Recurring concern

Unreliable operation and access of the BadgerNet clinical information system

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First reported 15 Sep 2023•Latest report 9 Nov 2023

Definition

What this concern includes

Includes failures in the named BadgerNet system and its directly integrated clinical workflows, including portal and chart availability, system implementation, access, display or configuration of clinical risk assessments, mapping of required guidance, and related controls needed to make safety-critical information and decision support available to authorised clinical staff.

Not included

Excludes generic electronic patient-record, IT access or information-sharing failures where BadgerNet is not explicitly the deficient system.
Excludes failures in clinical assessment, treatment or escalation after the relevant BadgerNet information or function was reliably available and suitable.
Excludes generic staffing, training, documentation or governance deficiencies unless they directly impair operation or access to BadgerNet.
Excludes unrelated clinical information systems, including EMIS, NOMIS, STORM, Lorenzo and other named systems, unless the assertion explicitly concerns BadgerNet integration.

Reports: 2
Individual concerns: 3
Date range: 2023–2023
Stated actions: 2

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

Clevermed Limited1

Department of Health and Social Care1

George Eliot Hospital NHS Trust1

National Institute for Health and Care Excellence1

Royal College of Midwives1

Royal College of Obstetricians and Gynaecologists1

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.

9 Nov2023
County Durham and Darlington
Concerns raised2
1. Failure of the BadgerNet NEWS risk assessment to fully map national guidance
2. Unavailability of the NEWTT2 chart on BadgerNet
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Implement Maternity functionality providing the Newborn Early Warning Score aligned with New Zealand national guidance.
  Stated by System C Healthcare LtdStated completed
2. Action
  Plan implementation of NEWTT2 in Neonatal EPR and Maternity for customer delivery after NHS England finalises its release.
  Stated by System C Healthcare LtdStated planned
Respondent positions 3
1. Position
  The Clinical Summary application did not contain NEWS, NEWTT or related functionality, so the referenced NEWTT chart was not generated by Badgernet.
  Stated by System C Healthcare LtdDisputes the concern
1. Position
  The Trust would need to investigate which solution generated the referenced NEWTT chart.
  Stated by System C Healthcare LtdRedirects responsibility
2. Position
  NEWTT2 implementation is deferred until NHS England finalises the guidance and releases its digital specification.
  Stated by System C Healthcare LtdUnable to act
AI-generated summary

Alfie Neil MAINS-FORSTER · 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

Alfie was born on 13 June 2022 and died in cardiac arrest at 01.50 on 14 June 2022 after intensive treatment. The postmortem cause of death was severe congenital pneumonia and meningitis, with suspected acute chorioamnionitis. The report identifies that antibiotics were not administered after concerning observations at 03.55, and raises concerns that electronic risk assessment did not fully map national guidance and that the NEWTT2 chart was not available on BadgerNet.

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 the BadgerNet NEWS risk assessment to fully map national guidance
Wider context from the report
“A) In the badgernet electronic system used at the Royal Victoria Infirmary by the Newcastle Upon Tyne Hospitals NHS Foundation Trust, the current risk assessment (NEWS) does not map the national guidance fully and if would be more user-friendly, and thereby assist towards more effective, and therefore safer, risk assessment for it to map the national guidance completely. ”
Source location
Alfie Neil MAINS-FORSTER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Unavailability of the NEWTT2 chart on BadgerNet
Wider context from the report
“B) The current NEWTT2 chart is not yet available and it would assist in the more effective management of risk for it to be on BadgerNet. This was supposed to be implemented in July 2023 but as yet it has not. ”
Source location
Alfie Neil MAINS-FORSTER · 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
Implement Maternity functionality providing the Newborn Early Warning Score aligned with New Zealand national guidance.

Verbatim wording from the response
“The customer agreed a deployment plan of Maternity for Go Live in January 2023 and Neonatal EPR for the 14th of November 2023.”

Source location
Response from System Connecting Care
Page 4 · response
Published 22 November 2023
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Plan implementation of NEWTT2 in Neonatal EPR and Maternity for customer delivery after NHS England finalises its release.

Verbatim wording from the response
“NEWTT2³ is planned to be introduced into Neonatal EPR and Maternity once the factors affecting deployment have been addressed. It should be noted that NEWTT2 was not fully agreed by NHS England until June 2023 and a digital specification will be made available by NHS England by Autumn 2024.”

Source location
Response from System Connecting Care
Page 4 · response
Published 22 November 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 Clinical Summary application did not contain NEWS, NEWTT or related functionality, so the referenced NEWTT chart was not generated by Badgernet.

Verbatim wording from the response
“The investigation found that on the 13th of June 2022, the customer site referenced in the report was utilising the Clinical Summary application for neonatal department only. The patient was not admitted into Neonatal and therefore was never added to the Clinical Summary.”

Source location
Response from System Connecting Care
Page 4 · response
Published 22 November 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 Trust would need to investigate which solution generated the referenced NEWTT chart.

Verbatim wording from the response
“The customer would not have been able to record National Early Warning Score (NEWS) or Newborn Early Warning Trigger & Track (NEWTT)² records within the Clinical Summary application as this was not part of the application, and therefore had to use another system or forms provided directly from the NHS as advised under the Newborn Early Warning Trigger & Track (NEWTT) – a Framework for practice (2015)².”

Source location
Response from System Connecting Care
Page 9 · response
Published 22 November 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
NEWTT2 implementation is deferred until NHS England finalises the guidance and releases its digital specification.

Verbatim wording from the response
“NEWTT2³ is planned to be introduced into Neonatal EPR and Maternity once the factors affecting deployment have been addressed. It should be noted that NEWTT2 was not fully agreed by NHS England until June 2023 and a digital specification will be made available by NHS England by Autumn 2024.”

Source location
Response from System Connecting Care
Page 4 · response
Published 22 November 2023
Open published response
15 Sep2023
Warwickshire
Concerns raised1
1. Unavailability of full Badgernet portal access
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Eclipse Morrison · 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

Eclipse Morrison died at Nottingham City Hospital on 21 July 2021, the day after her birth, following perinatal asphyxia and complications associated with gestational diabetes, excessive fetal growth and shoulder dystocia. The principal concerns included failures to follow up missed appointments, consider and discuss appropriate timing and mode of delivery, identify risk factors during labour, and ensure adequate fetal monitoring. Further concerns related to the implementation and quality assurance of Badgernet, escalation procedures for ultrasound concerns, counselling about shoulder dystocia, and interpretation of Montgomery guidance.

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 full Badgernet portal access
Wider context from the report
“2. Access to Badgernet portal / full implementation of the Badgernet software It seems that the Badgernet system is being relied on to address a number of issues which were identified in this case, and heavy reliance is being placed on a system which is not yet fully implemented. The concern remains that a critical aspect of this system, access to the portal, will not be in place until autumn 2023 at the earliest. ”
Source location
Eclipse Morrison · Prevention of Future Deaths report
Page 3 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised2

Failure of the BadgerNet NEWS risk assessment to fully map national guidance

Unavailability of the NEWTT2 chart on BadgerNet

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised1

Unavailability of full Badgernet portal access

Actions described in response 2

Respondent positions 3