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. Shropshire, Telford and Wrekin

    AI-generated summary

    Patricia Violet PALIN · 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

    Patricia Violet PALIN died on 2 October 2017 after presenting to hospital with sepsis and kidney damage. The report describes delayed recognition and treatment, including delayed antibiotics, absence of oxygen administration, failure to remove leg dressings for examination, and failure to follow sepsis guidelines. Concerns also included limited access to GP records, insufficient A&E doctor cover, and an unavailable prescribed antibiotic.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide Shropdoc personnel with access to referring patients’ GP records

    Wider context from the report

    “1. Shropdoc personnel, be that Doctors or Urgent Care Practitioners are not able to access the referring patients GP records. This meant that they did not have the full picture of Patricia’s past medical history before administering any advice or treatment. This is not a one off isolated incident and applies to every case that is referred to Shropdoc. Evidence was given at the inquest from the Shropdoc Urgent Care Practitioners that it would have assisted them. ”

    Source location

    Patricia Violet PALIN · 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

    Write to practices encouraging discussion of enhanced Summary Care Records with patients who have chronic illness.

    Verbatim wording from the response

    “I’m afraid I don’t have figures for the proportion of Shropshire and Telford patients with severe frailty who have an enhanced SCR. The CCGs may be able to provide these. Clearly, GPs have a responsibility to encourage uptake in this group. In addition, there seems little doubt that there are potential benefits in all patients classed as frail having an enhanced SCR, and that could be extended further. As far as I am aware, there are no plans by the Government to extend the requirement beyond those with severe frailty. GP workload and manpower issues limit the capacity of practices to do more but I will write to practices encouraging GPs to discuss the benefits of allowing an enhanced SCR with all their patients with chronic illness.”

    Source location

    2018-0183-Response-by-Shrewsbury-and-Telford-Hospitals-NHS-Trust
    Page 7 · response
    Published 8 July 2018

    Open published response
  2. Surrey

    AI-generated summary

    Daniel Maher · 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

    Daniel Maher was found hanging at his home on 26 May 2016, and efforts to resuscitate him were unsuccessful. The report raised concerns that significant information about vulnerable individuals may not be readily accessible when mental health services in West Sussex and Surrey are involved, including because of limited access to records and reliance on verbal referrals without routinely shared paperwork.

    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 routinely share clinical assessment records with receiving community mental health services outside the county

    Wider context from the report

    “During the course of the inquest the court heard evidence from mental health professionals working on behalf of both West Sussex County Council and SABP. The court was told that it was not an uncommon occurrence for patients who are detained in Surrey under s.136 MHA to be taken to Langley Green Hospital in West Sussex for assessment and then, at some point thereafter, to be released back into the care of the community health services in Surrey. Given that this is not an uncommon occurrence I have concerns regarding the sharing of information as between the respective mental health services in West Sussex and Surrey. - The court was told that mental health professionals cannot access patient information which is held on the computerised systems of mental health services outside their own county. As a result, they are dependent on seeking that information directly from their colleagues in other counties, which the court was told was a time consuming process and also impracticable in relation to mental health assessments carried out during anti-social hours. - The court was also told that it is common practice, after a mental health assessment has been completed at the s.136 suite at Langley Green Hospital, for a verbal referral to be made by telephone in respect of patients being referred to community mental health services outside of the county. The court was told that key paperwork, such as the clinical record of the s.136 assessment, is not routinely shared on the making of such referrals. In fact that the Approved Mental Health Professional employed by West Sussex County Council indicated that she was not allowed to fax such paperwork to other agencies for reasons of data protection. - As a result of the above I am concerned that significant information relating to the clinical history, presentation and risk of vulnerable individuals is not easily accessible by the relevant healthcare professionals, in circumstances in which an individual is assessed at the s.136 suite in West Sussex, and has either previously been under the care of, or is referred back into the care of, mental health services in Surrey. Consideration should be given to whether any steps can be taken to address the above concerns. ”

    Source location

    Daniel Maher · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Birmingham and Solihull

    AI-generated summary

    Leah Abby Ratheram · 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

    Leah Abby Ratheram, who had autism, foetal alcohol syndrome and a history of self-harm, died after being found hanging from a tree on 7 October 2016. The report raised concerns about the lack of coordinated care and unclear responsibility between mental health organisations, ineffective sharing of records and risk information, and uncertainty about the Mental Health Act assessment process.

    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 and access mental health records effectively between organisations

    Wider context from the report

    “2. Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process. It was unclear how staff from each organisation would access each other’s records when patients present to one or other of the services. ”

    Source location

    Leah Abby Ratheram · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  4. Liverpool and the Wirral

    AI-generated summary

    Amy Rose COOPER · 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 was born at 40 weeks’ gestation by caesarean section on 8 July 2015 and required immediate resuscitation before being confirmed dead later that evening. Intrauterine growth restriction was not evident to the community midwives or hospital maternity unit until post-mortem investigations; the report also raised concerns about incompatible record-keeping systems and the sharing of maternity information between services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services

    Wider context from the report

    “It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area. Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care. This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information. This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place. Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome. ”

    Source location

    Amy Rose COOPER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Inner North London

    AI-generated summary

    Keith Gallimore · 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

    Keith Gallimore, who had discussed plans to commit suicide with a clinical psychologist, was found deceased at home on 4 December 2014. The medical cause of death was the combined toxic effects of heroin and cocaine, and suicidal or accidental intent could not be established to the required standard. Concern was raised that potentially important iCope information was not accessible to other services within the same Trust without a proactive request, including in out-of-hours settings.

    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 an out-of-hours process for obtaining and transferring iCope notes to Rio

    Wider context from the report

    “(1) I am concerned that potentially important information, documented by a service provided by CANDI, is not accessible by other services within the same Trust, without a proactive request being made. It was not clear why this restriction is in place, nor what steps could be taken if information were required in an ‘out-of-hours’ setting, at which time the iCope service would not be available to copy notes to Rio. Although there was no evidence that, had the iCope notes been available to the Crisis Team, the outcome of Mr Gallimore's case would have been different, I am concerned that future deaths could result because of this issue. ”

    Source location

    Keith Gallimore · 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

    Maintain a protocol for checking new referrals against IAPTUS and recording relevant current or recent ICope contacts on RiO.

    Verbatim wording from the response

    “I agree that there is a gap in information sharing between ICope and rest of the Trust, this is because of the use of different electronic patient record systems. ICope is obliged to use electronic patient records system called IAPTUS because of national data reporting requirements, whilst all other services in the Trust use electronic patient records system called RIO. ICope has an established protocol for checking all new referrals against the RIO system and for making entries on RIO where patients have either current or recent contact with the service.”

    Source location

    2015-0184-Response-by-Camden-and-Islington-NHS-Trust
    Page 1 · response
    Published 11 May 2015

    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

    Train designated acute-assessment staff across liaison, crisis-resolution and bed-management teams to check IAPTUS records and access clinical notes.

    Verbatim wording from the response

    “One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will be able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO.”

    Source location

    2015-0184-Response-by-Camden-and-Islington-NHS-Trust
    Page 2 · response
    Published 11 May 2015

    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

    Entering all ICope patient data in both systems is impractical and would provide little benefit because of the service’s referral volume.

    Verbatim wording from the response

    “One possible solution would be for all ICope staff to enter all their patient data on RIO as well as IAPTUS. Given the number of referrals to the service (some 17,000 in the last year) this is impractical and would mostly be of little benefit. Following discussion between leads in our Acute Division and ICope it was agreed that the most effective solution would be to provide IAPTUS training to a small number of front-line staff (who provide services 7 days a week/ 24 hours a day) in the Acute Division. This means that staff working in the acute assessment teams will be able to make routine checks on all new patients against the IAPTUS system and have immediate access to the full clinical notes. All IAPT staff are already trained on the use of RiO electronic system and have access to RiO.”

    Source location

    2015-0184-Response-by-Camden-and-Islington-NHS-Trust
    Page 2 · response
    Published 11 May 2015

    Open published response
  6. Cornwall

    AI-generated summary

    Shannon Kimberley Gee · 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

    Shannon Kimberley Gee, aged 16, died as the result of an Accident. The report raised concerns about gaps between mental health services, delays of weeks in resolving disputes over responsibility for treatment, and difficulties transferring medical notes and 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

    Difficulties in transferring medical notes and records

    Wider context from the report

    “The situation now is improved from when ████████ encountered the delay in treatment to her but, on the evidence should ████████ a delay of ‘weeks’ in resolving clinical disputes as to which organisation should treat a patient is still worrying. Ideally, there should be a seamless union between the two organisations. The fact that there is not appears to be a consequence of the maximum threshold for treatment by OSW being lower than the minimum threshold for acceptance on to the CMHT workload. Put another way, it is entirely conceivable that both OSW and CMHT may be correct in applying their respective rules as to whether a patient needs to be taken on where that patient’s presenting complaints falls between the two organisations’ rules. That may require formal guidance to resolve hence directing this letter to the Secretary in addition to the Commissioners. The difficulties set out concerning the transfer of medical notes and records appear more difficult to justify. ”

    Source location

    Shannon Kimberley Gee · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  7. Manchester South

    AI-generated summary

    THOMAS PATRICK MAHER · 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

    Thomas Patrick Maher fell on a ward at Trafford General Hospital on 3 February 2014 and fractured his acetabulum. The report identified concerns about missing clinical records, assessments and alarm arrangements relating to falls risk, delays and problems in transferring him between hospitals, ward placement, medication administration, notification of next of kin, and the transfer of patient notes. The investigation recorded the medical cause of death as chest sepsis, hospital-acquired pneumonia and a left acetabulum fracture of the hip, with other conditions also listed.

    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 patient-note transfer between paper-based and electronic hospital systems

    Wider context from the report

    “8. There is an apparent major problem with regard to patient notes where those at MRI are ‘paper based’ whereas those at Trafford are electronic. I was told that it will be at least two years before this situation is reconciled. This is inherently dangerous in that the treating doctors may not have the up to date notes available to them. Both senior doctors who gave evidence to me described the system of transfer of notes between hospitals as “impossible”. ”

    Source location

    THOMAS PATRICK MAHER · 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

    Develop and roll out the Chameleon electronic patient-record system across the Trust in stages.

    Verbatim wording from the response

    “There is a longer term aim that all patient records, including nursing notes and charts, will be electronic across the whole of the Trust using a system called Chameleon. This will minimise the risks that documentation will be lost. The timeframe for this to be complete across the entire Trust is 2018. However, this is being developed and implemented in stages so it is likely that Trafford will be fully electronic before then.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 1 · response
    Published 5 June 2014

    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 electronic patient records on Ward 16 so clinicians at both sites can access up-to-date notes without transferring paper records.

    Verbatim wording from the response

    “Medical records at Trafford Hospital are electronic and are easily accessible to all medical staff at MRI on any computer. However, until February this year Ward 16, which is a ward based at Trafford but managed by Manchester Royal Infirmary, were still using paper documentation. This is why ████████ was unable to access Mr Maher's records. Ward 16 is now using the EPR system in line with the rest of Trafford Hospital. Therefore, up to date case notes are now available to Clinicians at both sites with no further need for transfer of paper notes between sites.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 5 · response
    Published 5 June 2014

    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

    Electronic records were accessible at both sites, so no further transfer of paper notes was considered necessary.

    Verbatim wording from the response

    “Medical records at Trafford Hospital are electronic and are easily accessible to all medical staff at MRI on any computer. However, until February this year Ward 16, which is a ward based at Trafford but managed by Manchester Royal Infirmary, were still using paper documentation. This is why ████████ was unable to access Mr Maher's records. Ward 16 is now using the EPR system in line with the rest of Trafford Hospital. Therefore, up to date case notes are now available to Clinicians at both sites with no further need for transfer of paper notes between sites.”

    Source location

    2014-0252-Response-by-Central-Manchester-University-Hospital-NHS-Trust
    Page 5 · response
    Published 5 June 2014

    Open published response
  8. North East Kent

    AI-generated summary

    Nicos Andreas MICHAEL · 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

    Nicos Andreas MICHAEL died in hospital on 1 November 2013 after suffering a cardiac arrest and significant brain injury following an acute anaphylactic reaction to intravenously administered Augmentin. The principal concerns were that allergy information was conflicting or incompletely recorded, a historic hospital record of an Augmentin reaction was not carried forward or passed to the GP, and systems did not reliably make previous allergy information available to treating staff.

    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 recorded medication allergy information across subsequent records and to GPs

    Wider context from the report

    “(1) There was no clear evidence (such as a document signed by Mr MICHAEL or a family member) detailing medication to which he/they was/were aware he was allergic. This led to there being conflicting evidence between his having (according to his son) highlighted his penicillin and Ibuprofen allergies to hospital staff and the allergy information for this admission recorded by hospital staff (which did not include penicillin but did include Ibuprofen). (2) The Root Cause Analysis conducted by the hospital into this death identified that Mr MICHAEL had three sets of hospital notes, in one of which there was a solitary entry to suggest that at a past medical attendance a reaction to Augmentin was noted. That information does not appear to have been translated in any subsequent entries nor to have been passed to his GP. (3)The importance of known or suspected allergies that have been recorded on previous contacts with a hospital being readily available to the hospital’s staff when next treating that patient cannot be over-emphasised. There was evidence that the RCA team have sought learning from this event and how to record accurately and continuously highlight all known allergies or reported allergies, and how that information can be kept and made available on every patient at presentation. However, the evidence also showed that the medical reporting and computer systems for patient tracking do not currently allow this facility in such a way, although the relevant Trust teams are investigating how this data recording can be made more accurate. (4) Although the Trust has indicated that electronic prescribing should now be prioritised (which it considers could potentially have flagged up the historic allergy documentation), the RCA gave no indication that this would be compulsory for the future, or that any steps were being taken to encourage or make compulsory the checking of earlier paper records for information contained therein on allergies. ”

    Source location

    Nicos Andreas MICHAEL · 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

    The records did not contain a consistently recorded penicillin allergy; staff were aware of the patient's reported allergies.

    Verbatim wording from the response

    “1. There was no consistently recorded allergy to penicillin contained in the healthcare records held by the Trust. Indeed the patient himself did not articulate an allergy to penicillin at his pre-operative assessment; he did state allergies to Ibuprofen and Aspirin and red “known allergy” wristbands were applied from the date of his admission. The staff on ICU and on Kent Ward were all aware of Mr Michael’s reported allergies.”

    Source location

    2014-0168-Response-by-East-Kent-Hospitals-University
    Page 1 · response
    Published 14 April 2014

    Open published response
  9. Milton Keynes

    AI-generated summary

    Doris Phoebe Miller · 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

    The circumstances of Doris Phoebe Miller’s death are not provided in the supplied text. Concerns included the GP surgery’s lack of access to her transferred medical records, ineffective communication about an urgent blood test, and the absence of a pulse oximeter at the surgery.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to provide the GP surgery with access to transferred patient records

    Wider context from the report

    “(1) Mrs Miller’s notes and records were unavailable to the GP surgery at Broughton Gate despite having been transferred to the surgery, following the closure of the Willen practice in April 2013. Indeed I was informed by a GP who gave evidence before me that she was still, in November 2013, unable to access the patient records. Over 2000 patients were transferred to Broughton Gate and if the circumstance above continues there is a possibility that lives will be put at risk. ”

    Source location

    Doris Phoebe Miller · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
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Data last updated 7 September 2026