22 Oct 2021 Anthony John Larcher · Prevention of Future Deaths report Dorset
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Concerns raised 1
Failure of SystmOne to make vital prison healthcare information readily identifiable View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS England
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
NHS England
Maintain prison-specific SystmOne templates and prescribing modules adapted for secure healthcare settings.
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NHS England
Provide prison sites access to integrated summary care records containing significant health information, medication and allergy details.
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NHS England
Develop SystmOne links to PNOMIS and enable community-record access through GP2GP electronic transfer.
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NHS England
Consider the concern when developing capabilities for the HJIS re-procurement.
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NHS England
Adopt GP2GP to enable electronic transfer of patient records into HJIS when patients enter the detained estate.
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NHS England
Adopt the Primary Care Registration Management system for HMPPS healthcare when delivered.
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NHS England
Support the HJIS transformation programme rolling out new Spine functionality across detained-estate sites.
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AI-generated summary
Anthony John Larcher · 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
On 21 March 2018, Anthony John Larcher, a serving prisoner at HMP Guys Marsh, was found in his cell. The report identifies concerns about monitoring prisoners under the influence of psychoactive substances, the lack of round-the-clock healthcare, healthcare involvement in ACCT reviews, the accessibility of medical information, and the reception of prisoners arriving in large cohorts.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of SystmOne to make vital prison healthcare information readily identifiable
Wider context from the report “iv. I am concerned that vital information contained within a prisoner’s medical health records stored on SystmOne, could be missed due to fact the software is more adapted to GP practice than prison healthcare . This could result in a future death and I request consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable and highlighted to avoid crucial information regarding a patient’s care and safety being missed.
” Source location Anthony John Larcher · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain prison-specific SystmOne templates and prescribing modules adapted for secure healthcare settings.
Verbatim wording from the response “4. Consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable (sic) and highlighted to avoid crucial information regarding a patient’s care and safety being missed.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide prison sites access to integrated summary care records containing significant health information, medication and allergy details.
Verbatim wording from the response “All sites have access to the integrated summary care record which houses the latest information regarding a patient’s significant health such as Diabetes, Mental health, for instance, along with regular medication and allergies. This is the same functionality available to other clinicians outside which can be accessed to verify the patient’s condition at that time.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop SystmOne links to PNOMIS and enable community-record access through GP2GP electronic transfer.
Verbatim wording from the response “Further improvements are planned over the next year to include the ability to link with PNOMIS and the capacity to access community records through GP2GP electronic transfer and, from 2022 should a patient wish to register with the detained estate as their GP practice the full medical record will be sent to the prison via GP2GP.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Consider the concern when developing capabilities for the HJIS re-procurement.
Verbatim wording from the response “7) As part of supporting the re-procurement NHS Digital will consider this matter of concern when developing of the set of capabilities for the HJIS re-procurement, and additionally would welcome the opportunity to speak to the witness that made the observations about SystmOne in order to gather more detailed input.” Source location 2021-0356-Response-from-NHS-Digital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt GP2GP to enable electronic transfer of patient records into HJIS when patients enter the detained estate.
Verbatim wording from the response “8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care:” Source location 2021-0356-Response-from-NHS-Digital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt the Primary Care Registration Management system for HMPPS healthcare when delivered.
Verbatim wording from the response “8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care:” Source location 2021-0356-Response-from-NHS-Digital_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Support the HJIS transformation programme rolling out new Spine functionality across detained-estate sites.
Verbatim wording from the response “8) Additionally, NHS Digital is currently supporting HJIS in the following related ways, and considers that these activities will also support improved access to a patient’s medical records within the HMPPS estate and between this and wider primary care:” Source location 2021-0356-Response-from-NHS-Digital_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The bespoke prison SystmOne module, templates and integrated summary care record are considered adequate existing adaptations for accessing and highlighting relevant patient information.
Verbatim wording from the response “4. Consideration is given to adapting SystmOne for better use in prisons to ensure information, especially where there are complex care needs, is easily assessable (sic) and highlighted to avoid crucial information regarding a patient’s care and safety being missed.” Source location 2021-0356-Response-from-NHS-England-and-NHS-Improvement_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Healthcare matters in the prison estate are commissioned by NHS England and Improvement, which has already provided a response.
Verbatim wording from the response “NHS England and NHS Improvement (NHSEI) is responsible for the commissioning of healthcare for the prison estate. I am aware that NHSEI has provided a response to you on the matters of concern in your report relating to healthcare. I will not repeat the detail of that response. However, I offer the following comments.” Source location 2021-0356-Response-from-Department-of-Health-Social-Care_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Matters of concern i, ii, iii and v do not relate to NHS Digital, so it has no comment on them.
Verbatim wording from the response “We do not consider that matters of concern i, ii, iii or v relate to NHS Digital and thus have no comment on these.” Source location 2021-0356-Response-from-NHS-Digital_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHSEI sets HJIS policy and holds the bespoke HJIS contract, rather than NHS Digital.
Verbatim wording from the response “1) The IT system used in HM Prison and Probation Service (HMPPS) healthcare settings is known as the health and justice information service (HJIS). HJIS is provided by an independent private sector IT supplier called TPP (tpp-uk.com) pursuant to a contract with NHS England and Improvement (NHSEI). HJIS is a modified version of TPP’s SystmOne product.” Source location 2021-0356-Response-from-NHS-Digital_Published
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation NHS Digital is unable to comment further on HJIS design and functionality under the current contractual arrangements.
Verbatim wording from the response “5) Therefore, NHS Digital is unable to comment further on the current design and functionality for HJIS.” Source location 2021-0356-Response-from-NHS-Digital_Published
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2 Jul 2021 Brooke MARTIN · Prevention of Future Deaths report Milton Keynes
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Concerns raised 1
Failure of healthcare information systems to provide providers with access to complete patient records View source
Linked response
Department of Health and Social Care
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AI-generated summary
Brooke MARTIN · 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
Brooke Martin was detained under the Mental Health Act at Isla House, where she was found hanging in her room on 11 June 2019 after earlier ligature-related incidents and concerns about observation and risk assessment. She died at Milton Keynes University Hospital. A principal concern was that incompatible NHS record systems prevented healthcare providers from accessing complete patient records, including information from an out-of-area hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of healthcare information systems to provide providers with access to complete patient records
Wider context from the report “During the course of the evidence it was explained to me that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient .
This situation should be reviewed to see how access across the NHS can be gained to patient records when required. I was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history . This would not be the case if he had direct access to the records.
” Source location Brooke MARTIN · Prevention of Future Deaths report
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The receiving provider was given comprehensive referral information, which it considered sufficient to proceed with admission.
Verbatim wording from the response “In preparing this response, my officials made enquiries with NHS England and NHS Improvement and its South East region. I am advised that as part of the referral process, comprehensive information relating to Miss Martin was shared by the Surrey and Borders Partnership NHS Foundation Trust, which Elysium Healthcare considered sufficient to proceed with Miss Martin’s admission. This included care plans, incident log, risk assessment and clinical information. In addition, I am informed that Miss Martin’s referral to Elysium Healthcare was discussed over a number of weeks between Trust and Elysium Healthcare staff, with continuing communication, including the submission of monthly reports, during Miss Martin’s admission to Chadwick Lodge.” Source location 2021-0299-Response-from-Department-of-Health-and-Social-Care_Published
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7 May 2021 John Graham Slope · Prevention of Future Deaths report Norfolk
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Concerns raised 1
Failure to obtain treatment summaries from other hospitals before procedures View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
John Graham Slope · 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
John Graham Slope underwent treatment including insertion of a salivary bypass tube after developing a fistula following laryngectomy. A tube was later found to be absent, and an abdominal X-ray showed a foreign body in his stomach that was not identified at the time. In August 2020 he was admitted extremely unwell with a perforated small bowel and a foreign body, was too unwell for surgery, and died shortly afterwards. Concerns included poor documentation and the absence of systems to record and identify the tube, as well as failure to document his concerns and obtain a treatment summary from another hospital.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to obtain treatment summaries from other hospitals before procedures
Wider context from the report “That the hospital did not request a summary of Mr Slope’s treatment at a different hospital before commencing the procedures , this could easily be requested via e mail.
” Source location John Graham Slope · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop operational workarounds to share and transfer information across regional clinical IT systems.
Verbatim wording from the response “Concerns about the lack of inter-connectivity of IT systems between the Trusts has been discussed at the ENT governance meetings; a risk assessment was completed, added to the NNUH (lead provider) risk register and approved in December 2020. At present, the clinicians do not have access to the relevant IT systems across the region to obtain full information for all patients for which they have clinical responsibilities, whether working from any site or remotely. A system wide approach is required to align the different IT systems, for example e-mail accounts, risk and incident management systems, dictation programmes,” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Progress the approved strategic case for a shared electronic patient record through national regulatory approval toward regional implementation.
Verbatim wording from the response “Longer term, our three hospital (JPUH, QEH, NNUH) electronic records system is now at the strategic outline case stage, which has been approved by all three hospital Trusts and is now with the national regulatory team to approve. This will see, upon implementation, a single patient record known as Electronic Patient Record (EPR), accessible electronically at all sites. The timeline for implementation depends on the pace of regulatory approvals and the governance cycle. The earliest implementation is likely to begin in 2022.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the regional shared-care record programme by scanning active patient records into the electronic document-management system for provider access.
Verbatim wording from the response “In the meantime, a shared care record programme across the region will provide patient data to each Trust. In essence, active patient records are being scanned onto Electronic Document Management System (EDMS) each time a patient is admitted to hospital or attends a clinic. This will improve the visibility of patient records to all providers in a read-only format and will improve communication about patients such as Mr Slope as it will amalgamate records which previously may have been held in paper format by different teams and avoid messages such as those made by the nurse specialists not being within the records viewed by the Consultant. The target for full implementation is September 2021.” Source location 2021-0144-Response-from-Norfolk-and-Norwich-University-Hospitals_Published
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Concerns raised 1
Failure to upload PDF medical records and important information promptly in original form to the electronic notes system View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Mina TOPLEY-BIRD · 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
Mina TOPLEY-BIRD, who had a severe and enduring mental illness and a history of suicide and self-harm attempts, was admitted to West Park Hospital after attempting to run into traffic and stab herself. On 8 May 2019, after being told that no bed was available for her in London, she said words to the effect of “I may as well kill myself”; she was later found hanging in her room and pronounced dead. Concerns included incomplete access to historic medical records, inability to print and share documents across NHS Trust systems, uncertainty about ligature-point assessments, limited bed-management coverage, and incomplete risk-assessment and safety-summary processes.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to upload PDF medical records and important information promptly in original form to the electronic notes system
Wider context from the report “1. Evidence was heard that medical records and other important information could not be uploaded to the Trust's electronic notes system - PARIS when received in PDF form . This meant staff had to precis notes onto the system, in this case when one person was working alone, on a nightshift was required to do this whilst dealing with a variety of different tasks. Important documents that cannot not to be uploaded immediately and in their original form concerns me that attending clinicians do not have access to these documents and can be hindered in making clinical decisions without them .
” Source location Mina TOPLEY-BIRD · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement Cito electronic records functionality for scanning, uploading and viewing documents.
Verbatim wording from the response “This issue regarding access to patient information will be fully resolved by the implementation of Cito, which is a full electronic records management solution and allows documents to be scanned in, uploaded or viewed. This solution will be fully implemented by August 2022.” Source location 2021-0100-Response-from-West-Park-Hospital-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Operational processes for locally commissioned mental health services are the responsibility of local NHS providers and their commissioning partners.
Verbatim wording from the response “Mental health services provided by TEWV are locally commissioned and therefore operational processes, such as those described, are the responsibility of local NHS providers and their clinical commissioning group (CCG) system partners, which commission the services.” Source location 2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforcement action was not required because the regulator concluded there was no ongoing risk to service users.
Verbatim wording from the response “My officials also approached the Care Quality Commission (CQC). The CQC has sought assurances from the Trust in relation to its investigation and has concluded that there is no ongoing risk to service users and that enforcement action was not required.” Source location 2021-0100-Response-from-Dept.-of-Health-and-Social-Care-Redacted
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28 Sep 2020 Mr William Ivan McKibbin · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Unavailability of medical records across Trust hospital sites View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Mr William Ivan McKibbin · 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 William Ivan McKibbin died at Trafford General Hospital on 20 August 2018 following complications of a traumatic brain injury sustained in an unwitnessed fall in hospital. The report raised concerns about bed-rail and bed-brake checks, the culture of openness and candour, communication between specialists and hospital sites, incident investigations, and the process for learning from deaths.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of medical records across Trust hospital sites
Wider context from the report “3. Given the operating model of the Trust, whereby different specialists provide services at different hospitals, it is a matter of concern that no proforma documentation / communication paradigm exists which sets out the minimum standard of information expected to be conveyed when a clinician seeks advice from a specialist based at another hospital.
The risk of death in this regard is currently compounded by the fact that medical records from one hospital are not necessarily accessible from another site within the Trust group .
” Source location Mr William Ivan McKibbin · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Trust-wide electronic patient record, with implementation work underway toward the planned September 2022 go-live.
Verbatim wording from the response “The matter of the clinical record is a valid concern and one that the Trust has recognised. To that end we have a detailed assessment of the risk and have been working with teams widely on the mitigation of the risks associated with paper and electronic records across our hospitals and services.” Source location 2020-0185-Response-from-Manchester-University-NHS-Foundation-Trust-Redacted.pdf
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Concerns raised 1
Unavailability of full patient medical records before anaesthesia View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Paul Vincent Reynolds · 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
Paul Vincent Reynolds underwent finger surgery under general anaesthetic after presenting to hospital with a swollen hand and a necrotic finger. He suffered a loss of blood pressure and a hypoxic period following the anaesthetic, and died from the hypoxic event on 31 December 2019. The concerns identified included the unavailability of his full hospital notes and an incomplete understanding of his underlying medical condition, leading to an inappropriate choice of monitoring and anaesthetic.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Unavailability of full patient medical records before anaesthesia
Wider context from the report “A Root Cause Analysis by an Independent Anaesthetist found:-
Root Cause
There was an incomplete appreciation and understanding of the patients underlying medical condition which led to an incorrect choice of monitoring and anaesthetic.
The unavailability of the full patient record meant that the anaesthetic team were reliant on the patient history and the admission clerking record to assess the patient.
Lessons Learned
The full set of patient medical records must be obtained as soon as possible following admission particularly when a procedure involving anaesthesia is planned.
The safe conduct of anaesthesia is reliant on being fully conversant with the patient's pre-existing medical conditions and patients should not be anaesthetised before the medical records have been obtained and reviewed.
Recommendations
1. Medical records must be obtained as soon as possible following admission to the ward by a ward clerk.
2. The ward administration team must check daily that all medical records are available or have been requested and an expected time-frame for the medical records to be available.
3. If adequate patient records are not available, the patient should not go to theatre unless it is a life or limb threatening emergency.
” Source location Paul Vincent Reynolds · Prevention of Future Deaths report
Open source report
Concerns raised 1
Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Laura Eve PARSONS · Prevention of Future Deaths report
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Report summary
Laura Eve Parsons was found dead at home on 5 November 2019, after consuming a fatal amount of liquid morphine prescribed for breakthrough cancer pain. She had previously been admitted to hospital following an accidental morphine overdose, but a repeat prescription was later issued without the electronic prescribing system directing the prescriber to review the prominent medical-record information about that overdose.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Electronic prescribing systems failing to direct prescribers to relevant medical records and the ‘Active Problems’ section
Wider context from the report “Ms Parsons was prescribed liquid morphine to treat ‘break through’ pain for cancer. It was first prescribed on 9th August 2019. Ms Parsons was admitted to hospital on 10th August 2019 with an accidental overdose of morphine. It appears 180mls were consumed in a 12 hour period. She recovered and was discharged from hospital. The remainder of the prescribed morphine was discarded.
On 31st October 2019 Ms Parsons requested a repeat prescription of liquid morphine from her GP surgery. This was authorised and a 500ml bottle of liquid morphine was dispensed to Ms Parsons. On 5th November 2019 Ms Parsons was found dead due to ingesting a fatal amount of morphine.
At inquest evidence was given that information such as recent overdose would be added to the ‘Active Problems’ section on a person’s medical records and would be prominent when any clinician accessed that person’s records.
It was explained at inquest that when a patient applies for a repeat prescription so far as the request is within the permitted timescale to issue a repeat of the prescribed item, then the prescription would be issued without any further scrutiny and the electronic systems would not take a prescriber to the patient’s medical records and in particular the ‘Active Problems’ section .
” Source location Laura Eve PARSONS · Prevention of Future Deaths report
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21 Feb 2020 Andrew Goldstraw · Prevention of Future Deaths report Central Hampshire
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Concerns raised 1
SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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Andrew Goldstraw · 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 Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report “B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT . Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions.
C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history.
D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there!
E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it.
F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this.
” Source location Andrew Goldstraw · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
Verbatim wording from the response “The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
Verbatim wording from the response “We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
Verbatim wording from the response “SystmOne is the medical records system for all prisoners and this contract with TPP is managed by NHS England and not directly by CNWL. However, with internal training and audit we hope to be able to overcome a significant proportion of the limitations identified. We will also be raising the Coroner’s concerns and our work around with TPP so that they can consider them in any future developments of the system” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
Verbatim wording from the response “Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.” Source location 2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Open published response
24 Dec 2019 Julie Helen Taylor · Prevention of Future Deaths report Manchester South
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Concerns raised 2
Incomplete digitisation preventing professionals from accessing each other's notes View source Failure of digital information access between acute and community trusts View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care NHS Greater Manchester Integrated Care Board
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AI-generated summary
Julie Helen Taylor · 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
Julie Helen Taylor, who had Down syndrome and significant learning disabilities, died at Stepping Hill Hospital on 23 September 2018 from pneumonitis following a chicken pox virus infection contracted while awaiting discharge. The concerns included inadequate reasonable-adjustment planning, lack of best-interests meetings and documented decision-making, poor communication between agencies, limited access to suitable learning-disability beds and support, information-sharing difficulties, and delayed recognition of chicken pox.
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 Incomplete digitisation preventing professionals from accessing each other's notes
Wider context from the report “8. The IT constraints meant that the acute trust could not access the community trusts records. The community trust itself had not fully digitised meaning not all professionals could see each other's notes . The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial.
” Source location Julie Helen Taylor · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of digital information access between acute and community trusts
Wider context from the report “8. The IT constraints meant that the acute trust could not access the community trusts records . The community trust itself had not fully digitised meaning not all professionals could see each other's notes. The community trust recognised the internal issue and was taking steps to fully roll out an integrated system however communication between trusts digitally was unlikely to improve despite a recognition that it would be beneficial .
” Source location Julie Helen Taylor · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local NHS is expected to reflect on the LeDeR findings and address local failings in care for people with learning disabilities.
Verbatim wording from the response “I am advised by NHS England and NHS Improvement that Ms Taylor’s death is currently being reviewed under the LeDeR process and I expect the local NHS to reflect on the findings of the review and take action to address any failings in the care provided locally for people with a learning disability. I have also asked officials to bring your report to the attention of the National Director for Learning Disabilities, Ray James, who is leading work nationally to improve services for people with learning disabilities and/or autism.” Source location 2019-0454-Response-from-the-Department-of-Health-and-Social-Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Community care matters in Derbyshire fall outside the Greater Manchester Health and Social Care Partnership’s remit.
Verbatim wording from the response “You have also identified a number of areas regarding community care in Derbyshire. As Derbyshire does not fall under the remit of the Greater Manchester Health and Social Care Partnership we are unable to provide a response to those issues.” Source location 2019-0454-Response-from-Greater-Manchester-Health-and-social-Care-Partnership-Redacted
Open published response
18 Nov 2019 Alex Grady · Prevention of Future Deaths report Manchester North
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Concerns raised 1
Failure to make complete lists of current and recent prescriptions readily accessible View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Alex Grady · 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
Alex Grady was found deceased in his bed on 26 February 2019 and died from combined toxicity involving prescribed and non-prescribed medication and illicit drugs. Concerns included the adequacy of support and follow-up when alcohol detoxification is managed solely by a GP, and the accessibility of complete prescription information to healthcare practitioners.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to make complete lists of current and recent prescriptions readily accessible
Wider context from the report “I heard evidence that the reason that the prescriptions for Chlordiazepoxide were not referred to in the two reports prepared by the GP for the purpose of this inquest was because of a ‘glitch’ in the computer system which meant that it was not included in the list of medications listed on the first screen of the patient’s records. My concern is that a complete list of all current and recent prescriptions should be readily accessible to GPs and other healthcare practitioners working within the practice .
” Source location Alex Grady · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.