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. Manchester South

    AI-generated summary

    Corinne Haslam · 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

    Corinne Haslam died at Tameside General Hospital on 18 March 2022 following complications involving myocardial ischaemia, acute exacerbation of chronic obstructive pulmonary disease, left ventricular hypertrophy and treated pulmonary thromboemboli. Concerns included barriers to obtaining physical-health specialist input for mental-health ward patients, incompatible electronic records between Mental Health and Acute Trusts, and unclear guidance on venous thromboembolism risk assessments.

    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 electronic records systems to support transfer of clinical information between mental health and physical health specialists

    Wider context from the report

    “2. It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems. The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa), with an inherent risk to patient safety arising from such information being held in silos. ”

    Source location

    Corinne Haslam · 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

    Issues concerning Pennine Care NHS Foundation Trust should be addressed in the Trust’s response.

    Verbatim wording from the response

    “I note that you have also addressed matters of concern to the Chief Executive of Pennine Care NHS Foundation Trust and I would expect the Trust’s response to address those issues.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 28 July 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Shared care records are considered a safe and secure way to bring together separate records from different health and care organisations.

    Verbatim wording from the response

    “With regard to the compatibility of electronic patient records, a shared care record joins up information based on an individual rather than an organisation, and is a safe and secure way of bringing an individual’s separate records from different health and care organisations together.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 28 July 2023

    Open published response
  2. Swansea and Neath Port Talbot

    AI-generated summary

    Samuel Alexander Morgan · 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

    Samuel Alexander Morgan, who was suffering from alcohol addiction and had diagnoses of ADHD and social anxiety, was found deceased at his parents’ house on 9 May 2019 after tying a ligature around his neck. The principal concern was that addiction and mental health services could not electronically access each other’s records, meaning important information about suicide risk and patient safety might be lost or insufficiently understood between treating teams.

    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 integrated electronic access to medical and treatment records between treating teams

    Wider context from the report

    “I am concerned that in cases where an individual is receiving treatment from alcohol and drug addiction services and treatment from the primary community mental health team that neither team is able to access the other teams records electronically. The lack of integrated electronic records between treating team means that important information regarding patient safety is not easily accessible between treating teams. Treating teams are reliant on referral letters which are necessarily limited and not always sufficient to capture all the detailed information available to a referring team. This is particularly concerning where there is dual diagnosis - such as substance misuse and mental health - given these are often complex cases. This is particularly the case where complex cases have not been referred into secondary mental health services and so do not have access to a care-coordinator who can oversee and understand the views of the various professionals treating and assisting an individual. I am concerned that the lack of such an integrated electronic system of medical and treatment records inhibits the effective sharing of information regarding patient safety and so increases the risk that information of significance regarding a risk to life will be lost between agencies and not sufficiently understood between all those managing risk. ”

    Source location

    Samuel Alexander Morgan · 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

    Enable two-way WCCIS information sharing between Swansea community mental health and drug and alcohol teams.

    Verbatim wording from the response

    “1. For Swansea based teams there is opportunity to share information between community mental health teams and drug and alcohol services via WCCIS which will allow 2 way sharing of all information in the WCCIS system relating to episodes of care both within community mental health services and drug and alcohol services. The technical changes to enable this will be completed within 10 working days and it is intended that this will be implemented week commencing 7th August 2023.”

    Source location

    Response from Swansea Bay University Health Board
    Page 2 · response
    Published 19 May 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Further WCCIS rollout is on hold pending Welsh Government approval of National Programme Team recommendations.

    Verbatim wording from the response

    “The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SB UHB is managed by Swansea Local Authority who”

    Source location

    Response from Swansea Bay University Health Board
    Page 1 · response
    Published 19 May 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    The Local Authority must request and implement any amendments to WCCIS system functionality.

    Verbatim wording from the response

    “The solution to this is intended to be the implementation of the Welsh Community Care Information System, (WCCIS) which is a national IT programme aimed at enabling the safe sharing of information between health and social care. This has been partially rolled out within the Health Board as part of the implementation of the solution within Swansea Local Authority. Further roll out within the Health Board is currently on hold pending the approval by Welsh Government of recommendations made within a Ministerial Advice Paper presented by the National Programme Team. The situation is complicated by the fact that only one of our Local Authority partners has chosen to implement WCCIS. The current deployment of the solution within SB UHB is managed by Swansea Local Authority who”

    Source location

    Response from Swansea Bay University Health Board
    Page 1 · response
    Published 19 May 2023

    Open published response
  3. Surrey

    AI-generated summary

    Amy Henderson · 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

    Amy Henderson, who had been diagnosed with post-partum depression and admitted to Priory Hospital, Woking after expressing suicidal thoughts and plans, died there on 21 March 2022 after taking her own life by suspension in a disabled toilet. Concerns included risk assessments and observations not being completed in line with policy, therapy notes indicating deterioration not being acted upon, incomplete information about her suicide risk, and ineffective management of the disabled toilet as a high-risk area.

    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 rapid access to NHS records on admission to a private hospital

    Wider context from the report

    “1. The information that Miss Henderson had practised tying a ligature was divulged by her at Kingston Hospital but not repeated on admission to the Priory Woking. The evidence given at the inquest was that there is no quick method to obtain NHS records on admission to a private hospital. A request could have been made but the records would have taken over a week to be released. The records were not sought. An ability to obtain the NHS records quickly would have been of assistance to the Priory clinicians. ”

    Source location

    Amy Henderson · 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

    Review national guidance on risk assessments.

    Verbatim wording from the response

    “NHS England has, however, been sighted on Priory Group’s Serious Incident Report regarding this matter and the resulting Action Plan and recommendations. I would like to provide some additional assurance that national guidance around risk assessments is currently being reviewed. I have also asked my regional colleagues to confirm whether Priory Woking now has access to GP records. NHS England is happy to provide further updates to the coroner in due course.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 27 April 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Implementation and operation of shared care records is assigned to Integrated Care Boards.

    Verbatim wording from the response

    “Implementation and operation of shared care records is the responsibility of Integrated Care Boards (ICBs). Initially, public sector connectivity is being prioritised but the forward programme plan for the Shared Care Record programme for 2023/25 acknowledges the important role that independent sector providers of care play. NHS England are aware that some ICBs are already engaging with Voluntary, Community and Social Enterprise organisations, recognising the important role that they play in the provision of care to their population. The Shared Care Record programme is also”

    Source location

    Response from NHS England
    Page 1 · response
    Published 27 April 2023

    Open published response
  4. Leicester City and South Leicestershire

    AI-generated summary

    Fadzai CHITAKUNYE · 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

    Fadzai Chitakunye died at Leicester Royal Infirmary on 26 February 2019 from a haemorrhage into her brain tumour. The report also records progression of hepatitis B infection following chemotherapy. A principal concern was the delay in transferring GP records, which may result in important medical history being missed, including hepatitis B information relevant to her treatment.

    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 in transferring GP medical notes between practices

    Wider context from the report

    “In this case the transfer of the notes from the deceased’s Nottingham general practitioner to the Leicestershire general practitioner took 11 months as reported to me by the GP. She also reports that notes still take about 16 weeks to be transferred between GP’s. Important information about the patient’s medical history may be missed particularly if the patient is not able to communicate effectively with the new GP. ”

    Source location

    Fadzai CHITAKUNYE · Prevention of Future Deaths report
    Page 1 · 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

    Invest in technology to improve patient care through the General Practice Forward View.

    Verbatim wording from the response

    “General practice is the cornerstone of our NHS and Government is committed to helping staff deliver for patients. The 2016 General Practice Forward View¹ strategy provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, a key aspect included investment in technology to improve patient care and work to increase the electronic transfer of records between practices.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 3 October 2022

    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

    Increase electronic transfer of health records between general practices through the General Practice Forward View.

    Verbatim wording from the response

    “General practice is the cornerstone of our NHS and Government is committed to helping staff deliver for patients. The 2016 General Practice Forward View¹ strategy provided support for practices to build the capacity and capabilities required to meet patients’ needs. As part of the GP Forward View, a key aspect included investment in technology to improve patient care and work to increase the electronic transfer of records between practices.”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 3 October 2022

    Open published response
  5. County Durham and Darlington

    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.

    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 print medical notes and other documents from the Trust IT system in shared premises

    Wider context from the report

    “2. It became apparent on the evidence that whilst Trust staff were working in premises operated by another Trust (in this case, County Durham and Darlington NHS Foundation Trust - CDDFT) they could not print medical notes and other documents from the TEWV IT system onto printers in 'shared' premises such as the A&E Department of the CDDFT. This again meant important documents can be unable to be shared with staff undertaking such tasks as Mental Health Assessments. ”

    Source location

    Mina TOPLEY-BIRD · Prevention of Future Deaths report
    Page 5 · 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

    Increase Liaison Team overnight staffing to two staff members.

    Verbatim wording from the response

    “The Trust has also since taken action and increased the staffing establishment of the Liaison Team, increasing the number of staff on duty overnight night to two. This means that if a document does need to be printed urgently, one member of staff can go to our nearby Trust premises to do this.”

    Source location

    2021-0100-Response-from-West-Park-Hospital-Redacted
    Page 2 · response
    Published 13 April 2021

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Operational 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
    Page 2 · response
    Published 13 April 2021

    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

    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
    Page 3 · response
    Published 13 April 2021

    Open published response
  6. East London

    AI-generated summary

    James Alexander 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

    James Alexander David Taylor died as a result of suicide after sustaining life-changing injuries in a road traffic collision, which led to refractory pain, sensory disturbances, psychological distress and suicidal ideation. The inquest heard that required long-term psychological therapy was not provided and that his participation in a functional neurological disorder programme ended after four days because of pain. Concerns were also raised about repeated changes of GP surgery, lack of continuity of care, and the absence of a clear transfer summary for his complex medical needs.

    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 care summaries when complex patients transfer between GP surgeries

    Wider context from the report

    “As a result of his complex health needs, Mr Taylor changed address on a number of occasions. This required a number of changes of general practitioner surgeries. In 4 years, Mr Taylor had changed surgeries 4 times. The Inquest heard evidence from his final general practitioner who confirmed that there was a large volume of records relating to Mr Taylor. The GP confirmed that no summary of care is provided to GP practices when transfer of patients take place. He confirmed the dangers of this, in that important clinical matters can be missed where a patient has a large volume of records. The general practitioner indicated that handover summaries should be provided to GPs when complex patients are transferred from surgery to surgery. Such transfer summaries could include a summary of past medical history and highlight acute, ongoing clinical conditions, together with any safeguards around prescribing of medication. Such summaries could ensure safety in the continuity of care ”

    Source location

    James Alexander David Taylor · Prevention of Future Deaths report
    Page 5 · 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

    Primary Care Support England, rather than the College, is responsible for the system of transferring GP records.

    Verbatim wording from the response

    “The responsibility for the system of transferring records lies with Primary Care Support England rather than RCGP, but our position is to support electronic transfer for the reasons articulated above.”

    Source location

    2020-0300-Response-from-Royal-College-of-GPs-Redacted
    Page 2 · response
    Published 8 January 2021

    Open published response
  7. Derby and Derbyshire

    AI-generated summary

    David Ball · Prevention of Future Deaths report

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

    Report summary

    David Ball was found deceased at home on 30 June 2019 after taking methadone and venlafaxine with the intention of taking his own life following delusions and paranoia. His discharge care plan was not fully implemented, including the planned community support. Concerns included poor communication between healthcare departments with separate patient records, and no process to ensure that emails were received or acted upon.

    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 shared patient care records across health care departments

    Wider context from the report

    “Different health care departments have different patient care records and the departments did not communicate with one another. Evidence was heard that healthcare professionals would have to rely on professional curiosity to ascertain crucial information regarding their patients. The examples used within the Inquest of David Ball were that the Hospital, Social Care and Derbyshire Healthcare all had different patient care records. ”

    Source location

    David Ball · 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 shared care record for Derby and Derbyshire to address information-sharing problems across multiple healthcare providers.

    Verbatim wording from the response

    “- Shared Care Record: A clear plan is in place to bring together a shared care record for Derby and Derbyshire plans to address the problems where there are multiple healthcare providers involved in a person’s care. This work is unlikely to be completed until 2024. In the meantime, there are systems in place to facilitate shared care conversations which include a Mental Health Liaison Team who will share relevant details on request and where appropriate in line with data protection regulations and a Mental Health Risk Triage Assessment Form, in use at Chesterfield Royal Hospital (CRH). This triage assessment form is designed to prompt the professional completing it to contact the Mental Health Liaison Team where a risk is identified.”

    Source location

    2020-0251-Response-from-NHS-England-and-NHS-Improvement-Redacted.pdf
    Page 2 · response
    Published 29 December 2020

    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

    Task the Learning from Deaths Forum with considering system improvements alongside the move to a shared care record.

    Verbatim wording from the response

    “The Forum will be tasked with considering system improvements complimentary to the move to a Shared Care Record and any recommendations will be escalated nationally through NHS E/I’s Executive Quality Group and associated sub-group which considers learning and improvement from these matters.”

    Source location

    2020-0251-Response-from-NHS-England-and-NHS-Improvement-Redacted.pdf
    Page 2 · response
    Published 29 December 2020

    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

    Coordination and management of discharge care plans fall outside NHS Digital’s area of responsibility.

    Verbatim wording from the response

    “We understand from the request that the discharge care plan was not followed, and this was not recognised. This is an issue of health and social care coordination and management.”

    Source location

    2020-0251-Response-from-NHS-Digital-Redacted.pdf
    Page 2 · response
    Published 29 December 2020

    Open published response
  8. Derby and Derbyshire

    AI-generated summary

    Mrs Christine Forbes · 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 Christine Forbes, a 72-year-old woman with a history of oxycodone stockpiling and misuse, died on 2 February 2020 after taking oxycodone and zolpidem. The principal concern was that patients registering with GP surgeries may be prescribed medication before their medical notes and relevant history are available.

    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 in transferring patients' medical notes and history to GP practices

    Wider context from the report

    “1. That when patients register at GP surgeries (across England) they do so without their medical notes and history. This material can take a significant amount of time to be sent to a GP practice after a request is sent to Primary Care Support England. Doctors and other medical practitioners are therefore treating and prescribing in situations where a full medical history is not known. ”

    Source location

    Mrs Christine Forbes · 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

    Enable all Derby and Derbyshire general practices to use GP2GP electronic record transfer.

    Verbatim wording from the response

    “All general practices across Derby and Derbyshire are enabled for GP2GP electronic record transfer; this is an electronic system which allows patients' electronic health records to be transferred between their old and new practices within a matter of minutes (at most 24hrs) , when a patient registers with a new GP practice.”

    Source location

    2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
    Page 1 · response
    Published 19 November 2020

    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

    Offer Ashbourne Medical Practice additional GP2GP and electronic record transfer training.

    Verbatim wording from the response

    “• Offer additional GP2GP/ Record Transfer training to Ashbourne Medical Practice”

    Source location

    2020-0181-Response-from-NHS-Derby-and-Derbyshire-Clinical-Commissioning-Group-Redacted.pdf
    Page 3 · response
    Published 19 November 2020

    Open published response
  9. Manchester South

    AI-generated summary

    Amy Hogan · 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

    Amy Hogan reported feeling unwell from around September 2019 and attended an out-of-hours doctor on 20 January 2020 with light-headedness, weakness and exhaustion. She became acutely unwell and collapsed at home the following day, dying at hospital aged 23. The principal concerns were that her previous GP records had not transferred and that the out-of-hours GP could not electronically access her regular records, including information that she was prescribed the oral contraceptive pill.

    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 transfer complete patient data when patients move between general practices

    Wider context from the report

    “1) The inquest heard evidence from Miss Hogan’s regular GP that, despite being requested, the General Practice records from her previous practice never arrived. It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories. It is a matter of particular concern that such issues create particular problems for vulnerable patients, who simply may not be in a position to do so; ”

    Source location

    Amy Hogan · 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 address root causes of electronic GP2GP record-transfer failures.

    Verbatim wording from the response

    “There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work.”

    Source location

    2020-0147-Response-from-NHS-England.pdf
    Page 2 · response
    Published 7 October 2020

    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

    Increase the GP2GP transfer file-size limit from 50MB to 100MB.

    Verbatim wording from the response

    “There is an ongoing programme of work to review and establish and reduce the root cause of electronic GP2GP (GP2GP is the formal term for the programme) record transfer failures. In March 2020 there was an increase applied by GP system suppliers to GP2GP transfer ‘file size’ from 50MB to 100MB, this will subsequently help to reduce the rate of failures further. Due to COVID-19 competing priorities, statistics are not yet available to demonstrate the effect this change has had. However, we anticipate analysis and collection of these metrics will resume as part of the recovery work.”

    Source location

    2020-0147-Response-from-NHS-England.pdf
    Page 2 · response
    Published 7 October 2020

    Open published response
  10. Manchester North

    AI-generated summary

    Beverley Shaw · 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

    Beverley Shaw was found deceased in her bed at home in Oldham in the early hours of 11 December 2018. The inquest heard that she had multiple prescribed medicines, was receiving methadone, and was using cocaine and butane gas. Concerns included inadequate communication between the substance misuse service and GP practice about her butane gas use, lack of a full medication review, and incomplete transfer of medical records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to transfer the full medical records and past medical history to the new substance misuse service

    Wider context from the report

    “○ The Court heard evidence that following the transition from another provider to Turning Point a decision was taken that all medical records relating to users of the substance misuse service do not need to be carried over to Turning Point. Unlike other medical records ie GP records which go with the patient when they move surgery the new substance misuse service only receives the last 6 months records hence they do not have the full past medical history available. ”

    Source location

    Beverley Shaw · Prevention of Future Deaths report
    Page 1 · 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

    Complete a wide-ranging review of GP communication across all community substance misuse services.

    Verbatim wording from the response

    “Whilst we recognise that the clinician had written to the GP, we accept that there is more that we could do to improve this communication, not only in this tragic case but also more broadly across our substance misuse services. Therefore, we have undertaken a wide ranging review of GP communication across all our community substance misuse services, not just in Rochdale and Oldham. That review has been led by our Senior Management Team, including our senior clinical team, and our Risk and Assurance department.”

    Source location

    2019-0191-Response-by-Turning-Point
    Page 1 · response
    Published 23 August 2019

    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

    Improve processes for transferring client data at the beginning and end of contracts.

    Verbatim wording from the response

    “We also reviewed our systems for following up requests to GPs for information and the way in which we transfer client data at the beginning and at the end of contracts.”

    Source location

    2019-0191-Response-by-Turning-Point
    Page 1 · response
    Published 23 August 2019

    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 commissioned provider is responsible for resolving transfer of full records when a new provider takes over.

    Verbatim wording from the response

    “Records This is related to the commissioned provider and I hope that they can resolve this issue with the transfer of full records with a new provider.”

    Source location

    2019-0191-Response-by-Hopwood-House-Medical-Practice
    Page 3 · response
    Published 23 August 2019

    Open published response
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Data last updated 7 September 2026