Recurring concern

Unreliable inter-agency information sharing for coordinated care

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First reported 29 May 2013•Latest report 15 Jun 2026

Definition

What this concern includes

Includes failures of the inter-agency care information-sharing system, including inadequate arrangements, communication channels, shared records or contact mechanisms when these prevent timely access to relevant care, needs or risk information between agencies.

Not included

Excludes information-sharing failures unrelated to coordination between agencies supporting a person.
Excludes failures confined to a single organisation's records, assessment, documentation or communication process unless the report directly links them to inter-agency information sharing.
Excludes generic staffing, confidentiality, policy or technology deficiencies that are not specifically tied to the unsafe inter-agency information-sharing condition.
Excludes hazards involving public access to harmful information or physical communication and rescue equipment.

Reports: 212
Individual concerns: 235
Date range: 2013–2026
Stated actions: 492

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.

Department of Health and Social Care57

NHS England39

Ministry of Justice14

Home Office11

Greater Manchester Health and Social Care Partnership9

HM Prison and Probation Service8

NHS Greater Manchester Integrated Care Board8

Care Quality Commission7

Greater Manchester Mental Health NHS Foundation Trust7

Birmingham and Solihull Mental Health NHS Foundation Trust6

Metropolitan Police Service6

College of Policing5

Greater Manchester Police5

Midlands Partnership University NHS Foundation Trust5

Pennine Care NHS Foundation Trust5

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.

15 Jun2026
West Sussex, Brighton and Hove
Concerns raised1
1. Fragmented information sharing and updating across healthcare providers
This report raised 3 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.
Actions described in response 5
1. Action
  Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.
  Stated by NHS EnglandStated in progress
2. Action
  Facilitate collaborative sharing of patient data across care settings and geographic boundaries through Connecting Care Records.
  Stated by NHS EnglandStated completed
3. Action
  Provide the National Care Records Service for secure access to national patient information, including Summary Care Records and additional clinical information.
  Stated by NHS EnglandStated completed
1. Action
  Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.
  Stated by NHS EnglandStated completed
2. Action
  Continue supporting interoperable shared care records and their development toward a joined-up Single Patient Record.
  Stated by NHS EnglandStated in progress
Respondent positions 2
1. Position
  Responsibility for delivering shared care records sits with local Integrated Care Boards, based on local health and care needs and existing systems.
  Stated by NHS EnglandRedirects responsibility
1. Position
  Referral routes, specialist service availability and information-sharing arrangements for ambulance clinicians are determined locally, not through a single national model.
  Stated by NHS EnglandRedirects responsibility
AI-generated summary

Alex Ganski · 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

Alex Ganski, aged 19, died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The principal concerns were the absence of a designated lead with oversight and authority across services, fragmented information sharing, and no clear national mechanism to identify and communicate his wider mental health and drug-misuse risks.

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
Fragmented information sharing and updating across healthcare providers
Wider context from the report
“The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically - directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across those patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records,such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resources grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”
Source location
Alex Ganski · Prevention of Future Deaths report
Page 4 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue rolling out Neighbourhood Mental Health Centres across England to provide more joined-up care and oversight.

Verbatim wording from the response
“As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England.”

Source location
Response from NHS England
Page 2 · response
Published 14 August 2026
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
Facilitate collaborative sharing of patient data across care settings and geographic boundaries through Connecting Care Records.

Verbatim wording from the response
“NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. This is discussed in more detail at point 3 below.”

Source location
Response from NHS England
Page 2 · response
Published 14 August 2026
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
Provide the National Care Records Service for secure access to national patient information, including Summary Care Records and additional clinical information.

Verbatim wording from the response
“The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, and it is free to use. NCRS is internet based, accessible via a web browser. NHS England’s national digital team have advised that they would expect the local Mental Health Trust, and the local Drug and Alcohol treatment service to have access to patient’s summary care records via NCRS however utilisation of this resource will vary according to the local business processes. Further information on NCRS can be available here: National Care Records Service - NHS England Digital.”

Source location
Response from NHS England
Page 3 · response
Published 14 August 2026
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
Provide the National Record Locator service to help care professionals locate and retrieve patient information and identify organisations involved in care.

Verbatim wording from the response
“NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history.”

Source location
Response from NHS England
Page 4 · response
Published 14 August 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue supporting interoperable shared care records and their development toward a joined-up Single Patient Record.

Verbatim wording from the response
“The NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records. Every Integrated Care Board (ICB) has a shared care record (ShCR) in place, which provides, through different suppliers, a mechanism to access shared information between NHS Trusts and general practice. Shared Care Records will include prescribed medications and will typically hold more information about an individual than a Summary Care Record.”

Source location
Response from NHS England
Page 5 · response
Published 14 August 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Responsibility for delivering shared care records sits with local Integrated Care Boards, based on local health and care needs and existing systems.

Verbatim wording from the response
“Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care record are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England.”

Source location
Response from NHS England
Page 5 · response
Published 14 August 2026
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
Referral routes, specialist service availability and information-sharing arrangements for ambulance clinicians are determined locally, not through a single national model.

Verbatim wording from the response
“Where a patient consents, or where information sharing is otherwise justified for direct care, ambulance clinicians may contact other healthcare professionals or specialist services involved in a patient's care. However, the availability of referral routes, specialist services and information-sharing arrangements is determined locally and is not subject to a single nationally mandated model.”

Source location
Response from NHS England
Page 6 · response
Published 14 August 2026
Open published response
8 May2026
South Yorkshire (Western)
Concerns raised1
1. Lack of communication and engagement between agencies involved in Ollie’s care
This report raised 2 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.
Actions described in response 32
1. Action
  Introduce named Targeted Early Help link workers and structured consultation routes for every Barnsley school.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
2. Action
  Strengthen Early Help–CAMHS coordination through direct contact, improved referrals, timely information sharing and joint planning.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
3. Action
  Require multi-agency information gathering and triangulation through updated practice standards and case-management guidance.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
1. Action
  Use supervision, case tracking and quality assurance audits to verify multi-agency contact, recording, role clarity and progression of actions.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
2. Action
  Train Targeted Early Help and Children’s Social Care staff in multi-agency working, information sharing, professional curiosity and contextual safeguarding.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
3. Action
  Implement the preventative, conversational Integrated Front Door model through phased test-and-learn activity, with operation planned by March 2027.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated planned
4. Action
  Complete local actions addressing information sharing and multi-agency discharge planning.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completed
5. Action
  Provide Barnsley CAMHS training on information sharing and multi-agency working.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completed
6. Action
  Train Targeted Early Help practitioners on CAMHS referrals and access to children’s mental health support.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completed
7. Action
  Provide annual Targeted Early Help training, with additional sessions arranged at social care’s request.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated planned
8. Action
  Meet with Targeted Early Help senior management to explore improved joint working and timely information sharing.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated completed
9. Action
  Establish daily Targeted Early Help attendance at the Branching Minds briefing.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated planned
10. Action
  Establish fortnightly CAMHS and Targeted Early Help case review meetings for coordinated working.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated planned
11. Action
  Hold bi-monthly strategic reviews of CAMHS and Targeted Early Help joint working and consider developing a Memorandum of Understanding.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated planned
12. Action
  Consider a collaborative Trust and partner-agency response to the Act’s information-sharing provisions.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustStated in progress
13. Action
  Introduce named Targeted Early Help link workers for every Barnsley school and structured consultation opportunities for school staff.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
14. Action
  Strengthen Early Help–CAMHS coordination through clearer referral, information-sharing and joint-planning pathways.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
15. Action
  Require practitioners to gather and triangulate information from education, health and other professional partners through updated practice standards.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
16. Action
  Use management supervision to check partner contact, follow-up, recording and progression of communication actions.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
17. Action
  Deliver multi-agency working, information-sharing, professional-curiosity and contextual-safeguarding training for Targeted Early Help and Children’s Social Care staff.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
18. Action
  Implement updated Multi-Agency Safeguarding Arrangements defining cross-agency information-sharing, accountability, escalation and professional challenge.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
19. Action
  Require direct contact, role clarification, recorded outcomes and ongoing coordination when children are involved with Targeted Early Help and CAMHS.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
20. Action
  Invite CAMHS practitioners to relevant family, safeguarding and professional meetings, with follow-up and escalation when participation does not occur.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
21. Action
  Audit multi-agency contact, role clarity and recorded communication, feeding gaps into management oversight, supervision and team learning.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated completed
22. Action
  Implement a conversational Integrated Front Door through phased 2026/27 test-and-learn activity, with operation planned by March 2027.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated planned
23. Action
  Introduce CAMHS co-location within the Integrated Front Door during 2026–2027.
  Stated by Barnsley Metropolitan Borough Council Children’s ServicesStated planned
24. Action
  Adapt escalation protocols so the school contacts the crisis team directly when students self-harm or may harm themselves.
  Stated by Barnsley AcademyStated completed
25. Action
  Use CPOMS profile pinning to identify agencies involved with students and improve communication oversight.
  Stated by Barnsley AcademyStated completed
26. Action
  Train safeguarding colleagues to routinely share relevant information with all agencies involved in multi-agency support.
  Stated by Barnsley AcademyStated completed
27. Action
  Formalise safeguarding quality assurance guidance covering information-sharing audits and termly complex-case reviews.
  Stated by Barnsley AcademyStated completed
28. Action
  Train seven additional staff in Early Help processes and use an Early Help Practitioner as the school liaison.
  Stated by Barnsley AcademyStated completed
29. Action
  Hold termly Compass Be liaison meetings focused on next steps for identified students with mental health concerns.
  Stated by Barnsley AcademyStated completed
Respondent positions 1
1. Position
  Barnsley Metropolitan Borough Council is the lead agency for the wider Barnsley Children’s Reform Agenda response.
  Stated by South West Yorkshire Partnership Teaching NHS Foundation TrustRedirects responsibility
AI-generated summary

Ollie Lee · 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

Ollie Lee, who had a history of suicidal thoughts and self-harm, died by suicide on 6 October 2024. The principal concerns were poor communication and engagement between the agencies involved, including failures to share information about self-harm and CAMHS discharge, which resulted in missed opportunities for continued mental health support. Important discussions about Ollie’s preferred name and pronouns were also not recorded 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 communication and engagement between agencies involved in Ollie’s care
Wider context from the report
“1) Poor communication and engagement between the agencies involved with Ollie including her school, CAMHS and targeted early help. 2) A lack of communication and engagement between targeted early help and CAMHS despite both agencies being aware that the other was involved. This led to a confusing picture and a missed opportunity for Ollie to remain open to CAMHS and receive psycho social intervention and continued support from CAMHS. ”
Source location
Ollie Lee · 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
Introduce named Targeted Early Help link workers and structured consultation routes for every Barnsley school.

Verbatim wording from the response
“Within Targeted Early Help, communication with schools has been further strengthened through the introduction of named link workers for each school across the whole of Barnsley, which has created clear and accessible points of contact and a more consistent professional relationship. This has been complemented by more structured consultation opportunities, enabling school staff to routinely seek advice from Targeted Early Help practitioners at the earliest sign of concern. In practice, this means emerging issues relating to attendance, emotional wellbeing or family stressors are shared earlier, discussed jointly and responded to through coordinated planning, reducing delay and preventing escalation.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 2 · response
Published 17 July 2026
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
Strengthen Early Help–CAMHS coordination through direct contact, improved referrals, timely information sharing and joint planning.

Verbatim wording from the response
“In parallel, communication with CAMHS has developed through a more integrated and coordinated approach to emotional health and wellbeing. Targeted Early Help practitioners are now more consistently involved in multi-agency discussions where children present with mental health needs, ensuring that information from CAMHS is understood within the wider family and environmental context. This has been supported by clearer pathways between Early Help and CAMHS, including improved referral processes,”

Source location
Response from Barnsley Metropolitan Borough Council
Page 2 · response
Published 17 July 2026
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
Require multi-agency information gathering and triangulation through updated practice standards and case-management guidance.

Verbatim wording from the response
“These improvements are reinforced through our updated practice standards, which explicitly require practitioners to gather and triangulate information from across the professional network, including education and health partners, rather than relying on a single service perspective. This expectation strengthens professional curiosity and ensures that assessments reflect a comprehensive and multi-agency understanding of the child’s lived experience.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 3 · response
Published 17 July 2026
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
Use supervision, case tracking and quality assurance audits to verify multi-agency contact, recording, role clarity and progression of actions.

Verbatim wording from the response
“Our practitioner supervision arrangements provide consistent management oversight of communication, managers routinely check that contact with key partners, including schools and CAMHS, has taken place, that information has been followed up and that actions are clearly recorded and progressed. This ensures that communication is not only expected but evidenced, and that any gaps or delay in information sharing are identified and addressed promptly.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 3 · response
Published 17 July 2026
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 Targeted Early Help and Children’s Social Care staff in multi-agency working, information sharing, professional curiosity and contextual safeguarding.

Verbatim wording from the response
“Practitioner capability has also been strengthened through targeted training and development. Staff across Targeted Early Help and Children’s Social Care have undertaken training focused on multi-agency working, information sharing, professional curiosity and contextual safeguarding. This includes reinforcing expectations around engaging with education and health partners, understanding thresholds for CAMHS involvement, and contributing effectively to multi-agency meetings. This training supports practitioners to communicate with confidence, understand the roles of partner agencies and ensure that information is shared clearly, appropriately and in a timely way.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 3 · response
Published 17 July 2026
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 the preventative, conversational Integrated Front Door model through phased test-and-learn activity, with operation planned by March 2027.

Verbatim wording from the response
“Further action is planned through Barnsley’s social care reform and Families First programme. Barnsley has agreed the move towards a preventative, conversational Integrated Front Door model, developed with partners across health, police and education. The model will prioritise professional conversations as the main route for triage and decision-making, with MASH-style safeguarding checks retained where risk is high or unclear. Its purpose is to improve information sharing at first contact, reduce unnecessary hand-offs, support more proportionate decisions and create a clearer single pathway between Family Help, Targeted Early Help, CAMHS and statutory safeguarding. Implementation is planned through phased test-and-learn activity during 2026/27, with the model due to be operational by March 2027.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 8 · response
Published 17 July 2026
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
Complete local actions addressing information sharing and multi-agency discharge planning.

Verbatim wording from the response
“The case note review identified areas of learning local to Barnsley CAMHS, including Information Sharing and Multi Agency Discharge Planning; the clinical quality of the Risk Assessment for Non-Engagement form (RANE); and the associated discharge processes. The local actions were completed by June 2025”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
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
Provide Barnsley CAMHS training on information sharing and multi-agency working.

Verbatim wording from the response
“Having identified local learning from the case note review related to multi-agency communication and engagement, on 4 April 2025, training was provided to Barnsley CAMHS by the Trust Safeguarding Children Team on Information Sharing and Multi-Agency Working. The purpose of the training was to reinforce the importance of multi-agency working and information sharing to promote best practice. The Trust also has a Safeguarding toolkit which supports clinical staff on a range of practice areas including information sharing, and quality and accuracy of documentation.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 2 · response
Published 17 July 2026
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 Targeted Early Help practitioners on CAMHS referrals and access to children’s mental health support.

Verbatim wording from the response
“Having identified learning related to multi agency communication and engagement in the case note review, on 28 January 2025 the Branching Minds Clinical Lead delivered training to Targeted Early Help Practitioners, who are children’s social care employees, in relation to the CAMHS referral process and access to mental health support for children and young people. The purpose of the training was to reinforce the multi-agency arrangements and set a clear expectation that communication between practitioners is active, timely, and accountable. This training is scheduled to be repeated in August 2026. In recognition of potential staff turnover within children’s social care, the Trust will be providing these training sessions annually, supported by additional sessions to be arranged at the request of social care services.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 3 · response
Published 17 July 2026
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
Provide annual Targeted Early Help training, with additional sessions arranged at social care’s request.

Verbatim wording from the response
“Having identified learning related to multi agency communication and engagement in the case note review, on 28 January 2025 the Branching Minds Clinical Lead delivered training to Targeted Early Help Practitioners, who are children’s social care employees, in relation to the CAMHS referral process and access to mental health support for children and young people. The purpose of the training was to reinforce the multi-agency arrangements and set a clear expectation that communication between practitioners is active, timely, and accountable. This training is scheduled to be repeated in August 2026. In recognition of potential staff turnover within children’s social care, the Trust will be providing these training sessions annually, supported by additional sessions to be arranged at the request of social care services.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 3 · response
Published 17 July 2026
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
Meet with Targeted Early Help senior management to explore improved joint working and timely information sharing.

Verbatim wording from the response
“On 8 June 2026, the General Manager for Barnsley CAMHS met with the Service Manager for the Targeted Early Help Service (TEHS) to explore opportunities for improving joint working and strengthening timely and effective information sharing between services. To further improve communication between CAMHS and TEHS, three key actions were agreed for initial implementation:”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 4 · response
Published 17 July 2026
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
Establish daily Targeted Early Help attendance at the Branching Minds briefing.

Verbatim wording from the response
“• Daily briefing attendance A representative from the Targeted Early Help Service will join the existing daily briefing at Branching Minds. This will enable TEHS to share relevant information about children and young people (CYP) known to their service and facilitate timely consultation with the crisis team where required.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 4 · response
Published 17 July 2026
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
Establish fortnightly CAMHS and Targeted Early Help case review meetings for coordinated working.

Verbatim wording from the response
“• Fortnightly case review meeting An initial fortnightly meeting will be established between CAMHS and TEHS, attended by a CAMHS Team Manager and a TEHS Team Manager, to review cases awaiting allocation or intervention. This will support information sharing and identify opportunities for coordinated or joint working.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 4 · response
Published 17 July 2026
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
Hold bi-monthly strategic reviews of CAMHS and Targeted Early Help joint working and consider developing a Memorandum of Understanding.

Verbatim wording from the response
“• Bi-monthly strategic review The TEHS Service Manager and the CAMHS General Manager will meet on a bi-monthly basis to review progress, evaluate the effectiveness of joint working arrangements, and consider the development of a Memorandum of Understanding (MoU). This will be informed by learning from these initial actions.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 4 · response
Published 17 July 2026
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
Consider a collaborative Trust and partner-agency response to the Act’s information-sharing provisions.

Verbatim wording from the response
“Finally, in April 2026 the Children’s Wellbeing and Schools Act 2026 received royal assent, and this includes the statutory duty for partner agencies to share information relevant to safeguarding and promoting the wellbeing of children and young persons. This statutory duty is intended to apply from September 2026 and national guidance to support its implementation is in consultation process. We are currently considering this within the Trust and with partner agencies to ensure a collaborative and robust response to the information sharing provisions of the Children’s Wellbeing and Schools Act 2026.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 5 · response
Published 17 July 2026
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
Introduce named Targeted Early Help link workers for every Barnsley school and structured consultation opportunities for school staff.

Verbatim wording from the response
“Within Targeted Early Help, communication with schools has been further strengthened through the introduction of named link workers for each school across the whole of Barnsley, which has created clear and accessible points of contact and a more consistent professional relationship. This has been complemented by more structured consultation opportunities, enabling school staff to routinely seek advice from Targeted Early Help practitioners at the earliest sign of concern. In practice, this means emerging issues relating to attendance, emotional wellbeing or family stressors are shared earlier, discussed jointly and responded to through coordinated planning, reducing delay and preventing escalation.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 3 · response
Published 17 July 2026
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
Strengthen Early Help–CAMHS coordination through clearer referral, information-sharing and joint-planning pathways.

Verbatim wording from the response
“In parallel, communication with CAMHS has developed through a more integrated and coordinated approach to emotional health and wellbeing. Targeted Early Help practitioners are now more consistently involved in multi-agency discussions where children present with mental health needs, ensuring that information from CAMHS is understood within the wider family and environmental context. This has been supported by clearer pathways between Early Help and CAMHS, including improved referral processes,”

Source location
Response from Barnsley Metropolitan Borough Council
Page 3 · response
Published 17 July 2026
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
Require practitioners to gather and triangulate information from education, health and other professional partners through updated practice standards.

Verbatim wording from the response
“These improvements are reinforced through our updated practice standards, which explicitly require practitioners to gather and triangulate information from across the professional network, including education and health partners, rather than relying on a single service perspective. This expectation strengthens professional curiosity and ensures that assessments reflect a comprehensive and multi-agency understanding of the child’s lived experience.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 4 · response
Published 17 July 2026
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
Use management supervision to check partner contact, follow-up, recording and progression of communication actions.

Verbatim wording from the response
“Our practitioner supervision arrangements provide consistent management oversight of communication, managers routinely check that contact with key partners, including schools and CAMHS, has taken place, that information has been followed up and that actions are clearly recorded and progressed. This ensures that communication is not only expected but evidenced, and that any gaps or delay in information sharing are identified and addressed promptly.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 4 · response
Published 17 July 2026
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
Deliver multi-agency working, information-sharing, professional-curiosity and contextual-safeguarding training for Targeted Early Help and Children’s Social Care staff.

Verbatim wording from the response
“Practitioner capability has also been strengthened through targeted training and development. Staff across Targeted Early Help and Children’s Social Care have undertaken training focused on multi-agency working, information sharing, professional curiosity and contextual safeguarding. This includes reinforcing expectations around engaging with education and health partners, understanding thresholds for CAMHS involvement, and contributing effectively to multi-agency meetings. This training supports practitioners to communicate with confidence, understand the roles of partner agencies and ensure that information is shared clearly, appropriately and in a timely way.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 4 · response
Published 17 July 2026
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 updated Multi-Agency Safeguarding Arrangements defining cross-agency information-sharing, accountability, escalation and professional challenge.

Verbatim wording from the response
“At a system level, Barnsley’s Multi-Agency Safeguarding Arrangements (MASA) (updated April 2026) provide the framework that underpins this practice, setting clear expectations for timely information sharing, joint working and collective decision-making across all partners. The MASA arrangements strengthen accountability by defining roles and responsibilities between agencies, including education and health, and by supporting effective escalation and professional challenge where communication is not timely or effective.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 4 · response
Published 17 July 2026
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
Require direct contact, role clarification, recorded outcomes and ongoing coordination when children are involved with Targeted Early Help and CAMHS.

Verbatim wording from the response
“Our current arrangements set a clear expectation that communication between practitioners is active, timely, and accountable. Practitioners are expected to make direct contact, be clear about why it is needed, and ensure that children known to more than one service are not supported through separate or disconnected activity.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 5 · response
Published 17 July 2026
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
Invite CAMHS practitioners to relevant family, safeguarding and professional meetings, with follow-up and escalation when participation does not occur.

Verbatim wording from the response
“Where CAMHS are actively involved with the child they are invited to family network meetings, child in need meetings, strategy discussions, child protection activity, or other relevant consultations. The right practitioner is identified so that contributions are based on direct knowledge, and where this does not happen, practitioners are expected to follow up and escalate.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 5 · response
Published 17 July 2026
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
Audit multi-agency contact, role clarity and recorded communication, feeding gaps into management oversight, supervision and team learning.

Verbatim wording from the response
“Practice standards, supervision frameworks, and quality assurance activity reinforce the same expectations. Audit work tests whether there is clear evidence of multi-agency contact, role clarity, and recorded communication between services. Where this is not evident, the response includes management oversight, reflective supervision, and feedback into team learning and wider partnership discussion.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 6 · response
Published 17 July 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a conversational Integrated Front Door through phased 2026/27 test-and-learn activity, with operation planned by March 2027.

Verbatim wording from the response
“Further action is planned through Barnsley’s social care reform and Families First programme. Barnsley has agreed the move towards a preventative, conversational Integrated Front Door model, developed with partners across health, police and education. The model will prioritise professional conversations as the main route for triage and decision-making, with MASH-style safeguarding checks retained where risk is high or unclear. Its purpose is to improve information sharing at first contact, reduce unnecessary hand-offs, support more proportionate decisions and create a clearer single pathway between Family Help, Targeted Early Help, CAMHS and statutory safeguarding. Implementation is planned through phased test-and-learn activity during 2026/27, with the model due to be operational by March 2027.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 9 · response
Published 17 July 2026
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
Introduce CAMHS co-location within the Integrated Front Door during 2026–2027.

Verbatim wording from the response
“This will be strengthened further through planned CAMHS co-location within the Integrated Front Door during 2026 to 2027. This will support earlier shared discussion, faster information exchange, and better visibility of children whose needs sit across both emotional health and safeguarding systems.”

Source location
Response from Barnsley Metropolitan Borough Council
Page 7 · response
Published 17 July 2026
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
Adapt escalation protocols so the school contacts the crisis team directly when students self-harm or may harm themselves.

Verbatim wording from the response
“• As a result of CAMHS sharing the crisis flowchart with schools, Barnsley Academy has adapted its protocols around escalating concerns for students who have self-harmed or are deemed to be at risk of harming themselves (including suicidal ideation). Whereas previously, parents or carers would have been advised to take their child to A&E to seek support, school now contacts the crisis team directly.”

Source location
Response from Barnsley Community Academy
Page 2 · response
Published 17 July 2026
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
Use CPOMS profile pinning to identify agencies involved with students and improve communication oversight.

Verbatim wording from the response
“• Following the updated guidance from the Department for Education’s Working together to improve school attendance in August 2024 (Appendix 1), school safeguarding leaders updated their approach to ease identification of agencies involved with students via the use of ‘pinning’ on CPOMs profiles. Whilst we recognise that this action was taken prior to Ollie’s death in October 2024, this has supported the ease and efficiency of communication with agencies and has provided a clearer oversight of their involvement for school leaders.”

Source location
Response from Barnsley Community Academy
Page 2 · response
Published 17 July 2026
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 safeguarding colleagues to routinely share relevant information with all agencies involved in multi-agency support.

Verbatim wording from the response
“• Barnsley Academy has completed regular professional development training with all safeguarding trained colleagues (DSLs/DDSLs) within the Academy, including most recently on Thursday 4 June 2026. The focus of the most recent training was around ensuring that where multi-agency support is in place for a student and their family, all relevant information is shared as routine with all agencies involved. Furthermore, particular emphasis was placed upon information sharing across agencies even when other stakeholders (e.g. a parent or Family Support Worker) state that they will share that information (Appendix 2).”

Source location
Response from Barnsley Community Academy
Page 2 · response
Published 17 July 2026
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
Formalise safeguarding quality assurance guidance covering information-sharing audits and termly complex-case reviews.

Verbatim wording from the response
“• In addition to training colleagues, Barnsley Academy has formalised its Safeguarding Quality Assurance and Supervision process guidance (Appendix 3) to ensure that specific reference is made to quality assurance of relevant information sharing across multiple agencies. Within the guidance the Designated Safeguarding Lead completes routine quality assurance audits (Appendix 4) to ensure efficiency and compliance in relation to CPOMs logs and to monitor the effectiveness of multi-agency working. Within the guidance, there is also clear reference made to quality assuring multi-agency working as part of termly complex case file reviews. Whilst the working practices have been in place for much longer, the formal guidance was updated on 5 June 2026 and outlines training commitments as well as quality assurance processes to ensure routine practice and accountability.”

Source location
Response from Barnsley Community Academy
Page 2 · response
Published 17 July 2026
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 seven additional staff in Early Help processes and use an Early Help Practitioner as the school liaison.

Verbatim wording from the response
“Targeted Early Help - Within school, an additional 7 members of staff have received central local authority training around Early Help processes since March 2025. As well as increased capacity to support referral processes, this has further enhanced staff understanding of how targeted early help services work and has made communication more efficient through a strengthening of cross-agency professional relationships and networks. As forementioned, from July 2024, Barnsley Academy has been allocated an Early Help Practitioner within targeted early help services who acts as a direct school liaison and primary point of contact. This has led to more proactive communication and support between early help and school.”

Source location
Response from Barnsley Community Academy
Page 3 · response
Published 17 July 2026
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
Hold termly Compass Be liaison meetings focused on next steps for identified students with mental health concerns.

Verbatim wording from the response
“Mental Health Services - The school has continued to hold link meetings once per term with a school liaison from Compass Be. However, as well as discussing whole school support, these meetings have become more focused to address next steps for specific caseloads of identified students, where mental health concerns have been raised.”

Source location
Response from Barnsley Community Academy
Page 3 · response
Published 17 July 2026
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
Barnsley Metropolitan Borough Council is the lead agency for the wider Barnsley Children’s Reform Agenda response.

Verbatim wording from the response
“All children’s services, including CAMHS, are involved in the broader Children’s Reform Agenda, which is a comprehensive plan aimed at transforming children’s social care and child protection policy, with a focus on improving multi-agency collaboration and enabling earlier, more effective support for children and families. BMBC are the lead agency of the wider Barnsley children’s services response to the Children’s Reform Agenda, and the Trust are committed to supporting the multi-agency response to the Children’s Reform Agenda. We understand BMBC have included a number of the initiatives, or proposed plans, in their response to the Regulation 28 report.”

Source location
Response from South West Yorkshire Partnership NHS Trust
Page 4 · response
Published 17 July 2026
Open published response
24 Apr2026
Inner West London
Concerns raised1
1. Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
This report raised 4 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.
Actions described in response 28
1. Action
  Design a standard care and crisis plan for use in the Universal Care Plan.
  Stated by OneLondon BoardStated completed
2. Action
  Build and link mental-health care and crisis plans in the Universal Care Plan and Mental Health Trust electronic records.
  Stated by OneLondon BoardStated in progress
3. Action
  Introduce the Thalamos electronic Mental Health Act system across London.
  Stated by OneLondon BoardStated completed
1. Action
  Ensure full London coverage of the Thalamos electronic Mental Health Act system.
  Stated by OneLondon BoardStated in progress
2. Action
  Share electronic Mental Health Act data, including alerts and relevant history, in the London Care Record.
  Stated by OneLondon BoardStated completed
3. Action
  Review presentation options with the London Care Record supplier to make important information clearer.
  Stated by OneLondon BoardStated planned
4. Action
  Take actions to address gaps in mental-health information sharing.
  Stated by OneLondon BoardStated planned
5. Action
  Conduct the London Care Record procurement exercise to determine future systems.
  Stated by OneLondon BoardStated in progress
6. Action
  Include pan-London mental-health information sharing and clear clinical alerts as essential procurement criteria.
  Stated by OneLondon BoardStated planned
7. Action
  Use the Delivery Oversight Group to manage and track implementation of the information-sharing improvement plan.
  Stated by OneLondon BoardStated planned
8. Action
  Complete an internal review of recorded information and its availability to other organisations.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
9. Action
  Adopt and operate London Care Record sharing to provide authorised clinicians with near-real-time access to relevant mental health information.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
10. Action
  Continue working with system partners to strengthen information sharing, improve shared-record consistency and usability, and support coordinated care.
  Stated by South London and Maudsley NHS Foundation TrustStated in progress
11. Action
  Develop and lead the Frontline Digitisation Programme, providing EPR adoption support, implementation guidance and safety oversight.
  Stated by NHS EnglandStated completed
12. Action
  Set a national interoperability initiative and commit investment to enable authorised professionals to access reliable records across England.
  Stated by NHS EnglandStated completed
13. Action
  Secure funding for South London and Maudsley NHS Foundation Trust to develop a business case for replacing its non-compliant EPR.
  Stated by NHS EnglandStated completed
14. Action
  Secure funding for London Ambulance Service NHS Trust to add linked dispatch, interoperability, emergency-department record linkage and EPR optimisation functionality.
  Stated by NHS EnglandStated completed
15. Action
  Promote Universal Care Plans to partner organisations for shared care planning.
  Stated by London Ambulance Service NHS TrustStated in progress
16. Action
  Maintain implemented clinical-system flags and visual prompts alerting clinicians to shared care plans and key documents.
  Stated by London Ambulance Service NHS TrustStated completed
17. Action
  Embed updated shared-record access and safety-information guidance in induction, mandatory training and clinical communications.
  Stated by London Ambulance Service NHS TrustStated completed
18. Action
  Integrate electronic patient care records with the London Care Record to reduce access time and streamline navigation.
  Stated by London Ambulance Service NHS TrustStated planned
19. Action
  Develop further visibility, access and flagging for National Care Record Service documents and alerts within clinical systems.
  Stated by London Ambulance Service NHS TrustStated planned
20. Action
  Enable visibility of Computer Aided Dispatch information within electronic patient care records to support clinical decision-making.
  Stated by London Ambulance Service NHS TrustStated completed
21. Action
  Embed mental health assessment guidance in the electronic patient care record tool to prompt care-record review.
  Stated by London Ambulance Service NHS TrustStated completed
22. Action
  Continue collaborating with regional, local and national partners to improve shared-care planning and cross-organisation information access.
  Stated by London Ambulance Service NHS TrustStated in progress
23. Action
  Collaborate with the Universal Care Plan team to develop mental-health and catheter-care personalised care-planning use cases.
  Stated by London Ambulance Service NHS TrustStated planned
24. Action
  Consider interoperability enhancements between the London Care Record and National Record Locator through OneLondon procurement and strategic planning.
  Stated by London Ambulance Service NHS TrustStated planned
25. Action
  Continue LAS participation in the NHS England Single Patient Record Programme Clinical Reference Group.
  Stated by London Ambulance Service NHS TrustStated in progress
Respondent positions 10
1. Position
  Technical constraints currently limit the ability to change how information is presented in the London Care Record.
  Stated by OneLondon BoardUnable to act
1. Position
  Further sharing of s136 information into the London Care Record depends on Mental Health Trusts and police organisations agreeing to share it.
  Stated by OneLondon BoardUnable to act
2. Position
  Work to address Mental Health Trust data-sharing gaps is constrained because funding has not yet been confirmed.
  Stated by OneLondon BoardUnable to act
3. Position
  Mental health crises should be led by health services, with police involvement limited to lawful powers, crime, or immediate serious harm.
  Stated by Metropolitan Police ServiceRedirects responsibility
4. Position
  Local shared care record organisations and NHS Trusts must agree additional information sharing and negotiate local data-sharing protocols.
  Stated by NHS EnglandRedirects responsibility
5. Position
  Responsibility for electronic-record information sharing and management rests with each organisation through established digital governance arrangements.
  Stated by NHS EnglandRedirects responsibility
6. Position
  NHS England states that interoperability is configured and managed locally through provider organisations and technology suppliers, with regional teams considering wider catchment areas.
  Stated by NHS EnglandRedirects responsibility
7. Position
  Further enquiries about NHS 111 and ambulance access to Summary Care Records through NCRS should be directed to the London Ambulance Service.
  Stated by NHS EnglandRedirects responsibility
8. Position
  Local Integrated Care Boards are responsible for delivering shared care records according to local needs, systems and plans.
  Stated by NHS EnglandRedirects responsibility
9. Position
  Additional London Care Record flagging is not considered beneficial because most attended patients already have information published there.
  Stated by London Ambulance Service NHS TrustExisting arrangements considered sufficient
AI-generated summary

Edward Muwanga · 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

Edward Muwanga died after entering the track at Queensway London Underground Station and being struck by a train on 7 August 2023. The concerns included police officers’ failure to understand and use relevant mental health powers, failure to identify a section 135 warrant, incomplete communication of his circumstances and health information to healthcare professionals, and a delay by central line controllers in alerting the train driver.

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
Fragmented healthcare record systems limiting the visibility and communication of important patient safety information
Wider context from the report
“(3) The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the treating Trust (SLAM) and NHS 111, and between the Ambulance Service (not NHS 111) and the treating Trust (SLAM). ████████ from London Ambulance Service NHS Trust writes to me in her PFD statement that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.” In her written evidence to me dated 19th March 2026 ████████ Chief Medical Officer of LAS NHS Trust, writes that “..there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms." Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists. ”
Source location
Edward Muwanga · 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
Design a standard care and crisis plan for use in the Universal Care Plan.

Verbatim wording from the response
“• In 2025 work was carried out to design a ‘care & crisis plan’ to be used in the UCP. Funding was also requested to support this work. We received funding for this work (confirmed in April 2026)”

Source location
Response from OneLondon Board
Page 3 · response
Published 19 June 2026
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
Build and link mental-health care and crisis plans in the Universal Care Plan and Mental Health Trust electronic records.

Verbatim wording from the response
“At the time of Edward Muwanga’s death, there was no Universal Care Plan (UCP) form because UCP was not being used to support mental health care. That is now changing and work is currently underway to build mental health care & crisis plans in the UCP – and for this to be linked to Mental Health Trust electronic patient record (EPR) systems.”

Source location
Response from OneLondon Board
Page 3 · response
Published 19 June 2026
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
Introduce the Thalamos electronic Mental Health Act system across London.

Verbatim wording from the response
“At the time of Edward Muwanga’s death, London had not yet implemented the eMHA system by Thalamos. Since the death of Edward Muwanga, a new eMHA by Thalamos system has been introduced in London. This system supports the digitisation of the Mental Health Act and aims to support more joined-up assessment,”

Source location
Response from OneLondon Board
Page 3 · response
Published 19 June 2026
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
Ensure full London coverage of the Thalamos electronic Mental Health Act system.

Verbatim wording from the response
“Currently we are still in the process of ensuring full coverage. However, the system is live in most Mental Health Trusts and available to their partners (Local Authorities etc). The eMHA by Thalamos system is live in the following 5 Mental Health Trusts in London:”

Source location
Response from OneLondon Board
Page 4 · response
Published 19 June 2026
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
Share electronic Mental Health Act data, including alerts and relevant history, in the London Care Record.

Verbatim wording from the response
“Data from eMHA is also now shared in the London Care Record.”

Source location
Response from OneLondon Board
Page 4 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review presentation options with the London Care Record supplier to make important information clearer.

Verbatim wording from the response
“The system used for the London Care Record is provided by Oracle Health. There are currently technical constraints and limitations on the ability of the NHS to change the way that the system presents information. However, we commit this year to –”

Source location
Response from OneLondon Board
Page 6 · response
Published 19 June 2026
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
Take actions to address gaps in mental-health information sharing.

Verbatim wording from the response
“• Actions will also be taken this year to seek to address the gaps in data sharing from Mental Health Trusts. (The budget for this work is not yet confirmed as available, but there is a route through London NHSE Regional governance to address this with Trusts, and commitment in principle has been obtained).”

Source location
Response from OneLondon Board
Page 6 · response
Published 19 June 2026
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
Conduct the London Care Record procurement exercise to determine future systems.

Verbatim wording from the response
“In parallel, the current contracts for the London Care Record are due to expire in the coming years – with aligned contract end dates of March 2028 agreed. This year there is a procurement exercise that has started in London which will look at what systems we will use in London.”

Source location
Response from OneLondon Board
Page 6 · response
Published 19 June 2026
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
Include pan-London mental-health information sharing and clear clinical alerts as essential procurement criteria.

Verbatim wording from the response
“• We commit to ensuring that the procurement specification will include as essential criteria the ability to share information pan-London from all Mental Health Trusts, and a ‘user interface’ which clearly alerts clinical staff to important and relevant information about the patient they are seeing / treated.”

Source location
Response from OneLondon Board
Page 6 · response
Published 19 June 2026
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
Use the Delivery Oversight Group to manage and track implementation of the information-sharing improvement plan.

Verbatim wording from the response
“We have introduced a new Delivery Oversight Group for OneLondon, and this will be asked to manage the oversight and track implementation of our plan to further improve our information sharing within our three major pan London systems (eMHA, London Care Record and Universal Care Plan as from June 2026). Through this, OneLondon will continue to seek to improve information sharing to support safer Mental Health care for Londoners.”

Source location
Response from OneLondon Board
Page 7 · response
Published 19 June 2026
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
Complete an internal review of recorded information and its availability to other organisations.

Verbatim wording from the response
“1.1 Approach to the review In response to the concerns identified by you, Sir, SLaM undertook a comprehensive internal review. The purpose of the review was to examine:”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 1 · response
Published 19 June 2026
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
Adopt and operate London Care Record sharing to provide authorised clinicians with near-real-time access to relevant mental health information.

Verbatim wording from the response
“Since March 2023, SLaM has adopted a London-wide sharing approach to ensure that appropriate information is available to clinicians at the point of need, regardless of where the patient presents.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 2 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue working with system partners to strengthen information sharing, improve shared-record consistency and usability, and support coordinated care.

Verbatim wording from the response
“While no single system currently provides a fully integrated, real-time view of all patient information, these developments represent meaningful progress in improving visibility of key information and supporting safer decision-making across organisations. The Trust recognises that safe clinical decision-making depends not only on the availability of information, but also on the ability of clinicians to identify and interpret it, alongside effective communication between services in crisis situations.”

Source location
Response from South London and Maudsley NHS Foundation Trust
Page 6 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop and lead the Frontline Digitisation Programme, providing EPR adoption support, implementation guidance and safety oversight.

Verbatim wording from the response
“NHS England has developed and led the Frontline Digitisation (FD) Programme to support NHS trusts in adopting Electronic Patient Record (EPR) systems, improve digital maturity, and enable better information sharing within and between organisations. In addition to supporting the procurement of EPR systems, the FD Programme provides guidance and oversight to help ensure that implementations are safe and effective.”

Source location
Response from NHS England
Page 2 · response
Published 19 June 2026
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
Set a national interoperability initiative and commit investment to enable authorised professionals to access reliable records across England.

Verbatim wording from the response
“Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between shared care records across England. This committed investment aims to enable any authorised health and care professional to have access to safe, reliable, and accurate records, regardless of the patient’s location or where care is provided. It is however, up to local shared care record organisations and participating NHS Trusts, to agree what information, in addition to the core information standard, is held and shared through the local shared care record. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local shared care record.”

Source location
Response from NHS England
Page 1 · response
Published 19 June 2026
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
Secure funding for South London and Maudsley NHS Foundation Trust to develop a business case for replacing its non-compliant EPR.

Verbatim wording from the response
“This trust uses the CareNotes Electronic Patient Record (EPR) system supplied by OneAdvanced (formerly Advanced). As part of the Frontline Digitisation (FD) Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the Digital Capability Framework (DCF). Through the FD Programme, the Trust secured funding to support development of a business case to replace its current EPR system.”

Source location
Response from NHS England
Page 2 · response
Published 19 June 2026
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
Secure funding for London Ambulance Service NHS Trust to add linked dispatch, interoperability, emergency-department record linkage and EPR optimisation functionality.

Verbatim wording from the response
“This Trust uses an electronic Patient Care Record (ePCR) system supplied by Cleric Computer Services Ltd. As part of the FD Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the DCF. Through the FD Programme, the Trust has secured funding to invest in additional functionality to support its EPR, including:”

Source location
Response from NHS England
Page 2 · response
Published 19 June 2026
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
Promote Universal Care Plans to partner organisations for shared care planning.

Verbatim wording from the response
“Promotion of Universal Care Plans The Trust has and continues to highlight the clear benefits to our partners in the development of UCP for shared care plans across organisations.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 3 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain implemented clinical-system flags and visual prompts alerting clinicians to shared care plans and key documents.

Verbatim wording from the response
“Digital Flagging and Visual Prompts Enhancements have been implemented (Appendix 2) within clinical systems to alert clinicians when a shared care plan or key document exists, prompting review at the point of care. This is intended to reduce the likelihood that critical information is overlooked due to time pressures in clinical interactions or where patient data records contain a volume of information.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 3 · response
Published 19 June 2026
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
Embed updated shared-record access and safety-information guidance in induction, mandatory training and clinical communications.

Verbatim wording from the response
“Training and Clinical Guidance Training materials and clinical guidance have been reviewed and updated to reinforce expectations regarding:”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 3 · response
Published 19 June 2026
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
Integrate electronic patient care records with the London Care Record to reduce access time and streamline navigation.

Verbatim wording from the response
“Improved System Integration The Trust has invested in improved in-context integration between the electronic patient care records (ePCR) and the LCR platform to reduce access time and streamline navigation between systems. Further developments are underway to improve visibility of NCRS held documents (on the National Record Locator) and alerts by the implementation of a flagging indicator which will highlight that a document exists in the patient’s record and prompt the clinician to access NCRS.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 3 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Develop further visibility, access and flagging for National Care Record Service documents and alerts within clinical systems.

Verbatim wording from the response
“Improved System Integration The Trust has invested in improved in-context integration between the electronic patient care records (ePCR) and the LCR platform to reduce access time and streamline navigation between systems. Further developments are underway to improve visibility of NCRS held documents (on the National Record Locator) and alerts by the implementation of a flagging indicator which will highlight that a document exists in the patient’s record and prompt the clinician to access NCRS.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 3 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Enable visibility of Computer Aided Dispatch information within electronic patient care records to support clinical decision-making.

Verbatim wording from the response
“From the 12th of May, functionality to improve visibility between internal systems has been enabled (notably, the visibility of information currently only visible within the Computer Aided Dispatch [CAD] system in ePCR), which will assist clinicians to access extra incident information, and support decision-making. This will provide the additional benefit of improved visibility of information which has been received by other providers into our CAD (e.g. from the Metropolitan Police Service (MPS) or NHS 111 services).”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 3 · response
Published 19 June 2026
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
Embed mental health assessment guidance in the electronic patient care record tool to prompt care-record review.

Verbatim wording from the response
“LAS Mental Health Team - Actions Taken - Planned and Ongoing Work Recent updates undertaken have strengthened the emphasis on accessing care records and obtaining collateral information in Mental Health assessments. The ePCR Mental Health Documentation Tool (launched in November 2025) now includes embedded Mental Health assessment guidance prompting crews to review care records, with further enhancements to be proposed through planned and ongoing work.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 4 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue collaborating with regional, local and national partners to improve shared-care planning and cross-organisation information access.

Verbatim wording from the response
“It also provided an overall understanding that better integration, the ability to surface key critical information quickly and the developments by future digital improvements are essential to the prevention of future harm. The Trust will continue to work closely with partner organisations to ensure patient safety remains central to future developments.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 2 · response
Published 19 June 2026
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
Collaborate with the Universal Care Plan team to develop mental-health and catheter-care personalised care-planning use cases.

Verbatim wording from the response
“• At an operational level, LAS has a touchpoint every other month with the Universal Care Plan team and are part of the UCP Clinical Transformation & Advisory Group. The LAS will be collaborating with the UCP team to develop the next two specific personalised care planning use cases – mental health and catheter care. As part of this learning, consideration for how information may be consistently shared across the correct platforms will be made. In addition, the UCP have received confirmation of funding which will allow them to develop integrations into two key Electronic Patient Records (Rio and Mosaics) to support the sharing of mental health information in the UCP.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 5 · response
Published 19 June 2026
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
Consider interoperability enhancements between the London Care Record and National Record Locator through OneLondon procurement and strategic planning.

Verbatim wording from the response
“• LAS is actively involved and participates in the One London board, as the only pan-London NHS provider organisation. Other representation is at an ICB and regional level. Consideration will be given to developing further enhancements to improve interoperability between the LCR and the NRL—notably the consumption of NRL records in the LCR in the first instance, with a longer-term view to also share information from the LCR into the NRL. This will be achieved through influence over the direction of procurement and strategic planning of the OneLondon 2.0 programme and approach to London Care Record, UCP and enhanced access and integration.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 5 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Continue LAS participation in the NHS England Single Patient Record Programme Clinical Reference Group.

Verbatim wording from the response
“• LAS’s paramedic Chief Clinical Information Officer and Deputy are part of the NHS England Single Patient Record Programme Clinical Reference Group. The SPR programme aims to create one unified, secure view of a patient’s health and care information across NHS services in England. This intends to bring together data currently held in multiple systems (e.g. GP, hospital, ambulance, mental health etc.) into a single, joined-up record, and is a core part of the NHS 10-year plan. The initial roll-out will focus on two identified priority areas (maternity and frailty) before looking to further areas. It is intended that the first priorities will go live around 2028.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 5 · response
Published 19 June 2026
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
Technical constraints currently limit the ability to change how information is presented in the London Care Record.

Verbatim wording from the response
“The system used for the London Care Record is provided by Oracle Health. There are currently technical constraints and limitations on the ability of the NHS to change the way that the system presents information. However, we commit this year to –”

Source location
Response from OneLondon Board
Page 6 · response
Published 19 June 2026
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 sharing of s136 information into the London Care Record depends on Mental Health Trusts and police organisations agreeing to share it.

Verbatim wording from the response
“• Thalamos have just completed developing a s136 status with the Met Police. This is now live. (Information will therefore also be available from City Police and British Transport Police for London Region.) This is live in the Thalamos product although it is not yet shared into the London Care Record. (There are no current timescales for this – but is achievable within the next 6 months if the Mental Health Trusts and the Police Organisations agree to sharing).”

Source location
Response from OneLondon Board
Page 5 · response
Published 19 June 2026
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
Work to address Mental Health Trust data-sharing gaps is constrained because funding has not yet been confirmed.

Verbatim wording from the response
“• Actions will also be taken this year to seek to address the gaps in data sharing from Mental Health Trusts. (The budget for this work is not yet confirmed as available, but there is a route through London NHSE Regional governance to address this with Trusts, and commitment in principle has been obtained).”

Source location
Response from OneLondon Board
Page 6 · response
Published 19 June 2026
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
Mental health crises should be led by health services, with police involvement limited to lawful powers, crime, or immediate serious harm.

Verbatim wording from the response
“The MPS operates within the nationally agreed Right Care, Right Person framework. This model is designed to ensure that individuals experiencing mental health crises receive a response from appropriately trained health professionals, with police involvement limited to circumstances where there is a legal power to exercise, a crime has occurred, or there is an immediate risk to life or serious harm requiring police capabilities. This case highlights the importance of maintaining that principle.”

Source location
Response from Metropolitan Police
Page 2 · response
Published 19 June 2026
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
Local shared care record organisations and NHS Trusts must agree additional information sharing and negotiate local data-sharing protocols.

Verbatim wording from the response
“Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between shared care records across England. This committed investment aims to enable any authorised health and care professional to have access to safe, reliable, and accurate records, regardless of the patient’s location or where care is provided. It is however, up to local shared care record organisations and participating NHS Trusts, to agree what information, in addition to the core information standard, is held and shared through the local shared care record. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local shared care record.”

Source location
Response from NHS England
Page 1 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Responsibility for electronic-record information sharing and management rests with each organisation through established digital governance arrangements.

Verbatim wording from the response
“Where multiple digital systems are used within a trust, including EPR systems, robust policies and procedures should be in place to set clear expectations, support appropriate clinical record management, and ensure the timely handover and escalation of abnormal results to the relevant individuals. Responsibility and accountability for the sharing and management of information held within electronic records, including information shared across different systems, rests with each organisation through its established digital governance arrangements.”

Source location
Response from NHS England
Page 3 · response
Published 19 June 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
NHS England states that interoperability is configured and managed locally through provider organisations and technology suppliers, with regional teams considering wider catchment areas.

Verbatim wording from the response
“While the FD Programme supports investment in local digital capability, interoperability is generally configured and managed locally, based on agreements between provider organisations and their technology suppliers, with NHS England regional teams taking account of wider catchment areas where appropriate.”

Source location
Response from NHS England
Page 3 · response
Published 19 June 2026
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 enquiries about NHS 111 and ambulance access to Summary Care Records through NCRS should be directed to the London Ambulance Service.

Verbatim wording from the response
“We would expect both the LAS and NHS 111 to have access to patients’ Summary Care Record (SCR) through NCRS. Any further enquiries about access to SCR through NCRS should therefore be directed to LAS.”

Source location
Response from NHS England
Page 4 · response
Published 19 June 2026
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
Local Integrated Care Boards are responsible for delivering shared care records according to local needs, systems and plans.

Verbatim wording from the response
“Responsibility for delivering shared care records rests with local Integrated Care Boards (ICBs). Each ICB develops its shared care record in response to local health and care needs, existing systems, and future plans. As a result, some shared care records are accessible to neighbouring ICBs, while others operate only within their own area. Future plans include improving connectivity so that shared care records can be used more consistently across England, regardless of where a person lives or receives care.”

Source location
Response from NHS England
Page 5 · response
Published 19 June 2026
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
Additional London Care Record flagging is not considered beneficial because most attended patients already have information published there.

Verbatim wording from the response
“- In-context access is supported in Adastra, and was enabled for ePCR in November 2025. - As most patients we attend will contain information published to the London Care Record, flagging is not deemed to bring any benefit.”

Source location
2026-0235 - Response from NHS Ambulance Service
Page 8 · response
Published 19 June 2026
Open published response
8 Apr2026
Nottinghamshire
Concerns raised1
1. Lack of formal information sharing and reliable handover between the CFT and Prison Healthcare
This report raised 5 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.
Actions described in response 10
1. Action
  Establish practical information-sharing arrangements and named contacts between community forensic and prison healthcare teams.
  Stated by Northamptonshire Healthcare NHS Foundation TrustStated completed
2. Action
  Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
3. Action
  Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
1. Action
  Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
2. Action
  Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated completed
3. Action
  Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
4. Action
  Work jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated in progress
5. Action
  Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.
  Stated by Nottinghamshire Healthcare NHS Foundation TrustStated planned
6. Action
  Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.
  Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated completed
7. Action
  Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.
  Stated by HM Prison and Probation Service and Ministry of Justice and Nottingham PrisonStated planned
AI-generated summary

Jonathan Mark Thornton · 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

Jonathan Mark Thornton died at Queens Medical Centre in Nottingham on 12 July 2024 after sustaining a severe head injury in an attack by a fellow inmate at HMP Nottingham on 28 June 2024. The report raises concerns about inadequate information sharing between community forensic, prison healthcare and operational prison staff, and about the categorisation and visibility of risk alerts on NOMIS/DPS, creating a risk of future deaths.

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 formal information sharing and reliable handover between the CFT and Prison Healthcare
Wider context from the report
“1. Information sharing between the CFT and Prison Healthcare. During the course of the inquest, I heard that there had been various barriers to information sharing between the community forensic team and prison healthcare. There was no formal system in place for the handover of information between these teams at the time of Jonathan’s death or at the conclusion of the inquest. Prison Healthcare staff were often unavailable or uncontactable for handover meetings. The handover of information between CFT and Prison Healthcare is vital for the risk assessment and management of prisoners who are known to the CFT (often some of the most complex and high-risk prisoners). I am concerned that the lack of formal information sharing between the two departments gives rise to a risk of future death. ”
Source location
Jonathan Mark Thornton · 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
Establish practical information-sharing arrangements and named contacts between community forensic and prison healthcare teams.

Verbatim wording from the response
“We have put practical arrangements in place between the Community Forensic Team and the Prison Healthcare Team at HMP Nottingham to make sure information is shared smoothly when someone comes into custody. This includes holding named contacts in each team.”

Source location
Response from Northampton Healthcare NHS Foundation Trust
Page 2 · response
Published 13 April 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Implement a formal information-sharing procedure requiring prompt, secure, documented handover of clinical and risk information, standard documents, and escalation when contact fails.

Verbatim wording from the response
“1. Introduction of a Formal Information-Sharing Guidance Document (December 2025)”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 1 · response
Published 13 April 2026
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
Share and agree the information-sharing guidance with CFT staff, Prison Healthcare providers, and HMP Lincoln to establish consistent cross-organisational expectations.

Verbatim wording from the response
“3. Guidance Shared with all CFT Staff”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 2 · response
Published 13 April 2026
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
Embed the information-sharing guidance through team briefings, clinical supervision, and induction for new staff.

Verbatim wording from the response
“2. Embedding the Guidance Through Training and Supervision”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 13 April 2026
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Maintain a dedicated CFT Link Worker as a consistent Prison Healthcare contact with oversight of information sharing, timely responses, continuity, and service liaison.

Verbatim wording from the response
“1. Appointment of a Dedicated CFT Link Worker”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 13 April 2026
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
Establish bimonthly interface meetings with HMP Nottingham Prison Healthcare teams to review cases, address communication issues, monitor guidance adherence, and escalate risks.

Verbatim wording from the response
“The Link Worker will also arrange and chair a bimonthly interface meeting with Prison Healthcare teams at HMP Nottingham. These meetings will:”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 13 April 2026
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 jointly with Northamptonshire Healthcare NHS Foundation Trust to clarify responsibilities, availability expectations, responsiveness, and escalation pathways.

Verbatim wording from the response
“3. Joint Working with Prison Healthcare Providers”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 13 April 2026
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
Conduct quarterly audits of information-sharing timeliness, documentation completeness, and escalation, and report findings to relevant quality and accountability groups.

Verbatim wording from the response
“4. Quarterly Audit and Reporting”

Source location
Response from Nottingham Healthcare NHS Foundation Trust
Page 3 · response
Published 13 April 2026
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
Issue and disseminate information-sharing guidance to prisons through booklet, wallet-sized and intranet formats.

Verbatim wording from the response
“A national Information Sharing Advisory Group (ISAG) is in place, which aims to improve information sharing between health and prisons. In order to improve practice, HMPPS Health and Care Information Sharing guidance was issued to prisons in July 2022 in two formats (A5 booklet and wallet size) and is available on the HMPPS intranet. The guidance aims to improve and achieve a more consistent approach to the sharing of information between all”

Source location
Response from HMPPS
Page 1 · response
Published 13 April 2026
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
Ask the Information Sharing Advisory Group to examine the circumstances of Mr Thornton’s death, identify learning and assess whether updated guidance is needed.

Verbatim wording from the response
“partner agencies and to give staff confidence in decision making, to reduce risk to self and others, and to achieve better outcomes for all staff, people in prison and people under probation supervision. We will ask the ISAG to consider the circumstances of Mr Thornton’s death to identify learning and whether there is a need for additional updated guidance.”

Source location
Response from HMPPS
Page 2 · response
Published 13 April 2026
Open published response
26 Mar2026
West Sussex, Brighton and Hove
Concerns raised1
1. Fragmented sharing and updating of health and drug-misuse information across providers
This report raised 3 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.
Actions described in response 4
1. Action
  Work with NHS England and sector partners to overcome barriers to data sharing between services.
  Stated by Department of Health and Social CareStated in progress
2. Action
  Strengthen clinical leadership, multiagency working and information sharing through children and young people’s mental health reforms.
  Stated by Department of Health and Social CareStated in progress
3. Action
  Reduce the longest waits for specialist mental health services.
  Stated by Department of Health and Social CareStated in progress
1. Action
  Accelerate rollout of Mental Health Support Teams across England toward full national coverage.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Alex Ganski · 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

Alex Ganski died from fatal injuries after jumping from a bridge while under the influence of ketamine and diazepam, following a relapse in drug misuse and longstanding mental health difficulties. The report identified concerns about fragmented information sharing between services and the absence of a clear lead with overall oversight and authority for his care, creating missed opportunities to address the combined risks of poor mental health, drug misuse and self-harm.

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
Fragmented sharing and updating of health and drug-misuse information across providers
Wider context from the report
“The evidence disclosed that whilst there were multiple agencies, organisations and healthcare providers who had been treating or triaging Alex’s mental and physical health conditions, including his misuse of illicit drugs: a. There was no – and nationally there appears to be no - policy, guidance or structure which would enable a designated lead, or ‘single point of contact’ with full oversight of, and (more importantly) authority over, Alex’s care – taking particular account of his young age. b. This represents a ‘care gap’ and missed opportunity whereby a nominated lead could ensure that each incident, attendance, relapse or overdose was alerted to those other agencies, organisations or providers who would need to know or who may benefit from knowing of the occurrence. And then – critically – directing and assuring the right treatment or long-term intervention to follow. c. The sharing and updating of information regarding Alex’s multiple health and drug issues was fragmented, in the absence of clear, national protocols and requirements as to the informing and alerting of new incidents, treatment, or other change in mental or physical health or addiction. d. I was encouraged to learn of the Plexus Care Record initiative in this local area (Plexus Care Record) but the evidence was that this is voluntary, and that not all providers or agencies are able or willing to connect or provide their records and share information. Moreover, I heard evidence that this is a local but not national initiative and hence information and record sharing elsewhere may be worse. As such the situation is ameliorated by local changes but appears to be a wider and national issue. I found that these factors were exacerbated in Alex’s case as a vulnerable 19 year old who had clearly been suffering with poor mental health and drug misuse whilst, and since, a child, noting that he lacked the experience and knowledge to successfully advocate for himself, or insight into his own needs. My further concern is that there was no simple mechanism or designation across the various patient record systems for those who may become involved with Alex, to know of the significant wider and historical health and drug misuse issues, in the absence of his own willingness or ability to fully disclose these at each turn. Especially when he may have been under the influence of substances. This meant repeated opportunities to better address Alex’s serious underlying conditions and issues were not taken. This lack of an easily recognised national designator, shown across systems and records, such as ‘person at [serious] risk’ gives rise to an incomplete understanding of, and risks a failure to sufficiently enquire into, someone’s full condition as and when services become intermittently involved, and creates a risk of further similar deaths. I add that I am very conscious of the Chief Coroner’s guidance to consider what can practically be achieved and not to engage with ‘ideal world’ scenarios, as well as considering the realistic prospect, including on resource grounds, that this report will be acted upon. I respectfully see no such barriers as regards the ‘lead point of contact’. I recognise information sharing will be subject to data protection and handling, consent, privacy and confidentiality issues, but progress has been made locally within existing resource and I consider that these issues need to be better addressed in the national healthcare context, else they will continue to be barriers to preventing deaths, rather than enablers to save lives. ”
Source location
Alex Ganski · 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
Work with NHS England and sector partners to overcome barriers to data sharing between services.

Verbatim wording from the response
“Regarding your concerns raised in relation to sharing information and data between services and clinicians, the delivery framework also states that all service providers need to work together with all relevant local services to agree data sharing arrangements that reflect the needs of people with a co-occurring mental health and substance use need. This is also in line with the NICE guidance recommendations on information sharing, 1.4.6 and 1.4.7. Work is ongoing alongside NHSE and sector partners to overcome barriers to data sharing between services.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
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
Strengthen clinical leadership, multiagency working and information sharing through children and young people’s mental health reforms.

Verbatim wording from the response
“Through our wider children and young people’s mental health reforms, we are working to strengthen clear clinical leadership and oversight, multiagency working, and information sharing, so that no child falls through gaps between services.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
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
Reduce the longest waits for specialist mental health services.

Verbatim wording from the response
“Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
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
Accelerate rollout of Mental Health Support Teams across England toward full national coverage.

Verbatim wording from the response
“Alongside this we are reducing the longest waits for specialist services, embedding mental health support for young people within new Young Futures Hubs, and accelerating the rollout of Mental Health Support Teams across England to reach full national coverage by 2029. These teams are designed to support earlier identification of risk, rapid information-sharing between services and clearer pathways into longer-term support where required.”

Source location
Response from Department of Health and Social Care
Page 3 · response
Published 2 April 2026
Open published response
16 Mar2026
Cumbria
Concerns raised1
1. Failure to pass full and accurate information between NWAS and CHOC
This report raised 1 other concern. 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.
Actions described in response 1
1. Action
  Review the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.
  Stated by North West Ambulance Service NHS TrustStated completed
AI-generated summary

Jardine Williams · 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

Jardine Williams, a 29-year-old mental health nurse, died on 24 March 2025 after making a 999 call reporting worsening mental health, suicidal thoughts, a plan and an intention to carry it out. The report raised concerns about unclear and confused communication between the North West Ambulance Service and Cumbria Health on Call, including a delay in returning the call after repeated unsuccessful attempts to contact her. The report did not find a causative link between that delay and the outcome, and stated that her intent could not be determined on the balance of probabilities.

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 full and accurate information between NWAS and CHOC
Wider context from the report
“As outlined above, I heard evidence that Miss Williams had made a 999 call which had been answered by the Northwest Ambulance Service (‘NWAS’) who, in turn passed the information to CHOC. (1) I found that the flow of information and communication between NWAS and CHOC was unclear and at times appeared to be confused. The information passed to CHOC at the outset, following the 999 call, appeared to be limited and may not have provided the receiving handler with the full picture of the situation. I was concerned that full and accurate information was therefore not passing between NWAS and CHOC. (2) Thereafter between 18.14 and 18.54 hours, 4 attempts were made by CHOC to call Miss Williams, but no successful contact was made. At 19.48 hours NWAS called CHOC for an update regarding Miss Williams. I heard evidence that as per the agreed procedure, a third and final attempt at contact would be made. By this stage however four unsuccessful attempts had already been made to contact Miss Williams, and the third attempt to contact her had been made at 18.25hours. I considered that the flow of information between CHOC and NWAS appeared to have confused on this issue. At 20.43 hours a further call was made to CHOC from NWAS for an update on the case, and again it was confirmed that no successful contact had been made with Miss Williams. Therefore, the call was taken back by NWAS approximately 2 hours 18 minutes after the third unsuccessful attempt was made to contact Miss Williams. Thereafter, an ambulance attended Flat 2 Harraby Green Hall at 20.58 hours. I did not find that there was a causative link between the call not being returned to NWAS after the third unsuccessful attempt to contact Miss Williams, and the eventual outcome. I was concerned that, in terms of the procedure, the call should have been returned by CHOC to NWAS after the third failed attempt to contact Miss Williams at 18.25 hours, but that the call was not returned to NWAS by CHOC until 20.43 hours. ”
Source location
Jardine Williams · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Review the incident collaboratively with CHOC’s medical and digital operations leads to identify communication and referral-process learning.

Verbatim wording from the response
“Since this inquest, NWAS’ Mental Health Liaison Lead contacted CHOC to review the incident collectively. This review was undertaken with CHOC’s Medical Director and Digital Operations/Programme Manager. CHOC have acknowledged the evidence already provided by NWAS that the incident should not have been transferred to CHOC due to the identified risk of suicide and that the information provided on this occasion ought to have contained more context. It was also acknowledged by CHOC that, as the incident was categorised as a Category 3 response, it should have been returned by CHOC following the third unsuccessful attempt to make contact, which did not occur.”

Source location
Response from Northwest Ambulance Service
Page 2 · response
Published 26 March 2026
Open published response
11 Mar2026
Cumbria
Concerns raised1
1. Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Review and improve how mental-health information and onward referrals are flagged, captured and displayed in SystemOne.
  Stated by WaythroughStated completed
2. Action
  Cooperatively review the joint-working protocol, including operational leads, single points of contact, referral information and cross-team applicability.
  Stated by WaythroughStated in progress
3. Action
  Invest in education and awareness-raising for frontline practitioners so the co-occurring protocol is understood and applied consistently.
  Stated by WaythroughStated planned
1. Action
  Improve documentation of RSC-CNTW information-sharing, including acknowledgement of information received and timely responses.
  Stated by WaythroughStated planned
2. Action
  Re-launch a refreshed co-occurring pathway across North Cumbria, with potential wider rollout across the CNTW catchment.
  Stated by WaythroughStated planned
AI-generated summary

CHARLOTTE LOUISE JONES · 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

Charlotte Louise Jones was found deceased at her home on 10 February 2025, with her death attributed to fatal levels of alcohol and bromazolam. She had a history of self-harm and substance use, and had multiple attendances at A&E following overdose and self-harm before her death. The principal concern was that CNTW and Recovery Steps did not have an adequate procedure for exchanging information about service users, including those not accepted onto a particular treatment pathway.

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
Inadequate information-sharing procedures for service users regardless of treatment-pathway acceptance
Wider context from the report
“Whilst CNTW and Recovery Steps have procedures by which information about service users is shared, those procedures are not yet appropriate to ensure adequate exchange of information about service users whether or not the service user has been accepted onto a particular treatment pathway. ”
Source location
CHARLOTTE LOUISE JONES · 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 improve how mental-health information and onward referrals are flagged, captured and displayed in SystemOne.

Verbatim wording from the response
“• A review of how mental health information is flagged and captured within RSC's clinical management system SystemOne has been undertaken, to ensure that mental health concerns and onward referrals are more prominently recorded and visible to all practitioners working with an individual.”

Source location
2026-0149 - Response from Recovery Steps Cumbria
Page 4 · response
Published 18 March 2026
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
Cooperatively review the joint-working protocol, including operational leads, single points of contact, referral information and cross-team applicability.

Verbatim wording from the response
“• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across North Cumbria, initially with a view of rolling this out across the wider CNTW catchment. The protocol will include clear escalation routes, improved communication pathways between RSC and CNTW, and a formalised process for following up on onward referrals where a response has not been received within an agreed timeframe. CNTW and RSC are in the process of cooperatively reviewing the protocol in line with the following aims:”

Source location
2026-0149 - Response from Recovery Steps Cumbria
Page 4 · response
Published 18 March 2026
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
Invest in education and awareness-raising for frontline practitioners so the co-occurring protocol is understood and applied consistently.

Verbatim wording from the response
“• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across North Cumbria, initially with a view of rolling this out across the wider CNTW catchment. The protocol will include clear escalation routes, improved communication pathways between RSC and CNTW, and a formalised process for following up on onward referrals where a response has not been received within an agreed timeframe. CNTW and RSC are in the process of cooperatively reviewing the protocol in line with the following aims:”

Source location
2026-0149 - Response from Recovery Steps Cumbria
Page 4 · response
Published 18 March 2026
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 documentation of RSC-CNTW information-sharing, including acknowledgement of information received and timely responses.

Verbatim wording from the response
“• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across North Cumbria, initially with a view of rolling this out across the wider CNTW catchment. The protocol will include clear escalation routes, improved communication pathways between RSC and CNTW, and a formalised process for following up on onward referrals where a response has not been received within an agreed timeframe. CNTW and RSC are in the process of cooperatively reviewing the protocol in line with the following aims:”

Source location
2026-0149 - Response from Recovery Steps Cumbria
Page 4 · response
Published 18 March 2026
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
Re-launch a refreshed co-occurring pathway across North Cumbria, with potential wider rollout across the CNTW catchment.

Verbatim wording from the response
“• A longer-term plan to re-launch a refreshed and updated co-occurring pathway across North Cumbria, initially with a view of rolling this out across the wider CNTW catchment. The protocol will include clear escalation routes, improved communication pathways between RSC and CNTW, and a formalised process for following up on onward referrals where a response has not been received within an agreed timeframe. CNTW and RSC are in the process of cooperatively reviewing the protocol in line with the following aims:”

Source location
2026-0149 - Response from Recovery Steps Cumbria
Page 4 · response
Published 18 March 2026
Open published response
25 Feb2026
Derby and Derbyshire
Concerns raised1
1. Lack of connectivity and information sharing between services
This report raised 2 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

Emma Irene TURNER · 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

Emma Irene Turner died at home on 29 January 2023 after her airway became obstructed by vomit following her eating some cake. The report identified concerns about inadequate and untimely multi-agency processes, safeguarding referrals, face-to-face assessments and welfare checks, as well as poor information sharing between services. It also identified a risk that the safeguarding referral form used by GPs could omit key information and delay responses.

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 connectivity and information sharing between services
Wider context from the report
“It is clear that her family cared and supported her but at the inquest the evidence exposed important issues with information sharing between services. Her mother, her carer should have been given more support and assisted in understanding what was in Emma’s best interests. The evidence at the inquest revealed a lack of connectivity between information systems used by different agencies; that impacted on their ability to review how other professionals would intervene in Emma's care. There had been a history of non-attendance and reluctance on the part of family members to engage with services. As a result, safeguarding referrals were made in 2018 by the Day Centre she had attended and in 2019 by a social worker after her discussions with the advanced nurse practitioner at the GP surgery. Although the evidence from the GP surgery, Derby City Council and their safeguarding team confirm that since Emma's death a number of relevant changes were being made to look after patients with learning difficulties particularly where they have not been brought to multiple appointments, in so far as the contents of the present safeguarding referral form which needs to be completed by a GP for vulnerable and learning difficulties adults, that present form is not tailored to the type of concerns that a GP would raise. The safeguarding template questions ask a variety of questions that are not relevant to a GP but to other agencies e.g. care homes, the police and community mental health teams. As a result there is a risk of there being a lack of key information provided to the safeguarding teams. Thus the safeguarding team may be delayed in responding in a timely way. ”
Source location
Emma Irene TURNER · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Dec2025
Northamptonshire
Concerns raised1
1. Failure of notification pathways to identify patients receiving private and NHS psychiatry
This report raised 2 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

Wendy Siobhan EYLES · 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

Wendy Siobhan Eyles died aged 55 on 31 October 2024 after being struck by a train at Kettering Station; the inquest concluded that appropriate mental health support and intervention had not been provided. Concerns included the absence of a protocol for patients receiving both private and NHS psychiatric care, risks from poor communication about medication changes, and possible lack of NHS awareness of private psychiatric 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
Failure of notification pathways to identify patients receiving private and NHS psychiatry
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that ".. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time...". It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”
Source location
Wendy Siobhan EYLES · Prevention of Future Deaths report
Page 2 · concerns
Open source report
22 Dec2025
Northamptonshire
Concerns raised1
1. Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment
This report raised 2 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.
Actions described in response 1
1. Action
  Develop and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.
  Stated by NHFTStated in progress
Respondent positions 2
1. Position
  The Trust cannot ensure notification of private psychiatric care because patients and private providers are not obliged to inform it.
  Stated by NHFTUnable to act
1. Position
  The Integrated Care Board is responsible for confirming actions to encourage GPs to notify the Trust about concurrent private psychiatric care.
  Stated by NHFTRedirects responsibility
AI-generated summary

Wendy Siobhan EYLES · 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

Wendy Siobhan Eyles died on 31 October 2024 after being struck by a train at Kettering Station having climbed down from the platform. The report identified concerns about the lack of a protocol for patients receiving both private and NHS psychiatric care, including risks that medication changes and treatment arrangements may not be communicated 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
Failure of notification pathways to ensure NHS mental health services are aware of private psychiatric treatment
Wider context from the report
“One of the findings of the Patient Safety Incident Investigation (PSII) was that “.. there is no protocol for patients open to private and NHS psychiatry at Northamptonshire Healthcare Foundation Trust. The Psychiatrist’s role in patient care is to review and recommend appropriate medication and it is problematic if two Consultants are overseeing this at the same time. It can cause confusion and detriment to the patient if medication changes are not communicated between parties and represents a risk to patient safety... It is notable that CMHT operational managers from across the service differ in their views on the appropriateness of a patient being open to NHS and private services at the same time..”. It also emerged at Inquest that a NHS Consultant may not be aware that the patient is also receiving private psychiatry. Where the GP is notified of private psychiatry, it does not trigger a notification to NHS mental health services. Notification of the dual treatment may then be entirely dependent upon the information being shared by the patient. ”
Source location
Wendy Siobhan EYLES · 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 and complete a Trust-wide protocol for managing patients receiving simultaneous NHS and private psychiatric care.

Verbatim wording from the response
“Protocol for patients receiving NHS and private psychiatry Patient safety is of paramount importance to NHFT. We understand that there are risks to a patient’s safety when they are receiving private psychiatric care alongside our own treatment plan. To manage these risks, we are developing a new private care protocol.”

Source location
2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
Page 1 · response
Published 18 March 2026
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 cannot ensure notification of private psychiatric care because patients and private providers are not obliged to inform it.

Verbatim wording from the response
“This new private care protocol will guide clinicians throughout the organisation on how to approach circumstances when it becomes known that their patient is accessing care from a private healthcare provider. It will operate within our existing policy framework, linked to existing policies and procedures for information sharing and record keeping. Work to develop this new protocol is underway and will be completed by the end of this month. Once in place it will apply to new and existing patients. Please let me know if you would like to receive a copy of the protocol and I shall arrange for it to be sent to you.”

Source location
2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 March 2026
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 Integrated Care Board is responsible for confirming actions to encourage GPs to notify the Trust about concurrent private psychiatric care.

Verbatim wording from the response
“Sharing information when patients are accessing private psychiatry I note that you sent a copy of your Report to the Northamptonshire Integrated Care Board (NICB), as the body responsible for commissioning primary care services from GPs.”

Source location
2026-0153 - Response from Northamptonshire Healthcare NHS Foundation Trust
Page 2 · response
Published 18 March 2026
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Fragmented information sharing and updating across healthcare providers

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.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Concerns raised1

Lack of communication and engagement between agencies involved in Ollie’s care

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.32

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Actions described in response 5

Respondent positions 2

Actions described in response 32

Respondent positions 1