Recurring concern

Failure to reliably transfer medical records between healthcare organisations

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First reported 28 Nov 2013•Latest report 20 Oct 2025

Definition

What this concern includes

Includes failures in the dedicated transfer of existing medical records between healthcare organisations, including delayed, incomplete, untraceable or systemically unsupported transfer between GP practices, hospitals, mental-health services or other healthcare organisations where the records are needed for safe care.

Not included

  • Excludes generic inter-agency information-sharing failures where the asserted object is not medical records or an equivalent clinical record transfer.
  • Excludes failures to create, complete or accurately maintain records when transfer or inter-organisational availability is not the unsafe condition.
  • Excludes failures limited to reviewing or acting on records after they have been reliably transferred and made available.
  • Excludes transfer of non-clinical records, administrative documents or information between organisations without a healthcare medical-record context.
  • Excludes communication of isolated clinical advice or results where the dedicated medical-record transfer process is not deficient.
Reports
29

Distinct published reports

Individual concerns
30

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
47

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

NHS England11
Department of Health and Social Care8
Care Quality Commission3
Betsi Cadwaladr University LHB2
NHS Greater Manchester Integrated Care Board2
Recipient name withheld2
Royal College of General Practitioners2
Barts Health NHS Trust1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Birmingham City Council1
Birmingham Women'S and Children'S NHS Foundation Trust1
Clinical Commissioning Groups (England)1
Dr Simon Chapple1
East Kent Hospitals University NHS Foundation Trust1
Egton Medical Information Systems Limited1

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.

  1. Avon

    AI-generated summary

    Ms. Amy Jo Cross · 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

    Ms. Amy Jo Cross was arrested on 9 June 2023, experienced reported drug and alcohol withdrawal symptoms, and died in a prison cell on 10 June 2023 after being found unresponsive before prescribed medication was administered. The report identified concerns about the transfer of healthcare information, including recent medication administration and physical observations, between police, court and prison healthcare providers, and the absence of a shared medical records system.

    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 a standard medical records system accessible to each healthcare organisation

    Wider context from the report

    “(2) There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information. ”

    Source location

    Ms. Amy Jo Cross · 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 discussions with PECS to commence pilots enabling Liaison and Diversion services to access and update the Digital Person Escort Record.

    Verbatim wording from the response

    “NHS England does commission Liaison & Diversion services, which also operate with police custody suites, addressing mental health and wider vulnerabilities. There is no indication that a referral was made in this case to Liaison & Diversion services at either Torquay or Exeter police custody suites. Liaison & Diversion services do not currently have access to enter information directly onto the DPER, but with an individual’s consent, they will share relevant health information with the police and the police will be responsible for updating the DPER. NHS England is in discussion with PECS to commence pilot schemes in London and West Yorkshire, whereby PECS will issue licences to Liaison & Diversion Services, to enable them to directly access the DPER and enter health information. The pilots are expected to commence in 2026 at the following sites:”

    Source location

    Response from NHS England
    Page 2 · response
    Published 23 October 2025

    Open published response
  2. East Riding and Hull

    AI-generated summary

    John Charles Spencer · 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 Charles Spencer became unwell on 17 May 2024 and died on 21 May 2024 after a bowel perforation caused by obstruction within a recurrent right inguinal hernia, resulting in purulent peritonitis. The principal concern was that the GP out-of-hours surgery could not access his relevant GP medical history because different computer systems prevented the exchange of information, potentially affecting the examinations undertaken when patients do not report relevant history.

    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 GP out-of-hours surgeries to access key GP medical history information after patient consent

    Wider context from the report

    “(1) The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery. Evidence was given that there are various reasons for this, including the patient not providing consent for the exchange of this information. However, on some occasions, even when a patient has consented, the patient record systems utilised by the GP registered practice and the GP out of hours surgery, insofar as being different computer systems or for whatever other technological reason, prevented the exchange of information into the GP out of hours surgery. In this case, evidence was heard that the GP practice was using the EMIS system and that the urgent treatment centre (GP out of hours surgery) was using SystmOne. That fact caused the GP out of hours surgery to not be able to access Mr Spencer’s GP medical summary. This situation generates a concern that, providing the patient has consented, key medical information may not be conveyed to the GP out of hours surgery which should be accessible to allow the appropriate exchange of medical information to inform what examinations should take place in an out of hours setting. This concern is particularly significant in circumstances where the patient does not say and/or present with the points in the medical history relevant to the GPs determination about what further examinations should occur flowing from the medical history of the patient. ”

    Source location

    John Charles Spencer · 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 greater integration and awareness of record sharing between in-hours and out-of-hours providers.

    Verbatim wording from the response

    “NHS England is aware of the challenge in sharing medical records between providers during the in-hours and out-of-hours period and the variability between areas using different technologies. We are also aware that use of the NCRS is variable across different care settings.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 21 May 2025

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with the Shared Care Records Programme to support wider access to relevant patient information.

    Verbatim wording from the response

    “We are therefore working across the health system to support greater integration and awareness of record sharing between in-hours and OOH providers. We are also working with the ShCR Programme to support wider access to relevant patient information.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 21 May 2025

    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

    Scrutinise providers’ handling of correspondence, clinical coding, information sharing, patient pathways and significant-event learning during inspection and monitoring activity.

    Verbatim wording from the response

    “As CQC is aware that computer systems across healthcare providers are often unable to communicate with each other we have taken steps to mitigate this issue. For example, we ensure that we look closely at how providers deal with incoming correspondence (e.g. letters from secondary care or other health and social care providers), coding, sharing of information with other healthcare providers and patient pathways during our inspection and monitoring activity. We also look closely at how they identify, record and learn from significant events such as this one and were satisfied with the significant event analysis undertaken by City Health Care Partnership in relation to this matter.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 21 May 2025

    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

    Migrate clinical IT from EMIS to TPP SystmOne and enable GP Connect to support consent-based access to medical summaries.

    Verbatim wording from the response

    “Relating to the matters of concern raised in your report, I can confirm that Holderness Health had a planned clinical IT system migration from EMIS to TPP SystmOne on 13th May 2024, with GP Connect enabled.”

    Source location

    Response from Holderness Health
    Page 1 · response
    Published 21 May 2025

    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

    Highlight the concerns to the Professional Record Standards Body regarding interoperability.

    Verbatim wording from the response

    “As a College our action shall be to highlight this tragic case to our health informatics group so they can use it in future discussions with NHS England. It is important that the area of Health informatics is not lost with the reorganisation of NHS and that the government both prioritise and progress action in this work. We shall also highlight your concerns to The Professional Record Standards Body (PRSB) who are dedicated to the development and implementation of health and care information standards and for whom this area on interoperability is relevant.”

    Source location

    Response from RCGP
    Page 2 · response
    Published 21 May 2025

    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

    Dictating providers’ computer systems and IT infrastructure is outside CQC’s role and remit.

    Verbatim wording from the response

    “It is not within the CQC’s role or remit to dictate the computer systems that providers operate or the IT infrastructure in use as this is a commissioning matter and not something we have any direct control over.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 21 May 2025

    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

    Decisions about providers’ computer systems and IT infrastructure are a commissioning matter, not under CQC’s direct control.

    Verbatim wording from the response

    “It is not within the CQC’s role or remit to dictate the computer systems that providers operate or the IT infrastructure in use as this is a commissioning matter and not something we have any direct control over.”

    Source location

    Response from Care Quality Commission
    Page 2 · response
    Published 21 May 2025

    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 remote surgery was not a significant or currently active problem and therefore would not generally appear in GP Connect’s limited summary.

    Verbatim wording from the response

    “Relating to the matters of concern raised in your report, I can confirm that Holderness Health had a planned clinical IT system migration from EMIS to TPP SystmOne on 13th May 2024, with GP Connect enabled.”

    Source location

    Response from Holderness Health
    Page 1 · response
    Published 21 May 2025

    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

    Making all GP IT systems identical is not possible because government policy promotes plurality among GP IT providers.

    Verbatim wording from the response

    “The innovation in General Practice IT systems has been led partly by a government strategy to create a Plurality of GP IT Providers by increasing the diversity in the marketplace through NHS frameworks like the GP IT Futures Framework and more recently the Tech Innovation Framework. The new Tech Innovation framework has even brought in a new provider into the marketplace in the last few weeks called Medicus Health. It is therefore not possible for all GP IT systems across both the in and out of hours period to be the same. Recognising that there would be patient benefit to other areas of the health system such as the Hospital Emergency Departments for access to the GP Summary work has been carried out to provide interoperability.”

    Source location

    Response from RCGP
    Page 2 · response
    Published 21 May 2025

    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 owns the interoperability strategy and GP Connect, so responsibility for this work lies with NHS England.

    Verbatim wording from the response

    “This work currently falls under NHS England who own the dedicated Interoperability strategy as well as GP Connect which is a new national service which enables healthcare staff to view GP patient records significantly improving data sharing between General Practice and other parts of the NHS. It is recognised that as technology progresses the sharing of records improves but within a robust information governance structure and data sharing agreements.”

    Source location

    Response from RCGP
    Page 2 · response
    Published 21 May 2025

    Open published response
  3. Devon, Plymouth and Torbay

    AI-generated summary

    Andrew James Tizard-Varcoe · 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 James Tizard-Varcoe died at home on 11 May 2022 due to the progression of an ear infection, later described at inquest as complications of necrotising otitis externa. Concerns included fragmented care across three hospital trusts, difficulties accessing medical records and establishing responsibility, delayed outpatient follow-up, and discharge without oral antibiotics despite microbiology advice.

    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 separate hospital trusts to provide clinicians with access to each other’s medical records

    Wider context from the report

    “(1) The evidence shows that Mr Tizard-Varcoe’s overall treatment for the ear infections between April 2021 and May 2022 was provided across three different health trusts and hospitals, Musgrove Park in Taunton, North Devon District Hospital in Barnstaple and Exeter Hospital; it is acknowledged that this was as a consequence of Mr Tizard- Varcoe’s vascular disease (being treated at Musgrove Park) and the locations of specialist doctors. Whilst being treated at Musgrove Park for a vascular problem, Mr Tizard-Varcoe consulted with ear nose and throat specialists for ear pain; subsequently between April 2021 and May 2022 he was seen on a number of occasions by clinicians in all three locations; this led to occasions when Mr Tizard -Varcoe was reviewed by clinicians without the full clinical picture due to the inability of separate hospital trusts to access each other’s medical records. The evidence revealed that on occasions it was difficult for Mr Tizard-Varcoe’s GP to work out who had responsibility for his care. It is my judgement that on occasions this led to less than optimal treatment for Mr Tizard Varcoe. ”

    Source location

    Andrew James Tizard-Varcoe · 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 collaborating with neighbouring NHS partners to coordinate care, treatment and information sharing for patients receiving cross-organisation care.

    Verbatim wording from the response

    “It would be unusual to undertake shared care between two neighbouring departments unless specifically requested. It is normally best practice for the same clinical consultant and team to manage care and treatment of a patient (where possible) for continuity. ENT and other specialties often work closely and collaboratively with colleagues from other NHS bodies, including teams in neighbouring hospitals and GPs in respect of patient treatment and this generally works well. Where SFT input is needed, we have and will continue to work with partners to ensure coordination, collaboration and optimal treatment in the best interests of the patients and their families.”

    Source location

    Response from NHS Somerset
    Page 1 · response
    Published 14 July 2025

    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 Somerset Integrated Care Board and the national team to develop an integrated electronic health record across Somerset services.

    Verbatim wording from the response

    “Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.”

    Source location

    Response from NHS Somerset
    Page 1 · response
    Published 14 July 2025

    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 a single electronic patient record across the merged Trust sites to improve coordination and continuity of care.

    Verbatim wording from the response

    “In April 2022, the two Trusts formally merged creating Royal Devon University Healthcare NHS Foundation Trust and by July 2022, both sites and all staff were using the same electronic records system (EPIC). This use of the one combined patient record has significantly improved care for patients receiving care across both sites and this has been a significant and important change since Mr Tizard-Varcoe’s death.”

    Source location

    Response from Royal Devon University Healthcare NHS Foundation Trust
    Page 2 · response
    Published 14 July 2025

    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

    Funding integrated information technology systems across organisations is beyond the Trust’s control.

    Verbatim wording from the response

    “Funding for integrated IT systems across organisations is something beyond the control of SFT but we are working with the NHS Somerset Integrated Care Board and the national team to develop an integrated Electronic Health Record across acute, community and mental health services in Somerset which will support better integration and interaction across our services as well as with neighbouring trusts and systems.”

    Source location

    Response from NHS Somerset
    Page 1 · response
    Published 14 July 2025

    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

    Merged services, a shared electronic record and planned Devon-wide integration are considered sufficient to improve coordination across sites.

    Verbatim wording from the response

    “I am assured that since the merger of the two Trusts and the implementation of Epic in across both sites and, continuity of care and patient safety has been improved.”

    Source location

    Response from Royal Devon University Healthcare NHS Foundation Trust
    Page 2 · response
    Published 14 July 2025

    Open published response
  4. Gloucestershire

    AI-generated summary

    Maria Simpson · 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

    Maria Simpson died on 24 August 2022 from massive recurrent pulmonary thromboembolism and deep vein thrombosis. The report states that referrals concerning anticoagulation were returned or not accessed before her death, and that this probably made more than a minimal contribution to her death. It also identifies concerns about non-uniform electronic record systems, delays when transferring records, and difficulty accessing historic referral 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 interoperable electronic patient-record systems between general practices

    Wider context from the report

    “Evidence was given in the inquest to the effect that medical General Practitioners have no uniform national case management system for electronic storage of patients’ records. This leads to a situation whereby, upon transfer of patient records from one practice to another, the receiving practice is obliged to input all the records afresh if the practices operate different systems. This can lead to delay in the compilation of records. Further, it appears that a case management system is unable to store electronically all historic documents such as referral letters from one clinician to another, due to electronic capacity issues. This leads to a situation where some patient information is stored electronically and some in paper form making it difficult for the GP to note quickly all relevant patient information. ”

    Source location

    Maria Simpson · Prevention of Future Deaths report
    Page 2 · 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

    Existing GMS requirements and GP2GP enable electronic patient records to transfer between practices using different systems.

    Verbatim wording from the response

    “The NHS General Medical Services (GMS) contract regulations stipulate that contractors must keep ‘adequate’ patient records either on forms provided by NHSE, in computerised records, or a combination of both. The contract also states that any computer system must meet the requirements set out in the GPIT Operating model and that the contractor must have regard for the guidance laid out in Digital Primary Care: Good Practice Guidelines for GP electronic patient records.”

    Source location

    Response from DHSC
    Page 1 · response
    Published 13 January 2025

    Open published response
  5. Inner West London

    AI-generated summary

    Judith Maike OBHOLZER · 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

    Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS providers.

    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 share medical notes and information between private practitioners and NHS providers

    Wider context from the report

    “4. In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers. This (along with other factors) led to delays in a treatment plan being set by Wandsworth SPA as they had to obtain further details regarding Mrs Obholzer’s CBT from Mrs Obholzer rather than being able to access the notes through a shared system. Consideration should be given to ensuring a system is in place to allow the sharing of medical information between practitioners across Trusts and also between NHS and Private providers. ”

    Source location

    Judith Maike OBHOLZER · 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

    Review and develop a consent process for recording and sharing information when patients receive both NHS and private care.

    Verbatim wording from the response

    “However, locally the Trust is reviewing its approach to how information can be shared in line with consent and the confidentiality policy. Naturally, the Trust is not able to share clinical information with a private practitioner (and vice versa) without the explicit consent of the patient, except in rare cases where risk considerations mean information sharing is essential.”

    Source location

    Response from SW London Mental Health Trust
    Page 6 · response
    Published 31 July 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

    Remind staff about the Urgent Care Pathway, checking private treatment and consent, and the Private Providers Shared Care Policy through a Monthly Learning Bulletin and local GP networks.

    Verbatim wording from the response

    “The Trust will remind all staff of the ‘Urgent Care Pathway’ in a Monthly Learning Bulletin article (to be published by October 2024). Staff will also be reminded to regularly check if service users are receiving private treatment and discuss consent to share information. Staff will also be signposted to the Trust’s ‘Private Providers Shared Care Policy’, so they are aware of the process if they are contacted by a private provider regarding a patient in crisis. This policy will also be shared through our local GP networks.”

    Source location

    Response from SW London Mental Health Trust
    Page 6 · response
    Published 31 July 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 trialling Summary Care Record access with private hospitals and privately funded healthcare services.

    Verbatim wording from the response

    “The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 July 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 an Expert Advisory Committee to seek approval for independent-sector rollout and consider its scope, exclusions, constraints, and caveats.

    Verbatim wording from the response

    “The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 July 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 the interface between NHS and non-NHS-funded independent health providers.

    Verbatim wording from the response

    “Work is also in progress to review the interface between the NHS and non-NHS funded independent health providers. This work is in its infancy, but NHS England can provide an update to the Coroner in due course if this would assist. We understand that the Care Quality Commission (CQC) are also undertaking work regarding standards for online care and are exploring opportunities for better sharing of information both into private sector providers and receiving information back to the patient’s registered GP practice from private providers.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 31 July 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

    National systems and guidance for information sharing between NHS and private providers are principally matters for NHS England and the Department of Health.

    Verbatim wording from the response

    “Systems and processes for information sharing between NHS and private providers is principally a consideration for NHSE and the DH who are best placed to provide guidance around the GDPR and confidentiality considerations.”

    Source location

    Response from SW London Mental Health Trust
    Page 6 · response
    Published 31 July 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

    Clinical information cannot ordinarily be shared between NHS and private practitioners without explicit patient consent, except where risk makes sharing essential.

    Verbatim wording from the response

    “However, locally the Trust is reviewing its approach to how information can be shared in line with consent and the confidentiality policy. Naturally, the Trust is not able to share clinical information with a private practitioner (and vice versa) without the explicit consent of the patient, except in rare cases where risk considerations mean information sharing is essential.”

    Source location

    Response from SW London Mental Health Trust
    Page 6 · response
    Published 31 July 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 improving information sharing and reviewing the interface between NHS and non-NHS-funded independent providers.

    Verbatim wording from the response

    “I know that NHS England has outlined to you the work they are taking forward to improve sharing of information and records overall. I understand that work is also in progress at NHS England to review the interface between NHS and non-NHS funded independent health providers, and that NHS England has offered to update you on this important work as it progresses. I assure you, I have written to NHS colleagues to ensure this is driven forward and these points are addressed.”

    Source location

    Response from DHSC
    Page 2 · response
    Published 31 July 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

    Responsibility for delivering shared care records sits with local Integrated Care Boards.

    Verbatim wording from the response

    “Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England. Further information on Integrated Care Boards and Systems can be found here: NHS England » What are integrated care systems?”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 July 2024

    Open published response
  6. Manchester South

    AI-generated summary

    James Neil COCKBURN · 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

    James Neil Cockburn had severe aortic stenosis and was awaiting assessment for suitability for open heart surgery when he suffered a myocardial infarction and died at home on 26 May 2023. The report identified delays in cardiology appointments and essential tests, together with communication delays between NHS trusts caused by separate IT systems, as substantive concerns affecting treatment planning and decision-making.

    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 separate trust IT systems to transmit test information into the other trust’s patient records

    Wider context from the report

    “The inquest heard that despite the referral being in August 2022 he had to wait months for his appointment due to the demand on cardiac services. This was significant across Greater Manchester but reflected a national picture of significant delays in patients waiting to see a cardiologist. As a consequence patient/s with cardiac issues are subject to delays in treatment plans and decision making regarding suitability for potentially lifesaving surgical procedures. In Mr Cockburn’s case he died whilst waiting assessment for his suitability for open heart surgery. It was 9 months since the first referral. The position the inquest was told is exacerbated due to significant wait times for essential tests such as trans oesophageal echocardiograms to be carried out due to a shortage of suitably quailed professionals to carry them out. In his case the position was further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal. ”

    Source location

    James Neil COCKBURN · 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

    Collaborate across patient-safety and digital-clinical-safety teams to extract learning from EPR incidents and provide scenarios for evaluating systems and processes.

    Verbatim wording from the response

    “Future plans include collaboration between the NHS England Patient Safety and Digital Clinical Safety Teams to take learning from incidents concerning EPR related patient safety and other relevant digital implementations, and to provide scenarios that Trusts can use to evaluate their systems and processes when preparing for their EPR implementations.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 4 July 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 improving interoperability between primary, secondary, tertiary and wider care information technology systems.

    Verbatim wording from the response

    “Inter-operability of different information technology systems to enable efficient and effective communication across primary care, secondary care, tertiary care and wider system partners is a challenge. This is both at a Greater Manchester level and wider. We continue to work towards improving this as a system.”

    Source location

    Response from GMIC
    Page 2 · response
    Published 4 July 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

    Challenge digital transformation leaders to examine interfaces between secondary and tertiary care systems and improve provider collaboration.

    Verbatim wording from the response

    “We acknowledge that there is still further work to do in relation to this and we will be challenging the leaders who support our digital transformation programmes to look in more detail at improving the interface between secondary and tertiary care systems and our providers in these sectors as to how they work together to enable this.”

    Source location

    Response from GMIC
    Page 3 · response
    Published 4 July 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 EPR optimisation programmes at MUFT and NCA are considered sufficient to address concerns about separate clinical information systems.

    Verbatim wording from the response

    “In 2022, MUFT secured funding to support levelling up capabilities following the acquisition of the North Manchester General Hospital site, to ensure the same level of EPR maturity as the other nine hospital sites within MUFT.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 4 July 2024

    Open published response
  7. East Sussex

    AI-generated summary

    Finlay Stuart Ian FINLAYSON · 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

    Finlay Stuart Ian FINLAYSON died following cardiac arrest at HMP Lewes on 25 January 2019; the stated causes were pulmonary thromboemboli due to deep vein thrombosis, against a background of metastatic carcinoma of the base of the tongue. Concerns included delays and possible omissions in transferring medical information between healthcare systems, poor record keeping, communication failures, delays in accessing healthcare, and failures in the emergency response.

    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 reliably transfer key medical information between incompatible systems

    Wider context from the report

    “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison. Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems. I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand. I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient. ”

    Source location

    Finlay Stuart Ian FINLAYSON · 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

    Delays in transferring medical information to prison healthcare staff

    Wider context from the report

    “During the course of the Inquest the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson's GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson's long term health issues as well as contact with his GP as recent as a week before going in to prison. Mr Finlayson sadly died in 2019 and I have heard evidence that the functioning of SystmOne has improved since his death. I was told, however, that there remains an issue with the interaction between SystmOne and other medical databases used in England and Wales. SystmOne appears to be the preferred system for many prisons and detention centres but there are still many GP surgeries that use other systems. I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone's record by hand. I am concerned about the potential delay this process could cause. I am also concerned that key information could be missed by virtue of these systems not communicating with each other. I have heard evidence as to the importance of someone's medical history being available for those within the prison setting to assist with careplanning and the provision of appropriate care and in my opinion, there is a risk that future deaths could occur unless action is taken to make the transfer of this information more efficient. ”

    Source location

    Finlay Stuart Ian FINLAYSON · 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

    Undertake an internal review of EMIS Web interoperability and medical-record transfer issues raised in the report.

    Verbatim wording from the response

    “We have undertaken an internal review of EMIS Web, focussing on the issues raised as areas of concern in the Report in relation to EMIS Web, namely a potential lack of interaction between clinical systems in prisons (predominantly SystmOne) and other clinical systems in community GP surgeries, and the evidence you heard that notes have to be printed and scanned on to SystmOne, with key information inputted manually, if an individual’s GP practice uses a clinical system other than SystmOne.”

    Source location

    Response from EMIS
    Page 1 · response
    Published 25 March 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

    Maintain compliance with the latest NHS England GP2GP specifications and associated processes for electronic medical-record transfers.

    Verbatim wording from the response

    “EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 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 reviewing EMIS solutions to identify potential performance improvements affecting medical-record transfers.

    Verbatim wording from the response

    “As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 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

    Enable functionality supporting automatic electronic transfer of prisoners’ full community GP records to prison GPs and back on release.

    Verbatim wording from the response

    “Since the time of Mr Finlayson’s death, more has been done to improve matters. Full GP registration (‘GMS’) has been introduced into prisons in the last two years as a result of policy change by NHS England. Functionality was enabled by TPP to enact this policy change. As a result, prisoners can now opt to have their community GP registration (and their community GP record) transferred to the prison GP. This involves the automatic electronic transfer of the full community GP record to the prison GP, which is then transferred out again on release of the prisoner to the community GP practice. This is an enormous improvement. This change applies regardless of whether the community GP practice uses SystmOne or EMIS.”

    Source location

    Response from TPP
    Page 1 · response
    Published 25 March 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 GP2GP functionality and NHS England specification compliance sufficiently mitigate the identified medical-record transfer risks; no further software development is required.

    Verbatim wording from the response

    “As detailed above, EMIS is compliant with NHS England GP2GP specifications, and we will continue to review our solutions to determine whether any performance improvements can be made. However, based on the information provided in the Report, and our subsequent review, we do not believe in this instance there are any software developments, beyond the existing functionality in the System, that are required to mitigate the specific risks raised in the Report.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 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

    EMIS cannot control whether prisons request medical records through GP2GP or a manual process.

    Verbatim wording from the response

    “EMIS are fully compliant, and have processes in place to remain compliant, with the latest versions of the NHS England GP2GP specification. Therefore, EMIS practices can receive medical record requests from prisons and return the requested information via the GP2GP process. EMIS practices also have the option to send printed medical records via courier when medical requests are not received from prisons via GP2GP (at the prison’s discretion). In either scenario, EMIS would not have any control over whether the prison requests the medical records via the GP2GP process, or via a manual process.”

    Source location

    Response from EMIS
    Page 2 · response
    Published 25 March 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

    GP data controllers are responsible for permitting data sharing and enabling the relevant reciprocal controls under data protection legislation.

    Verbatim wording from the response

    “Your report highlights that information was not freely shared between the GP (using SystmOne) and the prison service. Functionality to allow seamless sharing of data is available within SystmOne, and this functionality was available to the detained estate (including prisons) from well before 2019. However, as is still the case, the sharing of data is dependent on the data controller (in this case the GP) permitting the data to be made available to other healthcare organisations. This responsibility is set out in UK Data Protection Legislation. Without the control in SystmOne being turned on by the GP data controller (and a reciprocal control on the receiving side being enabled) the data is not visible. Dame Fiona Caldicott and other data champions have tried to make information sharing ‘the norm’ but there is still resistance in many areas.”

    Source location

    Response from TPP
    Page 1 · response
    Published 25 March 2024

    Open published response
  8. North Wales (East and Central)

    AI-generated summary

    Philip David 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

    Philip David Taylor had mental health difficulties, was admitted to a private psychiatric unit outside the NHS North Wales area, and died by suicide at home on 23 August 2023 after discharge to the Home Treatment Team. The concerns included inadequate information sharing and coordination between the Health Board and the private unit, including delayed or missing discharge documentation and no agreed written standards for communication and documentation.

    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

    Delays and failures in transferring and acting on discharge clinical documentation

    Wider context from the report

    “c. The prescription and administration record together with a copy of the pre-admission paperwork were only sent to the Health Board two days after the deceased was discharged. d. The discharge summary was emailed to the Health Board three days after discharge, but this was either not received by the Health Board or received and not acted upon. In fact, it is the deceased’s wife who had informed the Home Treatment Team that the deceased had been discharged. On knowing this, no one sought to request the discharge summary from Ty Grosvenor, even where there was a change in medication dosage. ”

    Source location

    Philip David Taylor · 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

    Develop a standard operating procedure governing information sharing, repatriation and discharge planning, and key documentation for out-of-area acute placements.

    Verbatim wording from the response

    “The learning from the inquest of Mr Taylor has identified that a standard operating procedure is required (SoP) and must include the requirements for sharing information, joined up planning for repatriation and/or discharge and standards for the development and sharing of key documentation.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 12 February 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

    Launch and implement the fully ratified standard operating procedure for out-of-area acute placements.

    Verbatim wording from the response

    “A multi-disciplinary task and finish group has been established, chaired by the Head of Integrated strategy and development, who is leading on the development of the SoP in collaboration with both operational and clinical teams. Progress will be overseen by the MHLD Policy and Procedure Group. Following ratification, the Task and Finish Group will oversee the launch and implementation of the SoP and compliance with the SoP will be monitored through established local and divisional Putting Things Right Meetings. I am advised that the SoP will be fully ratified by the end of August 2024.”

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 2 · response
    Published 12 February 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

    Lawful constraints prevented delaying discharge or requiring a joint discharge meeting for an informal patient who wished to leave.

    Verbatim wording from the response

    “2. The third ward round took place on 14 August. Mr Taylor wished to leave. He was an informal patient. He did not meet the criteria for detention under the MHA. Nor did he lack capacity so a deprivation of liberty under the Mental Capacity Act was not available. He had to be discharged as there was accordingly no lawful basis to refuse this. It was agreed that to enable this to take place in an orderly fashion he would leave the next day. Elysium had no alternative but to proceed with this.”

    Source location

    Response from Elysium Healthcare
    Page 2 · response
    Published 12 February 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 framework agreement and internal policy adequately govern information sharing; concurrent discharge letters are not contractually required.

    Verbatim wording from the response

    “The Elysium internal policy is to ensure the relevant information is given to home teams so that they can follow up within 72 hours (as was done here). In case it is of assistance to put the issue in context, the contract we have with Surrey requires that information only within 5 days of discharge.”

    Source location

    Response from Elysium Healthcare
    Page 3 · response
    Published 12 February 2024

    Open published response
  9. Inner North London

    AI-generated summary

    Jennifer Ruth Whinney · 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

    Jennifer Ruth Whinney developed recurrent infections in her PICC lines after being admitted to the Royal London Hospital for bowel surgery, leading to septicaemia and multi-organ failure. She died following surgery to repair a bowel fistula. The report raised concern that her medical records were not sent to a specialist appointment and that there was no individual responsibility for ensuring records accompanied patients, risking important information not being passed on.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to ensure that patient notes accompany external appointments

    Wider context from the report

    “Jennifer was referred to the colorectal specialist team at the Royal London Hospital and seen in late May. The witnesses were unable to give me the exact date of the appointment. Jennifer’s notes were not sent to the appointment with her. I heard that patient records at Queens Hospital are not electronic. Ward staff compile the notes which are sent physically with the patient if they attend any external appointment. I heard that no one person has responsibility for ensuring that the notes are sent. Jennifer was articulate and understood her health problems well and so was able to provide the colorectal surgeon with her medical background. I am concerned that another patient may not be able to provide such a full and accurate history and that critical information may not be passed on. ”

    Source location

    Jennifer Ruth Whinney · 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

    Review the process for sending patient notes to external hospital appointments and identify governance gaps.

    Verbatim wording from the response

    “1. A review of the process for sending patients notes accompanying them to external hospital visits has been undertaken and we have identified gaps in the governance of this. The policy has now been revised internally and the updated policy, was approved at the Policy Ratification Group that took place today, on 22 January 2024. The changes include both implicit responsibility of handing the patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. A copy of this policy is included with this response for His Majesty’s Coroner’s kind review.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 1 · response
    Published 1 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Revise and approve the external patient transfer policy, including handover responsibility, a transfer checklist, receipt signatures, and a minimum medical-information dataset.

    Verbatim wording from the response

    “1. A review of the process for sending patients notes accompanying them to external hospital visits has been undertaken and we have identified gaps in the governance of this. The policy has now been revised internally and the updated policy, was approved at the Policy Ratification Group that took place today, on 22 January 2024. The changes include both implicit responsibility of handing the patients notes over to the nurse / medical escort or ambulance driver as appropriate, a checklist for the transfer of patients externally as well as a signature section to acknowledge receipt of the notes. A copy of this policy is included with this response for His Majesty’s Coroner’s kind review.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 1 · response
    Published 1 December 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Digitise medical notes across hospital sites to enable seamless transfer of records between digitally enabled hospitals.

    Verbatim wording from the response

    “3. The Trust is currently embarking upon its journey into digitisation of medical notes which should be completed in mid-late 2025. Once this is completed it is envisaged that the issue of medical notes being sent between hospital sites, that are also digitally enabled should be seamless; although it is recognised this is a lengthy timescale.”

    Source location

    Response from Barking, Havering and Redbridge University Hospitals NHS Trust
    Page 2 · response
    Published 1 December 2023

    Open published response
  10. North West Wales

    AI-generated summary

    Lynsey Sarah Smalley · Prevention of Future Deaths report

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

    Report summary

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

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Risk of full or partial loss of paper medical notes during transfer

    Wider context from the report

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

    Source location

    Lynsey Sarah Smalley · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Participate in regional and local-authority discussions to assess alternative digital patient-record options for North Wales.

    Verbatim wording from the response

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

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 14 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop a Health Board strategic outline case for electronic patient records, incorporating MHLD requirements to address fragmented care records.

    Verbatim wording from the response

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

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 14 September 2023

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Work with the Chief Information Officer to consider options for a more timely MHLD digital-record solution.

    Verbatim wording from the response

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

    Source location

    Response from Betsi Cadwaladr University Health Board
    Page 3 · response
    Published 14 September 2023

    Open published response
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Data last updated 7 September 2026