Recurring concern

Unreliable access to relevant clinical records for safe care

Get email alerts

Request correction

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.

13 Jan2025
Birmingham and Solihull
Concerns raised1
1. Lack of access to all clinical records when planning treatment
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.
Actions described in response 1
1. Action
  Implement an electronic patient record providing staff with accessible medication details and individual patient risk factors.
  Stated by Birmingham Women'S and Children'S NHS Foundation TrustStated planned
AI-generated summary

Aarav Pal CHOPRA · 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

Aarav Pal CHOPRA died on 22 November 2023 after an intercostal artery was damaged during a liver biopsy, causing a haemothorax, cardiac arrest and hypoxic brain injury. The report identified concerns about inadequate planning and communication, delayed recognition and treatment of the haemothorax, unclear decision-making, trainee competence, consent, patient risk factors, prophylactic antibiotics, learning from deaths and access to complete electronic records.

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 all clinical records when planning treatment
Wider context from the report
“6. Electronic patient records: I heard evidence that the lack of electric medical records meant clinicians found it difficult to see all of the patient’s medication details. My concern is that critical information can be missed if clinicians do not have access to all the clinical records when planning treatment. ”
Source location
Aarav Pal CHOPRA · 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 an electronic patient record providing staff with accessible medication details and individual patient risk factors.

Verbatim wording from the response
“The importance of effective communication between colleagues will be reiterated across the workforce. In addition to this, the roll out of the Electronic Patient Record (EPR), which is due to go live in May 2025 will provide the ability to see at a glance individual patient risk factors.”

Source location
Response from Birmingham Women's and Children's NHS Foundation Trust
Page 2 · response
Published 13 January 2025
Open published response
16 Dec2024
Staffordshire and Stoke-on-Trent
Concerns raised1
1. Failure to access and act on MDT treatment decisions
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 2
1. Action
  Implement a new iPortal alert, populated by the multidisciplinary team, to notify clinicians that an ICD is required before discharge.
  Stated by University Hospitals of North Midlands NHS TrustStated planned
2. Action
  Introduce resident doctor induction teaching requiring clinicians to check the ICD decision before discharge.
  Stated by University Hospitals of North Midlands NHS TrustStated planned
AI-generated summary

Anne Patricia Leake · 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 Patricia Leake suffered cardiac arrest and arrhythmia, underwent heart valve surgery, and was released from hospital without the planned ICD being fitted. Three days later, she suffered a cardiac arrhythmia and died. The report identified concerns about hospital teams using inaccessible ward-based notes, the absence of a shared electronic records system, and continued reliance on manual transcription of treatment 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 access and act on MDT treatment decisions
Wider context from the report
“(1) Mrs Leake received treatment from three hospital teams: cardiology, cardiothoracic surgery and coronary intensive care. Each team uses their own ward-based medical notes which are not accessible by the other teams. Whilst each team has access to the iPortal system on which Mrs Leake’s MDT decision was stored, it was apparent that this was not accessed and acted upon. As a result, the MDT decision regarding Mrs Leake’s ICD was overlooked. (2) Plans to introduce electronic patient records to which all medical teams have access are still at an early stage and no date has been identified for moving over to a single electronic notes system. (3) The steps which the Trust has taken as a result of Mrs Leake’s death to address the risk of MDT decisions being missed in the future still rely upon the manual transcription of decisions from one set of medical notes to another, with the continuing potential for human error and important decisions about treatment being overlooked. ”
Source location
Anne Patricia Leake · 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 a new iPortal alert, populated by the multidisciplinary team, to notify clinicians that an ICD is required before discharge.

Verbatim wording from the response
“As an immediate action, the development of a new alert within iPortal will be implemented – this will be populated by the multidisciplinary team to inform clinicians that an ICD is required prior to discharge. The team are going to introduce teaching into the resident doctor induction to ensure this is checked prior to discharge.”

Source location
Response from University Hospitals of North Midlands NHS Trust
Page 2 · response
Published 27 December 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Introduce resident doctor induction teaching requiring clinicians to check the ICD decision before discharge.

Verbatim wording from the response
“As an immediate action, the development of a new alert within iPortal will be implemented – this will be populated by the multidisciplinary team to inform clinicians that an ICD is required prior to discharge. The team are going to introduce teaching into the resident doctor induction to ensure this is checked prior to discharge.”

Source location
Response from University Hospitals of North Midlands NHS Trust
Page 2 · response
Published 27 December 2024
Open published response
29 Oct2024
Cumbria
Concerns raised1
1. Lack of ambulance call-handler access to patients' medical records
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.
Respondent positions 2
1. Position
  NHS England will respond to concerns about sharing and accessing information from NHS 111 and patient records.
  Stated by Department of Health and Social CareRedirects responsibility
1. Position
  Health advisors are not expected to interpret comprehensive medical records; limited history questions and clinical escalation are considered safer and more effective.
  Stated by NHS EnglandExisting arrangements considered sufficient
AI-generated summary

Lee Armstrong · 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

Lee Armstrong became unwell on 30 January 2024 and, after an initial ambulance-service call, became increasingly unwell before a further call led to an ambulance attending. He suffered an Addisonian Crisis, cardiac arrest and severe brain injury, and died on 2 February 2024. Concerns included the failure of the NHS Pathways system to ask about existing medical conditions, the lack of sharing of information supplied through 111 online with ambulance call handlers, and call handlers' lack of access to relevant medical records.

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 ambulance call-handler access to patients' medical records
Wider context from the report
“(3) I note that NWAS call handlers are not provided with access to (even an abridged version) of a patient's medical records. I am concerned that this means that call handlers cannot see relevant details of medical history. ”
Source location
Lee Armstrong · Prevention of Future Deaths report
Page 3 · concerns
Open source report
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England will respond to concerns about sharing and accessing information from NHS 111 and patient records.

Verbatim wording from the response
“reduce unwarranted variation across services, helping ensure appropriate prioritisation, equity of access and uniformity of response across England. In the case of Mr Armstrong, I understand that his pre-existing condition of Addison’s disease would have changed his call categorisation, and that NHS England, as the appropriate body, will be responding to your concerns raised on this matter as well as on the issue of appropriate patient record sharing and access to information gained from NHS 111. However, I would note that interpreting full medical records is outside of the scope and expectations of call handlers.”

Source location
Response from DHSC
Page 2 · response
Published 1 November 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Health advisors are not expected to interpret comprehensive medical records; limited history questions and clinical escalation are considered safer and more effective.

Verbatim wording from the response
“Although comprehensive system training is provided, it is not within the scope or remit of the Health Advisor to understand or interpret the full range of medical elements as would be encountered in summary medical records, or from access to information on current medications. It is not safe or effective to expect this staff group to make sense of such information and it could add confusion or delays and cause harm if incorrect conclusions were drawn. It is for these reasons that questions on past medical history or pharmacology are only asked where it is deemed that a clear understanding can be sought and where it might make a difference to the outcome.”

Source location
Response from NHS England
Page 4 · response
Published 1 November 2024
Open published response
2 Oct2024
Staffordshire and Stoke-on-Trent
Concerns raised1
1. Failure of bank staff to access patient notes before 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 6
1. Action
  Support NHS and foundation trusts to acquire modern electronic patient record systems and improve their effectiveness after deployment.
  Stated by NHS EnglandStated in progress
2. Action
  Provide UHDB with a list of liaison bank and Crisis Home Treatment staff requiring patient-notes access.
  Stated by Midlands Partnership University NHS Foundation TrustStated completed
3. Action
  Work with other NHS trusts to maintain processes and safeguards that enable staff to access necessary patient records for safe care.
  Stated by Midlands Partnership University NHS Foundation TrustStated in progress
1. Action
  Reiterate to MPFT the available routes for obtaining emergency Meditech V6 access for bank staff.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated completed
2. Action
  Develop a written standard operating procedure with MPFT formalising emergency access arrangements for bank staff.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated in progress
3. Action
  Work with MPFT to arrange Meditech V6 access for current short-term Liaison Psychiatry bank staff who lack it.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustStated in progress
Respondent positions 2
1. Position
  Individual healthcare providers, not NHS England, determine bank staff access levels to electronic patient records under local policies and risk assessments.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Bank staff access risk is mitigated by working with an authorised colleague and using established emergency access processes when required.
  Stated by University Hospitals of Derby and Burton NHS Foundation TrustExisting arrangements considered sufficient
AI-generated summary

Alix Elizabeth Knowles · 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

Alix Elizabeth Knowles, aged 30, attended hospital on 8 December 2023 after attempting to cut her throat and threatening suicide, but was discharged home after a mental health assessment. In the early hours of 9 December 2023, she jumped from a bridge onto the road below and was hit by two motor vehicles. The substantive concerns were that bank staff could not access patient notes before assessments and that different NHS Trusts could not access one another’s patient notes because of incompatible computer systems.

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 bank staff to access patient notes before assessments
Wider context from the report
“1. Bank Staff are not able to access patient notes before assessments; ”
Source location
Alix Elizabeth Knowles · 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
Support NHS and foundation trusts to acquire modern electronic patient record systems and improve their effectiveness after deployment.

Verbatim wording from the response
“As a response to this, NHS England set up the Frontline Digitisation Programme (FLD) in 2021 and has been supporting NHS and Foundation Trusts in acquiring modern EPR systems and helping them develop their system’s effectiveness once deployed. The FLD programme comes with substantial financial and specialist IT support to bring all Trusts to an optimum level of digital maturity.”

Source location
Response from NHS England
Page 1 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide UHDB with a list of liaison bank and Crisis Home Treatment staff requiring patient-notes access.

Verbatim wording from the response
“Following this inquest, several meetings have taken place between MPFT and UHDB to consider the most efficient way for bank staff to obtain access to patient notes. As a result of these meetings, it has been agreed that a list of all liaison bank staff and Crisis Home Treatment staff have been provided to UHDB who will allow them access to their patient notes system V6. A joint Standard Operating Procedure for the ‘Referral Process to Liaison Psychiatry Team and Crisis Resolution and Home Treatment Team for patients 16 years old and over within the Emergency Department’ has also been developed to outline the referral process for all staff.”

Source location
Response from Midlands Partnership University NHS
Page 1 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with other NHS trusts to maintain processes and safeguards that enable staff to access necessary patient records for safe care.

Verbatim wording from the response
“2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this. While MPFT recognises this as an ongoing issue, we work closely with other trusts to ensure we have processes and safeguards in place to allow staff to access patient notes when required. We are unable to comment on the”

Source location
Response from Midlands Partnership University NHS
Page 1 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Reiterate to MPFT the available routes for obtaining emergency Meditech V6 access for bank staff.

Verbatim wording from the response
“If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.”

Source location
Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a written standard operating procedure with MPFT formalising emergency access arrangements for bank staff.

Verbatim wording from the response
“If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.”

Source location
Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with MPFT to arrange Meditech V6 access for current short-term Liaison Psychiatry bank staff who lack it.

Verbatim wording from the response
“We are also working together with MPFT to arrange access to Meditech V6 for any of their current short term bank staff in the Liaison Psychiatry team who do not already have access.”

Source location
Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Individual healthcare providers, not NHS England, determine bank staff access levels to electronic patient records under local policies and risk assessments.

Verbatim wording from the response
“The first concern raised in your Report was that bank staff are not able to access patient notes before assessments. Individual healthcare providers determine the access levels that different members of staff have to different parts of their electronic patient record systems. This decision will be in line with each Trust’s access policy and risk assessment, and is determined solely by individual healthcare providers. I note that you have also addressed your Report to Derby and Burton Hospital (Royal Derby Hospital) and Royal Stoke University Hospital and refer you to their responses on this matter.”

Source location
Response from NHS England
Page 1 · response
Published 4 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Bank staff access risk is mitigated by working with an authorised colleague and using established emergency access processes when required.

Verbatim wording from the response
“As was confirmed by MPFT in court, their substantive staff in Liaison Psychiatry do have access to Meditech V6 records at UHDB, and they have subsequently confirmed that long-term bank staff also have access to Meditech V6. The issue that arose in this case is that the individual MPFT bank nurse from the Liaison Psychiatry team did not have access to the Meditech V6 records as UHDB had not been notified of the need for access on this occasion and therefore UHDB were not aware of until after Miss Knowles' death. As we heard during the inquest hearing, MPFT explained that they mitigate the risk of bank staff not having access to Meditech V6 by always ensuring that they are on shift with a member of staff who does have access. The bank nurse confirmed in her evidence that the Meditech V6 notes were accessed by a colleague from MPFT Liaison Psychiatry team on the night in question.”

Source location
Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024
Open published response
11 Sep2024
Manchester South
Concerns raised1
1. Failure to store neurology notes in the patient record in an accessible location
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.

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

Nisren Abdul-Karim · 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

Nisren Abdul-Karim had underlying health conditions and developed hallucinations before being admitted to Wythenshawe Hospital, where she sustained a fractured hip in an unsupervised fall. She was transferred to Trafford General Hospital for rehabilitation, continued to deteriorate, and died there on 5 January 2024. The principal concern was that neurology notes recorded on patient pass were difficult to access and contained limited detail, resulting in disjointed neurology care and an unclear overview, particularly at sites without face-to-face neurology services.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to store neurology notes in the patient record in an accessible location
Wider context from the report
“The evidence before the inquest was that the neurology service based at Salford Royal Hospital provided a service across Greater Manchester. However the notes kept by the neurology team were not stored on the patient’s notes but recorded on patient pass. This meant accessing the notes required recognising that patient pass needed to be accessed. In addition the evidence was that the detail within the neurology notes on patient pass was very limited and meant that it was difficult to fully understand the neurology advice given or the contact that there had been with neurology. As a consequence delivery of neurology care was disjointed and meant there was no clear neurology overview held by neurology. This impacted on the care that could be provided to patients and the provision of advice to other clinicians. Illustrative of this one neurologist was unaware that it was one of their neurology colleagues had diagnosed a neuro degenerative disease. This is exacerbated in relation to sites such as Trafford Hospital where all contact with neurology is telephone or patient pass as there is no face to face neurology service. ”
Source location
Nisren Abdul-Karim · Prevention of Future Deaths report
Page 2 · concerns
Open source report
12 Aug2024
Manchester North
Concerns raised1
1. Lack of ability to access relevant parts of medical records
This report raised 13 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Circulate a reminder explaining how to access patients’ entire CareNotes records.
  Stated by Priory GroupStated completed
2. Action
  Add a prompt to select the CareNotes ‘Entire Record’ tab to the admission checklist.
  Stated by Priory GroupStated planned
Respondent positions 1
1. Position
  Sharing correspondence with the patient's GP is considered sufficient because the GP remains the central coordinator and other services can request information through it.
  Stated by Priory GroupExisting arrangements considered sufficient
AI-generated summary

Mr David 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

Mr David Thompson had a longstanding affective disorder and a history of alcohol and illicit drug use. After receiving inpatient and outpatient mental health care, he consumed alcohol and inflicted deep cuts to his wrists; he died on 3 March 2024 from hypovolaemic shock caused by the wrist injuries. Concerns included gaps in discharge planning and follow-up at Priory Dorking, incomplete awareness of his care and relapse history at Priory Altrincham, and a lack of communication between NHS and private consultants.

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 ability to access relevant parts of medical records
Wider context from the report
“1. On the outpatient appointment in January 2024 the fact that Mr Thompson had been an inpatient in the Priory in Dorking following his discharge from the Priory Altrincham was not known. There was a lack of awareness as to how to access certain parts of the medical records which would have shown this information. Mr Thompson did not volunteer this information so there was no discussion with him as to why he had relapsed so quickly. ”
Source location
Mr David Thompson · 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
Circulate a reminder explaining how to access patients’ entire CareNotes records.

Verbatim wording from the response
“This concern was addressed in the action plan that was imbedded within the TIR report and this was shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on CareNotes (Priory’s electronic patient records platform), the system defaults to show only active documents. This is intended to ensure only records relevant to the current episode of care are present. To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A reminder of the presence of this function has since been circulated to all Priory colleagues and a prompt to select ‘entire record’ will be added to the admission checklist.”

Source location
Response from Priory Group
Page 3 · response
Published 12 August 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Add a prompt to select the CareNotes ‘Entire Record’ tab to the admission checklist.

Verbatim wording from the response
“This concern was addressed in the action plan that was imbedded within the TIR report and this was shared with the court ahead of the inquest. For this reason, we did not expect this to be a matter of concern listed in the Regulation 28 report. To summarise, when any user opens a patient’s record on CareNotes (Priory’s electronic patient records platform), the system defaults to show only active documents. This is intended to ensure only records relevant to the current episode of care are present. To view records relating to any previous episodes of care, an ‘Entire Record’ tab is to be selected. A reminder of the presence of this function has since been circulated to all Priory colleagues and a prompt to select ‘entire record’ will be added to the admission checklist.”

Source location
Response from Priory Group
Page 3 · response
Published 12 August 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Sharing correspondence with the patient's GP is considered sufficient because the GP remains the central coordinator and other services can request information through it.

Verbatim wording from the response
“It is important to mention that whilst Priory have made advances to the systems and process in place to gather these details and encourage our multi-disciplinary teams to facilitate such contact (with patient consent), all correspondence relating to a patient’s admission, discharge and outpatient care is shared with a patient’s GP (with patient consent). The patient’s GP remains the central coordinator of a patient’s care. Other care services involved in a patient’s care and treatment can request access to this information via the GP. Should an external service (whether private or NHS) seek additional detail to the information held by the GP, Priory clinicians will make themselves available, at short notice if required, to engage in discussions about a patient’s care and treatment.”

Source location
Response from Priory Group
Page 4 · response
Published 12 August 2024
Open published response
25 Jun2024
South Wales Central
Concerns raised3
1. Failure to provide mental health practitioners with easy access to all relevant clinical records
2. Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records
3. Failure to ensure mental health practitioners are aware of all relevant clinical records
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Develop the business case for introducing and deploying mental health systems across NHS Wales.
  Stated by Welsh GovernmentStated in progress
2. Action
  Work with Cwm Taf Morgannwg University Health Board to accelerate implementation of electronic mental health patient records.
  Stated by Welsh GovernmentStated in progress
3. Action
  Prioritise and plan implementation of a national integrated mental-health records solution through workshops and related planning exercises.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
1. Action
  Develop a contingency business case with implementation timescales and deployment plans for procuring a mental-health information solution.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
2. Action
  Continue working with the national Connecting Care programme to deliver an integrated mental-health information solution as a priority.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated in progress
3. Action
  Implement and disseminate the Clinical Information Access and Recording Matrix and accompanying procedure across mental-health and learning-disability services.
  Stated by Cwm Taf Morgannwg University Local Health BoardStated completed
AI-generated summary

Isobel Lilian Stapleton · 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

Isobel Lilian Stapleton, aged 32, was admitted to hospital for assessment and discharged to her father’s home with home treatment support. On 9 July 2022, she sustained likely self-inflicted injuries at home and died despite paramedic attendance; the inquest concluded that she died from suicide. Concerns included limited access to complete clinical records and a lack of clinical psychologist access for inpatient and home treatment teams, with psychotherapy waiting lists lasting months.

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 provide mental health practitioners with easy access to all relevant clinical records
Wider context from the report
“(1) Mental health practitioners are not easily able to access all of a patient's relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation. ”
Source location
Isobel Lilian Stapleton · Prevention of Future Deaths report
Page 2 · concerns
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
Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records
Wider context from the report
“(3) Mental health practitioners in Wales currently have no way easily to access NHS England clinical records. ”
Source location
Isobel Lilian Stapleton · Prevention of Future Deaths report
Page 3 · concerns
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
Failure to ensure mental health practitioners are aware of all relevant clinical records
Wider context from the report
“(2) Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper. ”
Source location
Isobel Lilian Stapleton · 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
Develop the business case for introducing and deploying mental health systems across NHS Wales.

Verbatim wording from the response
“In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This work will improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.”

Source location
Response from Welsh Government
Page 1 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Work with Cwm Taf Morgannwg University Health Board to accelerate implementation of electronic mental health patient records.

Verbatim wording from the response
“In relation to the first three matters of concern in your report, I wish to highlight that a business case is being developed by Digital Health and Care Wales for the introduction and deployment of mental health systems across health boards in NHS Wales. Once a timetable for deployment has been agreed, this will be communicated. However, it is anticipated that this will be a phased approach over a number of years. This work will improve digital and data service provision in mental health. It will be based on the principle of parity with physical health and will deliver on key areas including electronic records, data sharing, use of digital across services, and improved mental health data. Officials are working with Cwm Taf Morgannwg University Health Board to accelerate the implementation of electronic patient records for mental health, ahead of the all-Wales system.”

Source location
Response from Welsh Government
Page 1 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Prioritise and plan implementation of a national integrated mental-health records solution through workshops and related planning exercises.

Verbatim wording from the response
“I can report that the Health Board had approved prioritisation of the implementation of the national Care Director solution under the Welsh Community Care Information System (WCCIS) programme. As a result, throughout Spring and Summer 2023 the Health Board commenced a series of workshops and planning exercises, supported by local authority colleagues and the national team within Digital Health Care Wales (DHCW). However, during this time, significant operational issues with the Care Director system identified by an early implementing neighbouring Health Board raised questions about future implementation. In addition, we noted that Care Director as a national solution will be withdrawn in January 2026, so all organisations are reviewing”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 2 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop a contingency business case with implementation timescales and deployment plans for procuring a mental-health information solution.

Verbatim wording from the response
“As a contingency measure we are also working with colleagues in another Health Board to accelerate the procurement and implementation of a Mental Health solution should the Connecting Care business case not be approved in the near future. CTMUHB are working on a business case for this which will include timescales and deployments plans, it is expected that we will be ready to procure in the Autumn of 2024.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue working with the national Connecting Care programme to deliver an integrated mental-health information solution as a priority.

Verbatim wording from the response
“The Health Board has continued to work with the National programme for Connecting Care, with an aim to deliver a fully integrated Mental Health solution as a priority. A Business Case was due to be submitted at the end of July 2024 for an alternative national solution but at the time of writing this response it has not been received by Welsh Government.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement and disseminate the Clinical Information Access and Recording Matrix and accompanying procedure across mental-health and learning-disability services.

Verbatim wording from the response
“As a mitigation for the multiple record system that are still in place across the Mental Health and Learning Disability (MHLD) Care Group the Health Board developed a Clinical Information Access and Recording Matrix (CIARM) in August 2023 for clinical team/staff access for all systems across the MHLD Care Group. This informs all clinical staff of how to access patient clinical risk and discharge planning information both in and out of hours and is the primary tool by which the MHLD Care Group mitigates the potential risks inherent with our present multiple systems.”

Source location
Response from Cwm Taf Morgannwg University Health Board
Page 3 · response
Published 27 June 2024
Open published response
24 Jun2024
Northamptonshire
Concerns raised1
1. Failure to provide EOC mental health professionals with access to relevant community mental health records
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
  Explore how to share complete patient records, including mental health data, with EMAS throughout the patient journey.
  Stated by East Midlands Ambulance Service NHS Trust and NHS Northamptonshire Integrated Care BoardStated in progress
2. Action
  Review whether accessing mental health records through SystmOne is the appropriate approach, considering clinician and patient-care implications.
  Stated by East Midlands Ambulance Service NHS Trust and NHS Northamptonshire Integrated Care BoardStated completed
Respondent positions 2
1. Position
  Accessing regional mental health records was not pursued further because system complexity, clinical risks, licensing, access and training created time and resource constraints.
  Stated by East Midlands Ambulance Service NHS Trust and NHS Northamptonshire Integrated Care BoardUnable to act
1. Position
  Existing NHFT response work and 24/7 mental health clinicians in the emergency operations centre should mitigate risks while a regional records-access solution is explored.
  Stated by East Midlands Ambulance Service NHS Trust and NHS Northamptonshire Integrated Care BoardExisting arrangements considered sufficient
AI-generated summary

Liam Paul McCarlie · Prevention of Future Deaths report

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

Report summary

Liam Paul McCarlie died by suicide after being found suspended by a ligature on 1 April 2023; death was confirmed shortly after midnight on 2 April 2023. The inquest identified a significant delay in ambulance attendance, which contributed to his death, and an insufficiently clear mental-health support plan while he awaited assessment for the Structured Clinical Management programme. A further concern was that mental-health professionals in the ambulance service’s emergency operations centre did not have access to relevant community mental-health records.

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 provide EOC mental health professionals with access to relevant community mental health records
Wider context from the report
“I was told that there was no technical reason why EMAS staff (especially the mental health nurse located in the EOS) could not access a patient’s mental health records if held on SystmOne. There are such technical reasons why EMAS staff do not have access to RiO (an entirely different database). A data sharing agreement is likely to be needed as may a particular patient’s consent. I am concerned that notwithstanding the recognition of the desirability for specialist mental health input, those mental health professionals within the EOC do not presently have access to records which may have been produced by the community mental health team. That is notwithstanding that the principal database used by the provider of community mental health treatment in Northamptonshire (the Northamptonshire Healthcare NHS Foundation Trust) is one to which EMAS does presently have access. Such information may be relevant to, for example, whether the patient has a history of suicidal ideation or attempts. That information may in turn be material to the triage and dispatch of ambulance resources. ”
Source location
Liam Paul McCarlie · 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
Explore how to share complete patient records, including mental health data, with EMAS throughout the patient journey.

Verbatim wording from the response
“The ICB has been working closely with EMAS and NHFT to explore how best to share the entire patient record, including mental health data, with the ambulance service at every stage of the patient journey from initial call to attendance on-scene.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review whether accessing mental health records through SystmOne is the appropriate approach, considering clinician and patient-care implications.

Verbatim wording from the response
“In July 2024 the National Ambulance Mental Health Group met, where it was identified that there would be varying risks in relation to regional providers undertaking a multi system approach. This was escalated to the National Ambulance Service Medical Directors Group as an area of concern. In the interim, whilst it has been explored and discussed, the possibility of access to mental health records via SystmOne for EMAS, the implications on the clinicians within EOC and the potential impact on patient care have led us to review whether this is the correct direction of travel. We are keen to implement a regional response to accessing mental health records within EOC to ensure consistency across the East Midlands. In the meantime, the response work from NHFT and the 24/7 mental health clinicians within EOC should mitigate against any risk in relation to correct response.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Accessing regional mental health records was not pursued further because system complexity, clinical risks, licensing, access and training created time and resource constraints.

Verbatim wording from the response
“EMAS have in the past attempted to deploy access to mental health records via other regional mental health Trusts who work off varying systems. This has proved complex with challenges identifying which systems to access dependent on the patient’s location within the region, and highlighted risks relating to multi system use within the Emergency Operations Centre (EOC). This has also proved challenging to enact in terms of time and resource to undertake licensing agreements, access, and training. As a result, access to these systems was not pursued further. EMAS are committed to working with the ICB and NHFT to identify the correct solution at pace, notwithstanding National work being undertaken in relation to alignment of systems that can be accessed by all.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing NHFT response work and 24/7 mental health clinicians in the emergency operations centre should mitigate risks while a regional records-access solution is explored.

Verbatim wording from the response
“In July 2024 the National Ambulance Mental Health Group met, where it was identified that there would be varying risks in relation to regional providers undertaking a multi system approach. This was escalated to the National Ambulance Service Medical Directors Group as an area of concern. In the interim, whilst it has been explored and discussed, the possibility of access to mental health records via SystmOne for EMAS, the implications on the clinicians within EOC and the potential impact on patient care have led us to review whether this is the correct direction of travel. We are keen to implement a regional response to accessing mental health records within EOC to ensure consistency across the East Midlands. In the meantime, the response work from NHFT and the 24/7 mental health clinicians within EOC should mitigate against any risk in relation to correct response.”

Source location
Joint Response from EMAS and Northamptonshire ICB
Page 2 · response
Published 27 June 2024
Open published response
24 Apr2024
Swansea and Neath Port Talbot
Concerns raised1
1. Unavailability of relevant medical records to s.12 doctors before MHA 83 assessments
This report raised 6 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 2
1. Action
  Continue working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.
  Stated by Swansea CouncilStated in progress
2. Action
  Provide all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.
  Stated by Swansea Bay University Local Health BoardStated planned
Respondent positions 3
1. Position
  Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.
  Stated by Swansea CouncilOutside remit
1. Position
  SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.
  Stated by Swansea CouncilRedirects responsibility
2. Position
  Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.
  Stated by Welsh GovernmentRedirects responsibility
AI-generated summary

Nicholas Kim Harrison · 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 Kim Harrison died on 9 April 2022 from injuries sustained when he was seriously assaulted by his son at the family home on 12 March 2022. The report identifies concerns about failures in mental health assessment, information-sharing, community engagement, patient risk assessment, Ward F security and staff training, and the scope and timeliness of investigations and complaints handling.

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 relevant medical records to s.12 doctors before MHA 83 assessments
Wider context from the report
“It is a mandatory requirement of the MHACOP Wales that a medical examination by a doctor of a patient in a formal assessment under the MHA 83 where they are considering admission to hospital must involve consideration by that doctor of all available relevant clinical information. I heard evidence in the inquest that doctors approved under s.12 MHA 83, and used by SBUHB to conduct assessments under the MHA 83, only have access to a patient’s medical records if they are employed by SBUHB. I heard that SBUHB rely heavily on s.12 doctors who are not directly employed by them and / or are locum doctors. I also heard that there is no system within SBUHB to ensure s.12 doctors are required to record the outcome of their assessment when there is a decision not to admit a patient to hospital. I heard evidence that there is no single digital record system / platform for Mental Health Services and associated access for practitioners across Wales. I am concerned that there is a system in place (or a lack of a system) in SBUHB and more widely across the NHS in Wales which is placing s.12 doctors at risk of acting contrary to the MHACOP Wales where they are unable to view a patient’s medical records prior to an assessment under the MHA 83. I am concerned that this creates a risk that assessments may be flawed and / or may not detect that a person requires admission to hospital in circumstances where that patient may pose a risk to their own life and / or to the lives of others and that this creates a risk that other deaths will occur. In addition, if a s.12 doctor is unable to record their assessment in a patient’s medical records there is a risk that important information may not be documented which may be relevant to an understanding of the risk a patient may pose to themselves or others thus creating a risk that other deaths will occur. ”
Source location
Nicholas Kim Harrison · Prevention of Future Deaths report
Page 4 · 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 working with the Health Board through joint forums to secure appropriate WCCIS access for mental-health professionals requiring it.

Verbatim wording from the response
“The Council will continue to work with SBUHB via the various forums referred to above in order to ensure, as far as is reasonably possible, that the appropriate mental health professionals, deemed by SBUHB as requiring WCCIS access, is granted such access. Discussions have already taken place between SBUHB and the Council with the view to arranging for all patient clinical notes to be available across the relevant systems accessed by both organisations.”

Source location
Response from City and County of Swansea
Page 6 · response
Published 9 May 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Provide all SBUHB-employed Section 12 doctors with read access to WCCIS for Mental Health Act assessments.

Verbatim wording from the response
“Regarding access to WCCIS for MHA Assessments, all S12 Drs employed by SBUHB will be given read access to WCCIS to enable them to access information pertaining to the patient being assessed under the MHA 83. AMHPs also have full access to WCCIS. Both organisations (SBUHB/CCOS) committed to reminding both the AMHP and the S12 Drs to discuss patient history and any collateral information prior to the assessment taking place who recognise the importance of an all Wales digital solution. The Health Board, in the letter sent on 3rd April 2024, (referenced on page of this letter) covered this important area.”

Source location
Response from Swansea Bay University Health Board 2
Page 4 · response
Published 9 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Some matters raised in the report fall outside the Council’s remit, so it will not respond to them.

Verbatim wording from the response
“It is not within the Council's remit to respond to all of the matters of concern set out by His Majesty's Coroner in the Report, and it is appropriate that the Council responds to the first and second matters of concern. I shall address each in turn:”

Source location
Response from City and County of Swansea
Page 1 · response
Published 9 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
SBUHB and NHS Wales must primarily address concerns about Section 12 doctors’ records access and assessment recording.

Verbatim wording from the response
“This is a matter of concern for SBUHB and NHS Wales to primarily address, but the Council wishes to comment specifically in relation to access to its systems by Section 12 doctors.”

Source location
Response from City and County of Swansea
Page 5 · response
Published 9 May 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Operational responses to the concerns are assigned to the health board and local authority, while Welsh Ministers set the policy and strategic framework.

Verbatim wording from the response
“I note the report has been sent to the UHB and the City and County of Swansea for a response and action and I expect them to provide responses within your timescale that address the concerns raised. I am issuing a separate Welsh Government response to ensure lines of accountability are clear. I take the concerns raised in the report very seriously and I would like to set out the actions being taken.”

Source location
Response from Welsh Government
Page 1 · response
Published 9 May 2024
Open published response
8 Jan2024
Suffolk
Concerns raised1
1. Lack of accident and emergency staff access to medication records and dispensing rationale
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 3
1. Action
  Continue transferring users from the legacy Summary Care Record application to the National Care Records Service to improve access to national patient information.
  Stated by NHS EnglandStated in progress
2. Action
  Add a Summary Care Record sentence limiting controlled medication following an overdose diagnosis to no more than a 48-hour supply.
  Stated by Rosedale SurgeryStated planned
3. Action
  Procure a shared electronic patient-record system across the three acute trusts.
  Stated by James Paget University Hospitals NHS Foundation TrustStated in progress
Respondent positions 4
1. Position
  Norfolk and Waveney Integrated Care Board is responsible for delivering local Shared Care Records relevant to local information sharing.
  Stated by NHS EnglandRedirects responsibility
1. Position
  The Trust’s investigative action and prescribing policy are considered to address concerns about A&E access to medication records.
  Stated by Department of Health and Social CareExisting arrangements considered sufficient
2. Position
  NHS England is responsible for delivering health services and considering further responses concerning access to medical records.
  Stated by Department of Health and Social CareRedirects responsibility
3. Position
  The Trust disputes that emergency department staff lacked access to relevant medical records, stating that staff could access Summary Care Record and SystmOne.
  Stated by James Paget University Hospitals NHS Foundation TrustDisputes the concern
AI-generated summary

Sarah Julie MITCHELL · 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

Sarah Julie MITCHELL, who had a history of chronic back pain, medication dependence, and previous overdoses, was found deceased at her residence on 22 September 2022. The post-mortem found multiple drug toxicity from prescribed medication. The principal concerns were that she received 28 days’ worth of medication in less than 48 hours despite known overdose and hoarding risks, and that emergency department staff had no process for accessing relevant medication records and dispensing information.

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 accident and emergency staff access to medication records and dispensing rationale
Wider context from the report
“The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk. The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place. ”
Source location
Sarah Julie MITCHELL · 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 transferring users from the legacy Summary Care Record application to the National Care Records Service to improve access to national patient information.

Verbatim wording from the response
“For background, it is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work was accelerated during 2023 and is projected to conclude during Q2 2024. NCRS is the successor to SCRa and by design removes a large amount of the reported barriers to adoption within many care settings. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, it is free to use and includes additional features and services beyond the legacy SCRa product.”

Source location
Response from NHS England
Page 2 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Add a Summary Care Record sentence limiting controlled medication following an overdose diagnosis to no more than a 48-hour supply.

Verbatim wording from the response
“From now on when a diagnosis of an overdose gets recorded we will add a sentence to give no more controlled medication than is needed for 48 hours, so they can contact the surgery again for a further supply after. This should be visible on the summary care record that the hospital is looking at.”

Source location
Response from Rosedale Surgery
Page 1 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Procure a shared electronic patient-record system across the three acute trusts.

Verbatim wording from the response
“Next Steps You may be aware that the Norfolk and Waveney Acute Hospital Collaborative are in the process of procuring an Electronic Patient Record system for use across the three acute Trusts. This will remove the need for separate systems, including EPMA and e-Discharge and will eliminate the issues of data transfer between systems.”

Source location
Response from James Paget University Hospitals NHS Foundation Trust
Page 3 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Norfolk and Waveney Integrated Care Board is responsible for delivering local Shared Care Records relevant to local information sharing.

Verbatim wording from the response
“Healthcare organisations use a combination of locally / regionally provided and nationally provided information sharing systems to support patient care. A contribution from the Shared Care Records programme would be helpful in this case to understand what information is provided in the area where the deceased received care through any local Shared Care Record or other local sharing agreements. You may wish to refer to Norfolk and Waveney Integrated Care Board (ICB) on this matter as ICBs are responsible for the delivery of Shared Care Records. This response focuses on nationally provided services.”

Source location
Response from NHS England
Page 1 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust’s investigative action and prescribing policy are considered to address concerns about A&E access to medication records.

Verbatim wording from the response
“In preparing this response, Departmental officials have made enquiries with NHS England. As I understand, the James Paget University Hospitals NHS Trust (the Trust) has provided a response which gives an update on the investigative action undertaken and assurance around the Trust’s prescribing policy. I trust their response addresses your specific concern around access to medical records for A&E staff.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England is responsible for delivering health services and considering further responses concerning access to medical records.

Verbatim wording from the response
“Following this, I am aware that ████████ in his capacity as Medical Director of NHS England too has provided a response. NHS England has provisioned a programme of work to transition records from the existing system to the new National Care Records Service (NCRS) service, which I note, by design will remove a large amount of the reported barriers to adoption within many care settings. NHS England is operationally responsible for delivering health services across the country and will carefully consider further responses provided by the Trust. I hope that as an executive non-departmental public body, sponsored by the Department of Health and Social Care, the response provided by NHS England has addressed your concern.”

Source location
Response from Department of Health and Social Care
Page 1 · response
Published 19 January 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The Trust disputes that emergency department staff lacked access to relevant medical records, stating that staff could access Summary Care Record and SystmOne.

Verbatim wording from the response
“Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medication, allergies and details of any previous adverse reactions to medicines, created from the GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.”

Source location
Response from James Paget University Hospitals NHS Foundation Trust
Page 2 · response
Published 19 January 2024
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Lack of access to all clinical records when planning 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.1

Concerns raised1

Failure to access and act on MDT treatment decisions

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

Lack of ambulance call-handler access to patients' medical records

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure of bank staff to access patient notes before 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.6

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Failure to store neurology notes in the patient record in an accessible location

Concerns raised1

Lack of ability to access relevant parts of medical records

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 raised3

Failure to provide mental health practitioners with easy access to all relevant clinical records

Unavailability of easy access for Welsh mental health practitioners to NHS England clinical records

Failure to ensure mental health practitioners are aware of all relevant clinical records

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.6

Actions described in response 1

Actions described in response 2

Respondent positions 2

Actions described in response 6

Respondent positions 2

Actions described in response 2

Respondent positions 1

Actions described in response 6