated in progress
Respondent positions 1
1. Position
  Implementation of the planned MHLD digital records system cannot proceed as expected because national arrangements changed following a Welsh Government decision.
  Stated by Betsi Cadwaladr University LHBUnable to act
AI-generated summary

Lynsey Sarah Smalley · 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

Lynsey Sarah Smalley, aged 42, set fire to her bed at home during an acute psychotic episode on 8 April 2021. She suffered inhalation injuries, was admitted to intensive care, and died at Ysbyty Gwynedd, Bangor on 16 May 2021. The substantive concerns were conflicting investigation reports, disjointed patient-safety and governance processes, delays in completing actions, and risks arising from paper-based medical records that may impede continuity of care.

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 paper-based medical records to provide all relevant care information to involved individuals and organisations
Wider context from the report
“b. A number of individuals and organisations are involved in the care of those under mental health teams or at times have contact with patients e.g. CMHT, Home Treatment Teams, Psychiatrists, Occupational therapists, Care Coordinators, out of hours crisis service (local authority based in Gwynedd), Police, Ambulance Service etc. As medical records remain paper based not all individuals or organisations who need to understand a patient’s circumstances/care/treatment are privy to all aspects of care/treatment. In addition, where a CMHT patient is receiving in-patient mental heath treatment the paper notes are transferred to the hospital setting. There is a risk that notes will become lost in full / in part. Having medical records electronically will not only allow full access to all notes to those who require which will inform future care/treatment but will also ensure effective continuity of care, without the risk of missing or lost notes. I have previously issued a Prevention of Future Deaths Report on this point, a copy of which was also sent to ████████, Health Minister. ”
Source location
Lynsey Sarah Smalley · Prevention of Future Deaths report
Page 3 · 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
Participate in regional and local-authority discussions to assess alternative digital patient-record options for North Wales.

Verbatim wording from the response
“Regional meetings are now taking place across Wales to discuss the options that have been presented to them by WG as alternative to WCCIS Care Direct Version 5. BCUHB has met with Local Authorities to discuss implications across health and social care services in order to come to an agreement on the preferred option for North Wales.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 14 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 a Health Board strategic outline case for electronic patient records, incorporating MHLD requirements to address fragmented care records.

Verbatim wording from the response
“In addition I am pleased to report that a Strategic Outline Case for an Electronic Patient Record system(s) is being developed on a Health Board wide level to address the issue of fragmented care records; the deadline for the strategic outline case is the end of January 2024. MHLD are taking a key role in shaping the outline case to ensure that the Division’s needs are considered as part of the Health Board wide proposal.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 14 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
Work with the Chief Information Officer to consider options for a more timely MHLD digital-record solution.

Verbatim wording from the response
“Whilst MHLD are keen to support and progress the processes outlined above, we are mindful of the scale of the task for agreeing a national solution and are therefore working with BCUHBs Chief Information Officer to consider options which may bring MHLD a more timely solution. This remains a major priority for the Division and is supported by the Health Board.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 14 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
Implementation of the planned MHLD digital records system cannot proceed as expected because national arrangements changed following a Welsh Government decision.

Verbatim wording from the response
“Within the notice, you also raised your continued concerns about the implementation of digital patient records for MHLD. In previous correspondence with you, the Health Board has reported significant delays with the development and implementation of a suitable system at a national level. I understand that you have raised your concerns about the delays with the Health Minister directly. We now know that following a decision made by WG the national system will not be progressing in the way that was previously expected. This has significantly altered MHLD divisional plans for digital transformation as these were dependent upon the use of the WCCIS Care Director Version 5 product, with a pilot having been due to start in September 2023, and the expectation that a wider adoption across all applicable MHLD services would follow.”

Source location
Response from Betsi Cadwaladr University Health Board
Page 3 · response
Published 14 September 2023
Open published response
2 Aug2023
West Yorkshire Eastern
Concerns raised1
1. Failure to make previous medical records available to clinicians in different geographical areas or Trusts
This report raised 4 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.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Dumile Daniel Thompson · 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

Dumile Daniel Thompson developed Ramipril-induced angioedema, deteriorated after an apparent initial improvement, suffered respiratory collapse causing catastrophic brain injury, and died several days later after life support was withdrawn. The principal concerns included inadequate recognition of the risks and trajectory of ACE inhibitor-induced angioedema, insufficient specialist airway reassessment and monitoring, lack of relevant guidance and training, and limited access to previous medical records affecting medication decisions.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to make previous medical records available to clinicians in different geographical areas or Trusts
Wider context from the report
“The evidence, including that of Independent experts in Immunology and Adult Critical Care and Anaesthetics, highlighted that: • National Guidance and training for front line/emergency staff did not, and still does not include specifics about the various types of angioedema (histamine/bradykinin mediated), the risk factors, and the diverging treatment pathways, including the need for specialty medicine input with certain types of angioedema. • NICE does not currently publish guidance or a clinical knowledge summary on emergency management of angioedema. • Those treating Mr Thompson on 23 October 2020 in the A&E department were therefore not aware of the complexity and fickle nature of ACE Induced angioedema, including the potential speed of deterioration in symptoms, even after what appeared to be initial improvement. • ACE Inhibitor angioedema is more common, up to four to five times more, in individuals of Black African or African Caribbean origin. This increased risk factor is not published in the BNF. • The NICE recommendation about using ARB as the preferred choice of medication in patients of Black African or African Caribbean origin is not highlighted in BNF, notwithstanding the BNF is the go-to source for medication management, contraindications, and cautions. It also came to light that Mr Thompson had transferred geographical areas such that clinicians were unable to access his previous medical records to determine why ARB’s, an alternative to ACE Inhibitors, had been preferred by clinicians on a previous occasion. His now treating clinicians were unable to access this information because such records are not readily available to, or shared with, clinicians in a different area/Trust. The reason for this is not entirely clear and was thought to be related to data protection though there is nothing to suggest Mr Thompson withheld his consent, or would have done so. ”
Source location
Dumile Daniel Thompson · Prevention of Future Deaths report
Page 2 · concerns
Open source report
8 Jun2023
North West Wales
Concerns raised1
1. Unavailability of all relevant notes electronically for fully informed treatment and care decisions
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 1
1. Action
  Continue Health Board engagement in WCCIS implementation, including reviewing functionality and supporting required development work.
  Stated by Betsi Cadwaladr University LHBStated in progress
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to ensure independent s.12 doctors have access to patients’ records for Mental Health Act assessments

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

Concerns raised1

Failure of the clinical record to present information as a continuous chronological running record

Concerns raised1

Lack of access to essential patient records before mental health liaison assessment and treatment

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Limited access to qualified mental health advice with relevant clinical records

Concerns raised1

Lack of radiologist access to patients’ medical notes during imaging assessment

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Lack of routine and easy access to patients’ Summary Care Records for SMH clinical staff

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.7

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Unavailability of electronic mental-health patient notes

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.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 2

Actions described in response 2

Respondent positions 1

Actions described in response 1

Respondent positions 1

Actions described in response 7

Respondent positions 1

Actions described in response 3

Respondent positions 1