Recurring concern

Unreliable inter-agency information sharing for coordinated care

First to latest report 29 May 2013 — 15 Jun 2026

Reports that mention this concern
212
Times this concern has been raised
235
Stated actions linked to this concern
492

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.

What is 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 and published responses 212 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Manchester South

    AI-generated summary

    Katie Croft · 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

    Katie Croft was a vulnerable child who had reported abuse and later disclosed thoughts of self-harm. She was found suspended from a ligature at home, sustained catastrophic brain damage, and died in hospital on 15 January 2019. Concerns included shortcomings in the police and social-care responses, failures to fully hear Katie’s voice and share relevant information, and uncertainty about guidance for schools teaching material involving suicide to vulnerable pupils.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to share Child and Family Assessments in accordance with best practice

    Wider context from the report

    “2. The Local Authority at the time were using a substantial number of agency social workers. As a result the Child and Family Assessment was not completed in accordance with best practice and not shared in accordance with expectations around best practice. The Local Authority has since made significant progress in moving away from a reliance on agency staff to fill gaps in social work cover. The inquest was told that agency social workers are still used extensively in other Local Authorities creating a risk that a similar situation could arise; ”

    Source location

    Katie Croft · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Cheshire

    AI-generated summary

    Mr Sam Spooner · 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

    Mr Sam Spooner died at Leighton Hospital on 31 August 2018 after being found unresponsive following an act intended to end his life. The report identified concerns about inadequate multi-agency information sharing, coordination and intervention despite known suicide risk, and excessive reliance on his family to keep him safe.

    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 multi-agency information sharing and communication between health care providers

    Wider context from the report

    “1) There was a lack of multi-agency information sharing, co-operation, co-ordination and effective communication both within and between health care providers which meant that: a) The private counsellor who provided treatment to Mr Spooner did not have adequate information from other health care providers as to his medical/mental health history, diagnosis and treatment by other healthcare professionals. b) There was a failure to adopt an effective multi-agency approach to the care for Mr Spooner from 20th August 2018 when it was known that he was actively considering ending his life. c) There was a failure to adequately intervene from 30th August 2018 when it was known that: (1) Mr Spooner had recently attempted to take his life; and (2) Mr Spooner had subsequently undertaken additional research and made further preparations to enable him to do so. 2) There was an excessive and unreasonable reliance placed upon Mr Spooner's family by health care providers to keep him safe when those providers knew that Mr Spooner's family were not in a position to do so. Health care providers lacked awareness of and/or failed to adequately involve other agencies who may have been able to keep Mr Spooner safe, for example the police who may have been able to exercise their powers under section 136 of the Mental Health Act 1983 to take Mr Spooner to a place of safety. ”

    Source location

    Mr Sam Spooner · 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

    Support NHS England and devolved health authorities in developing improved mental-health care, including information sharing, case coordination and family-carer support.

    Verbatim wording from the response

    “Additionally, RCGP regularly inputs into national organisations looking to improve the responsiveness and understanding of mental health services. For example, I have personally attended and input into the All Party Parliamentary Group on Suicide and Self Harm. We also regularly support NHS England and devolved nations health authorities in the development of improved care, frequently alongside our sister Royal College, the Royal College of Psychiatrists. Work has included strategies to improve information sharing and case co-ordination as well as support for family members/carers.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 2 · response
    Published 27 December 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Amend assessment and consent forms to ask about psychiatric history and obtain consent to contact relevant mental health practitioners.

    Verbatim wording from the response

    “She has spoken to other private psychotherapists and her Clinical Supervisor about their respective practices. Mrs ████████ always asks clients whether they have ever been under Mental Health Services, but she has now amended her assessment and consent forms (which are attached) so that she asks more particular questions about previous psychiatric history. It is also the case that NICE issued guidelines on 10 September 2019 (i.e. after Mr Spooner's death) in relation to multi-agency suicide prevention partnerships and Mrs ████████ has both considered those guidelines and thought about how she might implement some changes in her practice, both as a result of those guidelines and as a result of this case.”

    Source location

    2019-0378-Response-from-Counsellor_Redacted
    Page 2 · response
    Published 27 December 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Existing RCGP mental-health education, guidance and service-improvement work is considered an adequate response to suicide-prevention concerns.

    Verbatim wording from the response

    “From the above, RCGP already undertakes considerable work in this important area as we see it as a key priority. I will ensure that the sad case of Mr Spooner is brought to the attention of our mental health leads and our educational convenors so that we can continue to do what we can to improve services for patients such as Mr Spooner.”

    Source location

    2019-0378-Royal-College-of-General-Practitioners
    Page 3 · response
    Published 27 December 2019

    Open published response

  3. Hampshire

    AI-generated summary

    William James Moody · 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

    William James Moody, aged 85, intentionally entered the River Itchen from the banks of his home on 19 April 2019 and could not be revived after being taken to Southampton General Hospital. The report raises concerns that Hampshire’s 999 call-handling system may cause delays, missed triage opportunities and inadequate information-sharing between emergency services during mental health crises involving suicidal ideation.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to share information between emergency agencies without repeating caller screening

    Wider context from the report

    “At Mr Moody’s Inquest I heard that his family (who were present throughout events as his daughter and son-in-law on the Estate in which Mr and Mrs Moody had a cottage) initially called 999 and asked for the Police to attend. The 999 call-taker triaged the call as requiring the attendance of Ambulance Service and deemed this to be a matter that the Police would not attend. This resulted in the family having to redial 999 and ask for an alternative service; during which some level of screening questions were repeated. This caused delay in the family reaching an appropriate service to attend. I heard evidence from the Mental Health Lead for Hampshire Constabulary who explained that as the incident on the 19th April 2019 was occurring in the person’s home and, as such the Police have no power to intervene where a person is in their own home and in mental health crisis and/or threatening to harm themselves. The situation on the 19th of April was distinguished from that which had happened the day before, on the 18th April, as the incident on the 18th had occurred in a public place and so, in that case, the police had a duty to attend. I heard further evidence that there is a Memorandum of Understanding (“MOU”) between Hampshire Police and the South Central Ambulance Service as to who is the primary response agency for persons making threats of suicidal ideation. Ultimately, the family were confused as to where help would come from and the call-handler will not transfer the call to a particular route/service unless the caller makes the decision as to which service they need. Despite there being a MOU between the agencies this does not appear to be something that the general public is aware of, and the task of making the general public aware of this is likely to be insurmountable and therefore it remains entirely foreseeable that future delays could occur because callers are unaware of which emergency service is the correct one to request in a situation where a person is suffering a mental health crisis episode and/or expressing suicidal ideation within the boundaries of their home. I heard further evidence regarding the existence of a different triage system, that operates in at least one area/jurisdiction of the country, but this only applies when a caller dials the 111 service; callers are given an option of accessing “Mental Health” services and this allows calls to be triaged through to an appropriately trained team/call-handler who can ask a set of wider diagnostic questions to understand and establish which agency, on the particular facts, should be the primary response service to that individual. In the situation of Mr Moody it transpired that it was actually a mixed response that was required; both the Police and Ambulance services. I am concerned that the current system of dealing with 999 calls in Hampshire gives rise to the potential for opportunities to be missed to triage the emergency call quickly and effectively, and to share information between agencies without the need to repeat the screening approach, and these factors may result in further deaths in the future. ”

    Source location

    William James Moody · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  4. Inner South London

    AI-generated summary

    Rebecca Marshall · 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

    Rebecca Marshall was referred for mental health assessment after escalating self-harm, depression, anxiety and angry outbursts. After moving to university accommodation in London, there was no interagency communication between the mental health services involved in her care, and urgent referrals did not result in a senior review. She was discovered deceased in her room on 27 November 2017, and the inquest concluded that she died as a result of suicide. The principal concerns included missed opportunities in her care and inadequate arrangements for sharing information and ensuring continuity of care between trusts when she moved areas.

    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 obtain and share information with other trusts for patients moving to or from the area

    Wider context from the report

    “(1) At inquest I was told that both Trusts involved: SLaM and KMPT had investigated the circumstances of Miss Marshall's death independently. (2) At a pre-inquest review hearing on 18 October 2018 I suggested that in light of the circumstances of the case it would be preferable for a joint report to be produced focussing on the apparent lack of interagency communication which had apparently led to Miss Marshall not being reviewed as required. (3) At inquest I was told that following the pre-inquest review hearing there had been a meeting between the two Trust's and that the report from KMPT would be exhibited to and form part of the report of SLaM Trust. (4) Both reports identified a number of missed opportunities in Miss Marshall's care, including steps to ensure joint ownership of her care when she became a student in London. (5) I was told at inquest of the lessons learnt by both Trusts and the actions completed. (6) From what I was told at inquest however, it appeared that KMPT had not taken any steps to address the issues of obtaining collateral information from or sharing information with other Trusts involved in the care of one of their patients, particularly if they have moved, permanently or temporarily to / from KMPTs area. (7) Miss Marshall formed part of what could be considered to be a particularly vulnerable group of individuals, namely a member of the student population suffering from mental health challenges whose continuity of care could not be guaranteed by good inter Trust communication. ”

    Source location

    Rebecca Marshall · 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 Transfer and Discharge of Care policy to cover transfers involving vulnerable populations, including students, travellers and refugees.

    Verbatim wording from the response

    “• The Transfer and Discharge of Care policy has been reviewed to ensure that it properly addresses any and all instances of care transfer, including vulnerable populations. This includes students, travellers and refugees.”

    Source location

    2019-0313-Response-by-Kent-and-Medway-NHS-Trust
    Page 2 · response
    Published 5 November 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Implement Trust-wide reminders and policy-sharing that disseminate learning from gaps in Rebecca’s care.

    Verbatim wording from the response

    “• A programme of reminders and sharing of the Transfer and Discharge of Care policy is in place across the Trust, underpinned by sharing the learning about the gaps in Rebecca’s care and what should have happened.”

    Source location

    2019-0313-Response-by-Kent-and-Medway-NHS-Trust
    Page 2 · response
    Published 5 November 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Incorporate South London and the Maudsley’s Transient People policy into the overarching policy document.

    Verbatim wording from the response

    “• We have liaised with South London and the Maudsley and are incorporating their Transient People policy in to our overarching document”

    Source location

    2019-0313-Response-by-Kent-and-Medway-NHS-Trust
    Page 2 · response
    Published 5 November 2019

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    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 testing and refining care-transfer processes.

    Verbatim wording from the response

    “You have my personal assurance as Chief Executive, that we will continue to test and refine our processes, sharing our reflection and learning from Rebecca’s story with staff who deliver front line care every day.”

    Source location

    2019-0313-Response-by-Kent-and-Medway-NHS-Trust
    Page 2 · response
    Published 5 November 2019

    Open published response

  5. South Wales Central

    AI-generated summary

    Ffion 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

    Ffion Jones died following an Addisonian crisis and cardiac arrest while waiting almost an hour for an ambulance at her GP’s surgery. Her urgent ambulance call was not escalated to the clinical support desk, and the report identified an ongoing lack of a dedicated means for external healthcare professionals to urgently discuss a patient’s clinical need with ambulance service staff. The report stated that there was a real risk of recurrence.

    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 a dedicated means for urgent clinical discussion between external healthcare professionals and ambulance service staff

    Wider context from the report

    “(2) There remains no dedicated means for an external health care professional to have urgent access to a discussion with a clinical member of ambulance service staff to ensure that their assessment of their patient’s clinical need is fully, properly and quickly conveyed to the ambulance service, and thus that there is a properly informed assessment of the urgency of the response. ”

    Source location

    Ffion Louise Jones · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  6. East Sussex

    AI-generated summary

    Reece Tristan Lapina-Amarelle · 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

    Reece Tristan Lapina-Amarelle, aged 20, died by suicide after being discharged from hospital with the expectation that he would immediately attempt to take his life. The report identifies concerns about insufficient resources and treatment for people with serious mental illness and substance misuse, inadequate information-sharing between services, limitations of voluntary support, and the Mental Health Act's failure to provide an appropriate plan of action focused on safety.

    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

    Insufficient information sharing between mental health and substance and alcohol misuse services

    Wider context from the report

    “(2) There is insufficient sharing of information between the Mental Health Trust and CGL (the Substance and Alcohol Misuse Service). ”

    Source location

    Reece Tristan Lapina-Amarelle · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Develop and implement secure digital record-sharing arrangements across NHS and partner organisations, including comprehensive shared care records.

    Verbatim wording from the response

    “The NHS Long Term Plan is committed to ensuring that by 2024 secondary care providers in England, including acute, community and mental health care settings, will be fully digitised, including clinical and operational processes across all settings, locations and departments. Data will be captured, stored and transmitted electronically, supported by robust IT infrastructure and cyber security, and Local Health and Care Records will cover the whole county.”

    Source location

    2019-0274-Response-by-NHS-England
    Page 3 · response
    Published 18 October 2019

    Open published response

  7. Black Country

    AI-generated summary

    Ms Shannon Quinn · 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

    Ms Shannon Quinn, a 24-year-old woman with a complex mental health history and repeated self-harm, was found hanging in her room at Oak House on 9 January 2019 and was pronounced deceased shortly afterwards. The report identified concerns including inadequate information sharing and joint care planning, insufficient staff training, escalating ligature risk without sufficient environmental measures, and failure to adhere to five-minute observations.

    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

    Inconsistent sharing of clinical documentation and care plans between statutory agencies and private-sector care providers

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector. In particular, there was no sharing of medical notes/care plans between the Birmingham and Solihull and Mental Health Trust and Oak House. ”

    Source location

    Ms Shannon Quinn · 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

    Discuss information sharing with Trust leaders and check improvements during the next Trust inspection.

    Verbatim wording from the response

    “At our next meeting with Birmingham and Solihull Mental Health Foundation Trust we will discuss with the senior leaders how information is shared with private providers who take patients from the trust and what action has been taken to ensure essential information is being shared.”

    Source location

    2019-0499-Response-from-CQC-Redacted
    Page 3 · response
    Published 25 March 2020

    Open published response

  8. East Sussex

    AI-generated summary

    Martin Leslie Haines · 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

    Martin Leslie Haines was detained at Lewes Prison and was found dead in his cell on 18 March 2018. He had Type II Diabetes and warning signs of cerebrovascular disease, but the appropriate diagnostic tests were not carried out; alcohol, Venlafaxine and Amitriptyline were later found in his system and considered by the pathologist to have contributed to his death. The principal concerns included inadequate diabetes and cardiovascular monitoring, healthcare falling below community standards, the ability to brew or distil alcohol in prison, a lack of protocols for responding to an unresponsive body, and insufficient communication between healthcare providers and the prison service.

    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

    Insufficient communication and information sharing between prison healthcare organisations

    Wider context from the report

    “(5) In my opinion, the underlying problems were due to the fact that responsibility for healthcare in the prison was split between the prison service, Sussex Partnership Foundation Trust (which is a mental health provider but was also contracted to run all healthcare, both physical and mental within the prison), Medco Ltd who provided the GPs and Forward Trust who were contracted to treat alcohol and substance misuse in the prison. There was insufficient communication between these bodies and they had separate IT databases. ”

    Source location

    Martin Leslie Haines · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Procure and award an integrated single-provider healthcare contract for HMP Lewes, using one provider and database to support integrated delivery.

    Verbatim wording from the response

    “NHS E have undertaken a procurement process for provision of these services after those dates. The services procured is an integrated model of delivery which means that the contract has been awarded to one provider for the delivery of all services to HMP Lewes residents. This is a tried and tested form of service delivery and puts the responsibility for delivery of all elements of the contract with one provider only. This will negate any communication issues and the provider will use one database system only.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Review providers’ use of SystmOne tasks in response to concerns about communication and messages going astray.

    Verbatim wording from the response

    “the Prime Provider model, giving them greater control over use of more innovative IT and software solutions. All users of SystmOne can create tasks for other team members and which are linked to patient records where applicable, thus reduces the risk of messages going astray. NHS E Commissioners will review the use of tasks by providers by end of October 2019, as a result of concerns raised in this Regulation 28 notice.”

    Source location

    Response from NHS England
    Page 4 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Improve health and care data collection and information-sharing before, during and after incarceration to support continuity of care.

    Verbatim wording from the response

    “The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are:”

    Source location

    2019-0486-Response-by-Department-of-Health-and-Social-Care
    Page 2 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Prison staff cannot access clinical records on SystmOne because such access is not appropriate.

    Verbatim wording from the response

    “Your final concern is that responsibility for healthcare is split between different contractors, and that there was insufficient communication between these bodies and their separate IT databases. As you know, the commissioning of healthcare in English prisons is the responsibility of NHS England and NHS Improvement (NHSE/I). HMPPS is responsible for ensuring access to healthcare services within establishments and, where required, at external healthcare facilities. With regard to the sharing of information between the various organisations, you will appreciate that it is not appropriate for prison staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily meeting between prison and healthcare staff at which important information is shared. Each staff team then ensures that their respective databases are updated.”

    Source location

    Response from HM Prison and Probation Service
    Page 2 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Healthcare providers are responsible for the quality and safety of care, including investigating care and considering improvements.

    Verbatim wording from the response

    “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Haines and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).”

    Source location

    2019-0486-Response-by-Department-of-Health-and-Social-Care
    Page 1 · response
    Published 16 August 2019

    Open published response

  9. East Sussex

    AI-generated summary

    Justin Peter Gallagher · 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

    Justin Peter Gallagher was received at HMP Lewes on 20 March 2016 and was later found collapsed in his segregation-block cell on 24 May 2016. He was taken to hospital, where he died on 17 June 2016; the post-mortem recorded hypoxic brain injury, cardiac arrest and laryngeal carcinoma with upper airway obstruction among the causes. Concerns included the absence of his previous medical history, a proper care plan and a single clinician responsible for his care, cancelled hospital appointments, missed opportunities to diagnose his cancer, lack of family involvement, and separate healthcare organisations using unconnected database systems.

    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 healthcare organisations to use integrated database systems

    Wider context from the report

    “(5) The underlying problem was that healthcare in the prison was the responsibility of three different organisations, namely the prison service, the local mental health NHS Trust (who were given the responsibility of dealing with all physical health matters and running the healthcare centre), and a separate organisation who supplied GPs. These three organisations had entirely separate database systems. ”

    Source location

    Justin Peter Gallagher · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Commission prison healthcare through a Prime Provider model using a single contract, provider and database.

    Verbatim wording from the response

    “In 2017, NHS England (NHSE) reviewed the model of commissioning in Kent, Surrey and Sussex as it was becoming increasingly apparent that the model was not delivering the benefits anticipated and services were not integrating effectively. In line with other prison groups in England, NHSE made the decision to commission services using a Prime Provider model. I can confirm that this model ensures a single contract and provider, and therefore better accountability for the delivery of integrated healthcare in a prison (or group of prisons). This will negate any communication issues and the single provider will use one database system only.”

    Source location

    2019-0491-Response-by-NHS-England
    Page 4 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent action was interpreted

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

    PFD Monitor interpretation

    Improve prison healthcare data and intelligence collection and enable information-sharing before, during and after incarceration to support continuity of care.

    Verbatim wording from the response

    “The Agreement sets out a joined-up, strategic approach to meet the complex nature of offender health care needs and provides the partnership members with an overarching framework for collaborative working at all levels. The Agreement has three shared core objectives to be delivered through ten high level priorities. These priorities are underpinned by the Agreement’s 2018 Workplan, which includes a commitment to deliver on three key issues that relate to the responsibilities of all organisations involved in prison care. These commitments are to:”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Clinical-record access is restricted, while daily prison-healthcare meetings and database updates are considered sufficient for information sharing.

    Verbatim wording from the response

    “With regard to the sharing of information between the organisations involved in the management and care of prisoners, you will appreciate that it is not appropriate for prison staff to have access to clinical records on SystmOne. At HMP Lewes, there is a daily”

    Source location

    2019-0491-Response-by-HM-Prison-and-Probation-Service
    Page 1 · response
    Published 16 August 2019

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Healthcare providers are responsible for the quality and safety of care provided at HMP Lewes.

    Verbatim wording from the response

    “Providers of healthcare services are responsible for the quality and safety of the care they provide. I expect the healthcare providers at HMP Lewes to look into the care provided to Mr Gallagher and to consider where improvements can be made. This includes how they work with the prison authorities and other relevant organisations, including NHS England which is responsible for commissioning healthcare services for prisoners. Given its role in monitoring, inspecting and regulating the providers of health and social care in prisons, my officials have brought your reports to the attention of the Care Quality Commission (CQC).”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 16 August 2019

    Open published response

  10. Milton Keynes

    AI-generated summary

    Sam Michael Carl Grant · 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

    Sam Michael Carl Grant, aged 16, died at home on 09/11/2018 after being found hanging by his sister. The report raised concerns about limited access to lower-level mental health support, incomplete information-sharing between services, and reduced confidential health-information sharing between the school and GP surgery.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure of school healthcare provision to share confidential health information with GP surgeries

    Wider context from the report

    “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services. 2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority. 3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school. 2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority. 3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school. ”

    Source location

    Sam Michael Carl Grant · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Failure to share relevant information between health agencies for fully informed healthcare decisions

    Wider context from the report

    “1) Sam’s GP referred Sam to CAMHS when he presented to the GP with irritability, anger and a report that he was close to being excluded from school. CAMHS rejected the referral because Sam did not meet their threshold of moderate to severe mental health issues. CAMHS did not suggest any alternative assistance. The GP did follow up with Sam to sign post him to two independent organisations who Sam would have to approach independently for help. The GP made it clear in his evidence that there is a lack of lower level assistance for young people who present with ‘life issues’ such as low mood, irritability and anger issues, but who nonetheless need help and assistance but do not meet the criteria for access to CAMHS services. 2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority. 3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school. 2) Sam had been referred to, and was receiving the services of COMPASS having been referred by his School. The GP was not made aware of this engagement and was unable to take this into account at the time when Sam did present himself to the GP. The evidence from COMPASS is that they maintain the confidentiality of patients even minors using their services unless they have express consent to disclose that information from the patient themselves. Without all relevant information neither the GP nor CAMHS was in a position to make a fully informed decision about the Sam’s needs. Sharing of information between relevant health agencies to ensure fully informed decisions are made as regards the healthcare needs of an individual should be a priority. 3) Evidence at the inquest from the GP also indicated that a reduction in healthcare provision at Sam’s school and in particular the removal of a medically qualified person(s) has meant that confidential health information is no longer shared between the school and the GP surgery. The school now only engages First Aiders, who are not medically qualified, and who do not therefore exchange information which in the past has proved essential in flagging concerns between the GP and the School. This is another route which has been closed and which would have allowed a potential flag to have been raised in respect of concerns around Sam and his wellbeing to be shared confidentially between GP and school. ”

    Source location

    Sam Michael Carl Grant · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026