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

Distinct published reports

Individual concerns
235

A report can raise multiple concerns

Date range
2013–2026

First to latest report issue date

Stated actions
492

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

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

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

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.

  1. West Sussex, Brighton and Hove

    AI-generated summary

    Caroline Victoria Forte · 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

    Caroline Victoria Forte had been receiving inpatient mental health treatment and was granted Section 17 weekend leave to stay at her parents' address. She was found hanging on 20 February 2022. Concerns included inadequate communication within the ward and with her family, the absence of an overarching care plan or risk assessment before leave, failure to follow the Section 17 leave policy, and difficulties sharing information from her private psychiatrist with NHS services.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of a clear pathway for sharing private psychiatrist consultation and treatment details with NHS inpatient settings

    Wider context from the report

    “Ms Forte had for a number of years been seeing a private psychiatrist. Details of her consultations and treatments were not made readily available to those working in the NHS Trusts. It appears that there is no clear pathway for details of any private psychiatrist consultations to be shared with those in either the acute or mental health inpatient settings. The concerns are that any relevant history may be lost and details of any regular medication being prescribed may not, in a time of crisis, be immediately known. ”

    Source location

    Caroline Victoria Forte · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  2. South London

    AI-generated summary

    Patrick Soames · 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

    Patrick Soames died by suicide on 21 June 2021 after a final month involving repeated serious self-harm, including cutting, medication overdose and excessive alcohol misuse, with multiple hospital attendances. The principal concerns were that information about his risk was fragmented across NHS Trusts, police forces, local authorities and geographical areas, with no effective system to consolidate or flag his recent self-harm history nationally.

    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 or provide access to critical self-harm risk information for directly involved NHS Trusts

    Wider context from the report

    “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself). 2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours. 3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it. 4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up. 5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history. ”

    Source location

    Patrick Soames · Prevention of Future Deaths report
    Page 3 · 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

    Lack of a single effective global focus for consolidating and retrieving cross-agency risk information

    Wider context from the report

    “1. 5 NHS Trusts and 3 police forces in different geographic areas had contact with Patrick in the final month of his life and each thereby gained some information about the risk to him. However, that information was by reason of the agencies falling into different geographic areas. There was no single effective global focus for the information being acquired piecemeal about Patrick’s pattern of serious self-harming behaviour. The various agencies were significantly impeded in forming a single clear picture of Patrick’s pattern of behaviour (which was particularly necessary in circumstances where he was not engaging and therefore not assisting in providing a complete history himself). 2. GPs act as a repository for information about contact with other clinical agencies (such as attendances at accident and emergency departments) and therefore serve as a point of contact for information about past history. However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP outside of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department. Several of Patrick’s attendances at accident and emergency departments were out of GP surgery hours. 3. I was informed at inquest that one local authority (in whose area Patrick resided) had been made aware by police of the risk to Patrick following one of his self-harm incidents (in respect of a particularly important piece of information) and had relayed that information to a 6th NHS Trust (not one of the 5 from which I heard evidence at inquest) but Patrick did not reside in that Trust area. Those Trusts which did have direct contact with Patrick were never made aware of that piece of information nor had any means of accessing it. 4. I heard evidence that there is no national ‘risk flagging’ system: for example, when a person attends an accident and emergency department having self-harmed, the fact of a previous self-harm attendance at a different accident and emergency department is not systematically flagged up. 5. In summary, there was no single effective global focus consolidating the information which was flowing into the various agencies about Patrick; no global focus to which those agencies could in turn refer in emergency to obtain the totality of information about Patrick’s recent pattern of behaviour; no national ‘risk flagging’ system to alert those agencies to his significant recent history. ”

    Source location

    Patrick Soames · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  3. Manchester North

    AI-generated summary

    Ania Sohail · 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

    Ania Sohail collapsed on 19 June 2021 after ingesting Propranolol tablets she had obtained from multiple online pharmacies and died later that day from Propranolol toxicity. The principal concerns included the lack of integrated information sharing between online pharmacies and prescribers, ineffective and poorly documented searches, inadequate post-leave assessment and care planning, and insufficiently auditable observation records.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of online pharmacy information sharing with patients’ GPs

    Wider context from the report

    “(2) There is no requirement for the on-line pharmacies to share information with the patient’s GP. This means that, in the absence of the patient’s consent to share information, the online prescriber is reliant on the accuracy and truthfulness of the history provided by the patient. ”

    Source location

    Ania Sohail · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    NHS England has no jurisdiction over private healthcare provision, including private online prescribing services.

    Verbatim wording from the response

    “NHS England has no jurisdiction over private provision. Private providers would need a very good reason to breach a patient’s refusal to share their information as they are legally obliged to safeguard sensitive information under the General Data Protection Regulation. The General Pharmaceutical Council has provided information to online pharmacies on Providing medicines online, which is available at: Online Pharmacy Services (pharms.com)”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 22 February 2023

    Open published response
  4. Dorset

    AI-generated summary

    Derek Larkin · 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

    Derek Larkin was found deceased at home on 2 June 2021 after returning from a care home, and a post-mortem examination demonstrated an overdose of prescription morphine. The report raises concerns that Adult Social Care did not have sufficient information about his prescribed medication, medication management, or concerns raised by family and healthcare professionals, including because its computer system could not communicate with the NHS SystemOne system.

    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 interoperability between Adult Social Care and NHS information systems

    Wider context from the report

    “There is no evidence that the Dorset Council Adult Social Care computer system Mosaic can communicate with the NHS SystemOne. The Adult Social Care team would benefit from having information about the medication being prescribed to a patient, with the patient’s consent, and when that medication was last reviewed. Dorset Council Adult Social Care would benefit from information held by a current or former GP practice as to a patient’s medication and how to manage any particular concerns raised by health care professionals or family where a patient is able to independently manage his medication. ”

    Source location

    Derek Larkin · 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

    Share the Coroner’s findings with relevant teams to inform future Dorset Care Record improvements.

    Verbatim wording from the response

    “The DCR continues to be developed and refined and I have shared your findings with the relevant teams to inform any future improvements. Further information related to the DCR is available via the following link: Dorset Care Record (dorsetccouncil.gov.uk)”

    Source location

    Response from Dorset Integrated Care Board
    Page 1 · response
    Published 23 January 2023

    Open published response

    Source evidence

    How this respondent position was interpreted

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

    PFD Monitor interpretation

    Full integration of Mosaic and SystemOne is constrained because separate data controllers own and regulate systems that are not designed to communicate.

    Verbatim wording from the response

    “SystemOne (a health service record keeping system) and Mosaic (Dorset Council’s social care record keeping system) are not designed to communicate with one another and are owned and regulated by separate organisational data controllers under the General Data Protection Regulation (GDPR) and Data Protection Act 2018.”

    Source location

    Response from Dorset Council
    Page 2 · response
    Published 23 January 2023

    Open published response
  5. South London

    AI-generated summary

    Samuel Robert Pearson · 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

    Samuel Robert Pearson had complex mental and physical needs and was moved to temporary accommodation after a van crashed into his home. The inquest narrative stated that the accident and accommodation increased his anxiety, and that he accidentally died after taking an overdose and alcohol on 6 July 2021. Concerns included inadequate multi-agency working and information sharing during the emergency move, and a referral-screening backlog that was not communicated to his GP.

    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 authorities to share information during emergency decants

    Wider context from the report

    “(1) Whilst there was good multi-agency working before Mr Pearson moved into his own accommodation, that was lacking when it became necessary to move him on an emergency basis despite the circumstances increasing his anxiety and vulnerability. Partnership working and sharing of information between the authorities may help mitigate risk in future cases of emergency decants. ”

    Source location

    Samuel Robert Pearson · 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

    Notify relevant Local Authority personnel promptly when future emergency decants involve vulnerable people receiving social care support.

    Verbatim wording from the response

    “1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this there is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.”

    Source location

    Response London Borough of Bromley Council
    Page 2 · response
    Published 11 November 2022

    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 Clarion with contact details for vulnerable adults’ services, children’s services and Local Authority housing contacts for emergency-decant notifications.

    Verbatim wording from the response

    “2. In respect of London Borough of Bromley’s largest provider Clarion, Senior Management in the Housing Department (LA) made contact with a Clarion Manager on the 14/12/22 and 29/12/22, raising the need to review their Emergency Decant Policy around notification of emergency decants to LBB where there is a vulnerable household member. Clarion have been asked to set out a notification protocol within this policy so that this can be agreed with the Local Authority. It is appropriate for the Housing Association to do this as they know their processes best. The Local Authority have already provided contact details to Clarion for vulnerable adults and children’s services as well as an LA housing contact, so that emergency decants can be notified as soon as the need is identified.”

    Source location

    Response London Borough of Bromley Council
    Page 2 · response
    Published 11 November 2022

    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

    Request a meeting with Bromley Federation of Housing Associations members to discuss notifying the Local Authority about relevant emergency decants.

    Verbatim wording from the response

    “3. Additionally, senior management in the LA Housing department have contacted Bromley Federation of Housing Associations to request that a meeting is convened to discuss this topic with their members, to ensure that they have due regard to arrangements for notifying LBB of emergency decants where there is a vulnerable household member.”

    Source location

    Response London Borough of Bromley Council
    Page 2 · response
    Published 11 November 2022

    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

    Housing associations are responsible for handling emergency decants and developing notification protocols because they know their processes best.

    Verbatim wording from the response

    “1. In respect to the Coroner’s concern (1), emergency decants are dealt with by Housing Associations in the London Borough of Bromley. The Local Authority’s OT (Occupational Therapy) service were not made aware of the emergency move/decant of Mr Pearson at the time it took place. When made aware the OT service raised their concern by email to the relevant personnel regarding the temporary accommodation provided. Arising from this there is the need for the relevant Local Authority personnel to be notified as soon as possible in the event of future emergency decants, when a vulnerable person subject to social care involvement (e.g adult social care/OT) is moved.”

    Source location

    Response London Borough of Bromley Council
    Page 2 · response
    Published 11 November 2022

    Open published response
  6. Manchester South

    AI-generated summary

    Philip Geoffrey Day · 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

    Philip Geoffrey Day was treated with methotrexate for psoriatic arthritis and developed neutropenic sepsis after blood tests showed neutropenia and a raised CRP. He died in hospital on 15 April 2022 after developing ileitis and colitis, followed by cardiac arrest and multi-organ failure. Concerns included delays in triage, medical review and treatment; inadequate communication of information from community clinicians to hospital staff; and insufficient recognition of neutropenic sepsis risk factors and red flags.

    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 recognised information-sharing pathway between community clinicians and secondary care

    Wider context from the report

    “2. In relation to Mr Day the inquest heard that the community OOH Doctor had correctly recognised the risk of neutropenic sepsis and had rung through to speak to a doctor at the hospital. At the inquest there was no documentation to assist in tracking that conversation or any evidence it had been recorded or acted on. It was clear from the evidence at the inquest that the sharing of information between community clinicians and secondary care was important and that there appears to be no recognised way for this to happened due to varied IT systems and no national recommendations for best practice in this scenario. As a consequence vital information is not available to ED teams. ”

    Source location

    Philip Geoffrey Day · 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

    Raise information-sharing processes between community out-of-hours services and emergency departments with NHS England.

    Verbatim wording from the response

    “I have asked officials to further raise the processes for information sharing between community out-of-hours services and emergency departments, with NHS England”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 7 November 2022

    Open published response
  7. Manchester South

    AI-generated summary

    Philip 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

    Philip Jones developed difficulty swallowing in February 2021, lost significant weight, and was diagnosed with Motor Neurone Disease after hospital admission in September 2021. He developed bronchopneumonia, deteriorated, was discharged home, and died there on 9 October 2021. Concerns included backlogs for neurology appointments, incompatible IT systems affecting information sharing, and delays in communications from consultants to other clinicians and patients.

    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 IT systems across healthcare organisations to support shared access to complete patient information

    Wider context from the report

    “2. The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult. This impacted the holistic view that clinicians needed of an individual patient. Whilst images could be shared there was no ability for notes for one Trust to be visible to a clinician at another Trust; ”

    Source location

    Philip 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

    Build digital infrastructure using artificial intelligence, automation and video-call technologies to support NHS services.

    Verbatim wording from the response

    “I also note your concern that incompatible IT systems between the hospitals in question made communication and information sharing in relation to Mr Jones’s treatment more difficult, as did the delay in the consultants communicating with other clinicians, including GPs, and as well as the patients themselves. I recognise that there needs to be adequate administrative support and greater use of digital technology to assist healthcare workers in completing non-clinical tasks, and that could increase the time they can spend caring for patients. This would provide a better patient experience and, ultimately, improve health outcomes.”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 October 2022

    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

    Publish a plan for digital health and social care to modernise digital technology and improve data use and care pathways.

    Verbatim wording from the response

    “You may wish to note that the Spending Review, announced in Autumn 2021, included £2.1 billion to modernise digital technology on the frontline to improve cyber security, improve the NHS’s use of data, and redesign care pathways. As well as a funding”

    Source location

    Response from Department of Health and Social Care
    Page 2 · response
    Published 3 October 2022

    Open published response
  8. Manchester South

    AI-generated summary

    John Edward Kay · 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

    John Edward Kay had previously undergone larynx removal for stage 4 cancer and had a speech valve, alongside significantly reduced respiratory lung function. He was admitted to Stepping Hill Hospital after a series of aspiration pneumonias and died there on 26 November 2021. Concerns included the failure to share information about caring for his valve with his care home, lack of regular monitoring and replacement, and limited understanding in the community of the specialist nurse service’s role and support.

    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 valve-care information with care homes

    Wider context from the report

    “1. The Inquest heard evidence that the management of a patient with a valve such as Mr Kay had is a complex one. It requires regular monitoring and replacement. The evidence was that when he went into a care home that information about how to care for his valve was not shared with the care home. The consequence was that he was not seen or referred for regular replacements of the valve which increased the risk of the valve not functioning correctly and him developing aspiration pneumonia; ”

    Source location

    John Edward Kay · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  9. Nottinghamshire

    AI-generated summary

    Kellum Paul Thomas · 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

    Kellum Paul Thomas, aged thirteen, collapsed at home on 9 June 2021 and died after a cardiac arrest caused by ventricular tachycardia deteriorating into ventricular fibrillation. Concerns included an 18-month gap without a functioning REVEAL heart-monitoring device, delayed replacement processes, and a significantly delayed outpatient letter containing medication and investigation information. The report also identified stretched team capacity and resources and stated that necessary actions to address these issues were not confirmed.

    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

    Delays in sending outpatient letters containing important clinical information

    Wider context from the report

    “2. Kellum’s outpatient letter from ████████ to both the GP and to Nottingham University Hospitals NHS Trust (where shared care was provided) was very delayed, with the outpatient appointment completed in March 21, and the letter not reaching its destinations until mid June 21, after Kellums death. This letter contained important information re a change in medication dosage and a request for NUH to arrange a further investigation. Again this issue appeared to be one of team capacity and resources. ”

    Source location

    Kellum Paul Thomas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  10. Cambridgeshire and Peterborough

    AI-generated summary

    Lewis Martyn POWTER · 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

    Lewis Martyn Powter, an IPP offender with emotionally unstable personality disorder and a long history of drug addiction, died from a self-administered overdose on 10 May 2020 after a period of abstinence and reduced drug tolerance. The concern was that there was no policy or guidance encouraging multi-agency meetings to share information about complex-needs IPP offenders, particularly where one care provider lacked access to the shared record system.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Unavailability of shared-record-system access for one care or treatment organisation

    Wider context from the report

    “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender. The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties. ”

    Source location

    Lewis Martyn POWTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Lack of policy, procedure or guidance on considering when to hold multi-agency information-sharing meetings

    Wider context from the report

    “that, where an IPP offender with complex needs is released and is not subject to MAPPA, but is subject to multi-agency intervention co-ordinated by the National Probation Service, there is no policy/procedure/guidance encouraging consideration to be given to the issues of whether and when to hold multi-agency meetings for the purposes of sharing information about the offender. The need for consideration to be given to holding such meetings is particularly acute where one of the organisations responsible for delivering care/treatment does not have access to the shared record system used by the other two parties. ”

    Source location

    Lewis Martyn POWTER · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026