Recurring concern

Unreliable consolidation and access to patients’ cross-service clinical risk information

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First reported 28 Nov 2013•Latest report 10 Jun 2026

Definition

What this concern includes

Includes failures to consolidate, link, flag, transfer, retrieve or provide access to clinically significant patient history and risk information across healthcare services, including information from different NHS Trusts, GP practices, emergency departments and receiving hospitals where the information is needed for safe assessment, treatment or risk management.

Not included

  • Excludes generic communication, documentation or coordination deficiencies where cross-service clinical history or risk information is not the material unsafe object.
  • Excludes failures to act on complete and accessible clinical history or risk information when the information-access process itself was reliable.
  • Excludes condition-specific information systems or pathways, such as allergy, mental-health, oxygen or medication systems, when that named concern provides the more specific supported boundary.
  • Excludes failures confined to creating, completing or maintaining a record within one service where no cross-service consolidation, transfer or access deficiency is identified.
  • Excludes non-clinical, administrative or operational information that is not needed for patient assessment, treatment or safety-risk management.
Reports
20

Distinct published reports

Individual concerns
20

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
35

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 England8
Department of Health and Social Care7
Care Quality Commission2
Recipient name withheld2
Bedford Hospital South Wing1
Central and North West London NHS Foundation Trust1
Cornwall Health Limited1
Cornwall Partnership NHS Foundation Trust1
Dr Simon Chapple1
East Cheshire NHS Trust1
Essex Partnership University NHS Foundation Trust1
Holderness Health1
Luton and Dunstable University Hospital1
Milton Keynes University Hospital1
Mr Simon Wright1

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. North East Kent

    AI-generated summary

    Hayley Smith · 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

    Hayley Smith developed severe and enduring anorexia nervosa and died on 29 December 2019 after an out-of-hospital cardiac arrest caused by severe hypoglycaemia. The inquest identified inadequate communication and information-sharing between the organisations involved in her care, including failures to share information about her Community Treatment Order.

    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 clinical record systems to provide cross-organisational access to crucial information

    Wider context from the report

    “(1) Evidence given at the inquest revealed that there were seven different organisations involved in Hayley’s care all of whom had different systems for recording their clinical notes: I. South London and the Maudsley NHS Foundation Trust (SLAM) II. North East London NHS Foundation Trust (NELFT locally known as the Kent and Medway Eating Disorders Team) III. The White House IV. Kings College NHS Foundation Trust (Kings) V. General Practitioner (GP) VI. East Kent Hospitals NHS Trust (EKHT for Queen Elizabeth the Queen Mother) VII. South East Coast Ambulance Service (2) The evidence given at the inquest revealed that each of the organisations were reliant on being copied into correspondence or on specific information being shared by others. The White House were not sent copies of clinical correspondence and at the time did not have access to GP records although since Hayley’s death do now have access to GP records. The mental health team at NELFT were responsible for managing Hayley’s CTO despite the fact that she was placed out of their geographical area but were not aware she had been seen by either the ambulance service or by Queen Elizabeth the Queen Mother hospital. (3) The evidence at the inquest revealed that communication between those involved in her short life was inadequate and, as each ran separate clinical records systems, they could not access crucial information which could have made a difference ultimately meaning Hayley may not have died when she did. It is highly likely that the paramedic at South East Coast Ambulance Trust who attended Hayley on 23rd December or the emergency department nurse who saw her at Queen Elizabeth the Queen Mother hospital on 24th December 2019 been aware that Hayley was on a CTO they or her treating mental health team would have been able to take steps which would have saved her life. (4) Evidence was given at the inquest that locally some steps have been taken to try to share key data between acute hospitals but there have been significant hurdles which have impeded the process namely, the different information technology systems used, licensing issues for the software, Data Protection requirements, confidentiality and consent issues as well as training and funding. (5) Hayley died following an out of hospital cardiac arrest on Christmas day 2019. If information been shared between different health care organisations particularly crucial information about Hayley’s CTO it is highly likely she would still be alive today. ”

    Source location

    Hayley Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. 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
  3. 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

    Unavailability of electronic access to regular GP records in out-of-hours care

    Wider context from the report

    “2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP receiving Miss Hogan had no electronic access to her regular GP records. Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients. ”

    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

    Enable authorised professionals to access GP records through GP-Connect across primary care settings.

    Verbatim wording from the response

    “Over recent months significant progress has been made around the access to GP records out of hours. As a response to the pandemic, we have enabled the use of GP-Connect across the whole primary care estate. This eases facilitation for authorised professionals in multiple care settings to directly access in a safe and secure manner GP records which are held at GP out of hours services, CCAS, Extended Access Hubs and NHS 111.”

    Source location

    2020-0147-Response-from-NHS-England.pdf
    Page 1 · response
    Published 7 October 2020

    Open published response
  4. 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
  5. Cornwall and Isles of Scilly

    AI-generated summary

    David John Buttriss · 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 John Buttriss died at home on 9 May 2016 after cutting himself during a mental health crisis, despite medical assistance and resuscitation. The report identified communication problems between the GP and mental health services, separate healthcare record systems that limited access to relevant information, and a lack of clarity about the appropriate crisis-response pathway and the roles of different mental health 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 access to relevant records across healthcare providers

    Wider context from the report

    “1. Mr Buttriss had contact with a number of health agencies in the weeks prior to his death including the Community Mental Health, Home Treatment team, GP, Out of Hours GP and Paramedics. It was clear from the evidence at the inquest that • There were Communication issues between the GP and mental health service. The mental health services had requested a patient profile from the GP on 14.5.16 which was not received. The Patient’s GP did not advise mental health services that Mr Buttriss had a mental health history pre-2009 when spoken to following his first self-referral on 14.5.16. It was not known whether this may have affected the decisions the mental health professionals took but it did and meant that his mental health issues were not known to the Cornwall Mental Health Service when they were contacted at the time of crisis • The health care records for the GP and the Mental Health services are held on different health care record systems held by the different healthcare providers. This meant that the GP did not have access to the mental health service records at the time of the consultation on by ████████ on 25th April nor did the mental health workers have information about the appointment with ████████ nor were they aware of the medication issues. The Out of Hours GP, ████████ did not have access to either the mental health or GP records and was in a difficult position when deciding how to deal with Mr Buttriss especially with regards to prescribing and sign posting to mental health professionals when she saw him in acute crisis on the 7th May. • It was clear from the evidence of the Paramedic and ████████ and the parents that there was lack of clarity of the appropriate method or pathway to deal with Mr Butriss on the night of 7th May when he was in crisis. The paramedic did speak to the Home Treatment Team for advice but as Mr Buttriss was reluctant to engage no intervention was made. There appeared to be confusions between the role of the Community Mental Health Service and the Home Treatment Team and the Home Treatment Team Out of Hours provision. ”

    Source location

    David John Buttriss · 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

    Lead the Global Digital Exemplar programme to improve electronic record sharing and disseminate digital information-sharing learning across NHS trusts.

    Verbatim wording from the response

    “We recognise that there are many challenges across the NHS to support secure data and record sharing, and we are actively leading a number of initiatives to address this. For example, the Global Digital Exemplar (“GDE”) programme, led”

    Source location

    2018-0010-Response-by-NHS-England
    Page 1 · response
    Published 7 March 2018

    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

    Support Local Health and Care Record Exemplars to establish safe, integrated access to permitted patient information across health and care organisations.

    Verbatim wording from the response

    “In addition, NHS England is working with a number of Local Health and Care Record Exemplars to support the provision of safe integrated care across health and care settings. The aim will be to establish a local record for authorised staff in different organisations to access permitted information about a patient’s history of contact with the NHS and related care services. This may include information from ‘physical health checks’ for people with serious mental illness which NHS England is encouraging a greater take up of. We have made progress on this with around 60 local information sharing initiatives underway, each aiming to share information across organisations – such as GP, Acute and Social Care settings – and across geographies as the patient moves.”

    Source location

    2018-0010-Response-by-NHS-England
    Page 2 · response
    Published 7 March 2018

    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 secure RiO access arrangements are considered sufficient for sharing health records with other agencies.

    Verbatim wording from the response

    “The Trust already works with other agencies to allow secure health record sharing. Agencies are requested to complete an application form for access to RiO, the Trust’s electronic health record system. The application form is a standard form which requires specific information detailing the individual, their role, employing organisation and the legal basis for access as well as confirmation of Information Governance training. The Trust has allowed access to RiO to a number of agencies including Cornwall Council, acute hospitals and GPs.”

    Source location

    2018-0010-Response-by-Cornwall-NHS-Trust
    Page 2 · response
    Published 7 March 2018

    Open published response
  6. Manchester North

    AI-generated summary

    Timothy John Smedley · 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

    Timothy John Smedley was found in a shallow waterway at the foot of Rakewood Viaduct on 7 June 2017, and his death was concluded to be suicide. The concerns identified were a lack of joint access to NHS records for out-of-hours services, fragmentation of care, and difficulties for people with alcohol addiction in accessing timely and appropriate mental health 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 access to NHS records by out-of-hours services

    Wider context from the report

    “1. The lack of (joint) access to NHS records by ‘out of hours’ services such as GPs, Urgent Care Centres etc. resulting in unsafe, fragmentation of care. ”

    Source location

    Timothy John Smedley · 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

    Expand Summary Care Record availability and use across more settings, including urgent and emergency care.

    Verbatim wording from the response

    “You may be aware of the introduction of the Summary Care Record which now covers more than 98 percent of the population. The Summary Care Record is being used successfully in many settings across the NHS such as A&E departments, hospital pharmacies, NHS 111, GP out-of-hours services and walk-in centres. Additionally, the Summary Care Record can be seen and used by authorised staff in other areas of the health and care system involved in the patient’s direct care.”

    Source location

    2017-0398-Response-by-Department-of-Health
    Page 2 · response
    Published 15 February 2018

    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 towards interoperable digital care records across health and care services.

    Verbatim wording from the response

    “We expect that challenges around the sharing of patient information will, in large part, be addressed by the move away from paper records to electronic systems for recording and sharing patient information. Digitisation provides an important opportunity to improve communication flow in the interests of patient safety, leading to improved outcomes and efficiency.”

    Source location

    2017-0398-Response-by-Department-of-Health
    Page 2 · response
    Published 15 February 2018

    Open published response
  7. Swansea and Neath Port Talbot

    AI-generated summary

    Hope Erin Evans · 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

    Hope Erin Evans, a premature baby born at 26 weeks, died from sepsis contributed to by ESBL E. coli contracted in hospital. The report states that the source was likely another baby, although the means of transfer was unknown. Concerns included important patient history not being captured and passed between hospitals, and the failure to complete All Wales Inter Hospital Transfer 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

    Failure to pass important patient history to the receiving hospital

    Wider context from the report

    “1. I have concerns that important patient history was not captured by the admitting hospital and passed to the receiving hospital. Mother A had received IVF treatment in India and had there acquired the ESBL E. coli. This important information was recorded in her medical notes which were with her. If the receiving hospital was aware of this the certainly the treatment of the twins would have been different and barrier nursing would have been implemented. ”

    Source location

    Hope Erin Evans · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  8. Manchester South

    AI-generated summary

    Audrey Lily Kelly · 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

    Audrey Lily Kelly complained of abdominal pain on 17 November 2013, was prescribed Trimethoprim by an out-of-hours doctor who could not access her GP medical notes, and was found deceased at home two days later. The investigation concluded that she died from natural causes. The principal concern was that out-of-hours services and hospital emergency departments could not access patients’ GP notes, including allergy information, which was considered a serious procedural lapse that could put lives at risk.

    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 out-of-hours and hospital emergency department clinicians with direct access to patients’ GP notes

    Wider context from the report

    “During the course of the evidence it was made very clear to me by the attending doctor who prescribed the medication and also by the nurse who took the call at the Out of Hours service that they could not /are not allowed to obtain and see the electronic notes held by the patient's own GP. This fact was backed up by a senior administrator of the Out of Hours service who reiterated that neither they nor the hospital Emergency Departments, have direct access to GP Notes. It seems to me that this is a serious lapse in the procedures and will inevitably lead to further lives being lost when, if the notes were available, those lives might be saved. In the case of the Out of Hours service it seems particularly absurd that these notes are not available when in fact the Out of Hours doctor is deputising for that very GP who not allowing access to the notes. It would appear therefore that there is an immediate need for directions to be issued to ALL OUT OF HOURS PROVIDERS and the appropriate Clinical Commissioning Groups to the effect that there must be free and unfettered access to ALL the GP notes in these circumstances. ”

    Source location

    Audrey Lily Kelly · 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

    Seek formal assurance from Mastercall on new-starter processes and contingencies for practitioners without NHS Smartcards.

    Verbatim wording from the response

    “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:”

    Source location

    2014-0155-Response-by-Department-of-Health2
    Page 2 · response
    Published 8 April 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

    Map and analyse shared-record access processes and systems with Mastercall to identify and mitigate further risks.

    Verbatim wording from the response

    “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:”

    Source location

    2014-0155-Response-by-Department-of-Health2
    Page 2 · response
    Published 8 April 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

    Work with Mastercall to provide fit-for-purpose mobile access to relevant patient information at the point of care through a governed improvement project.

    Verbatim wording from the response

    “Stockport CCG is already engaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures:”

    Source location

    2014-0155-Response-by-Department-of-Health2
    Page 2 · response
    Published 8 April 2014

    Open published response
  9. South London

    AI-generated summary

    Simon William McAndrew · 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

    Simon William McAndrew died in hospital on 3 July 2011 after being found hanging from a tree at the residential home where he lived and subsequently suffering severe brain injury. The principal concerns were poor communication and confusion between services about responsibility for his psychiatric care, including the sharing of key information and provision of appropriate crisis guidance to the residential home.

    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 key clinical staff can access important electronic information held in different NHS trusts

    Wider context from the report

    “Mr McAndrew had a drug misuse issue and a mental health issue. Each was dealt with by different specialist psychiatrists. After a long period of in-patient treatment at the Gordon Hospital Mr McAndrew was located in a residential home in another Borough. His key caseworker was not easily able to keep in touch with him. His methadone management was managed by Lantern House, a local NHS facility in the London Borough of Croydon. When acute psychiatric issues arose Lantern House staff ordinarily worked in close liaison with the local acute mental health trust (SLAM). At the material time it was not appreciated that Mr McAndrew’s psychiatric care remained with the Gordon Hospital. Correspondence from one trust to another was copied to the consultant psychiatrist at Lantern Hall but was not seen by her. This might have been because she was on leave when it was received and the copy letter was then scanned into the electronic patient record but not left in the consultant’s ‘in-tray’ for perusal on her return. An opportunity was missed to ensure effective communication with the Gordon Hospital staff. Junior staff, whether medical or nursing, had no ‘front page’ on the electronic patient record that contained information that the primary psychiatric care was held by the Gordon Hospital; so an inappropriate referral was made to SLAM. For so long as the national computer database for all NHS patients is a far-off ideal, some better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust. This is especially important in psychiatric illness, where patients may not be able to provide the relevant, important information themselves. ”

    Source location

    Simon William McAndrew · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report
  10. 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