Recurring concern

Unreliable operation of SystmOne for safety-critical prisoner information

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First reported 2 Nov 2015•Latest report 19 Jan 2023

Definition

What this concern includes

Includes failures of the named SystmOne system and its directly associated workflows affecting authorised access, staff use, recording, coding, searching, flagging or display of safety-critical prisoner information, including problems encountered when detainees arrive at immigration removal centres.

Not included

Excludes failures of other named clinical or custodial information systems, such as Lorenzo, EMIS, NOMIS or STORM, unless the assertion explicitly concerns SystmOne.
Excludes generic clinical-record, information-sharing, training or access deficiencies where SystmOne is not the deficient system.
Excludes failures to act on complete and accessible SystmOne information when the system and its directly associated controls operated reliably.
Excludes unrelated SystmOne administrative or technical problems that do not affect safety-critical prisoner information, assessment or care.

Reports: 3
Individual concerns: 3
Date range: 2015–2023
Stated actions: 5

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.

NHS England2

Central and North West London NHS Foundation Trust1

HM Prison and Probation Service1

Ministry of Justice1

Office of the Chief Coroner1

Winchester Prison1

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.

19 Jan2023
County Durham and Darlington
Concerns raised1
1. Failure to record and clearly flag family history of sudden cardiac death in SystmOne
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.
Respondent positions 1
1. Position
  No specific read code for sudden death syndrome is provided because there is no evidence supporting screening for the condition.
  Stated by NHS EnglandUnable to act
AI-generated summary

Joseph Andrew Price · 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

Joseph Andrew Price was found dead in his cell at HMP Durham on 20 September 2020, after being remanded there ten days earlier. The pathologist concluded that the medical cause of death was Sudden Cardiac Death, following evidence of a paternal family history of premature cardiac-related deaths. The principal concern was that this family history had not been recorded or elicited during healthcare assessments, making it unavailable to inform possible genetic screening; symptoms before death were also potentially confusable with drug withdrawal and mental or emotional distress.

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 record and clearly flag family history of sudden cardiac death in SystmOne
Wider context from the report
“Additionally, the health care provider proposed the introduction of a read code specifically for ‘FH: Sudden Cardiac Death’ in the SystmOne template. This read code does not currently exist in SystmOne and so locally, the health care provider has now added it as a prompt in the read code for ‘FH: Cardiac Disorder (XM1JV)’ and add to this (‘incl. Sudden Cardiac Death’). By adding ‘FH: Sudden Cardiac Death’ as a read code in its own right, it will make it easier to search for and flag on the SystmOne records of prisoners so staff can clearly see and be aware of this previous family history. ”
Source location
Joseph Andrew Price · 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
No specific read code for sudden death syndrome is provided because there is no evidence supporting screening for the condition.

Verbatim wording from the response
“In relation to your concern raised over a lack of appropriate read code for sudden cardiac death, there is no specific read code for sudden death syndrome on any clinical system, which is likely due to the fact there is no evidence to screen for it. NHS England is however refreshing the secondary health screening template to include a specific prompt for users to ask relevant questions relating to family history.”

Source location
Response from NHS England
Page 2 · response
Published 24 January 2023
Open published response
21 Feb2020
Central Hampshire
Concerns raised1
1. SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk 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 2
1. Action
  Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.
  Stated by Central and North West London NHS Foundation TrustStated completed
2. Action
  Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.
  Stated by Central and North West London NHS Foundation TrustStated planned
Respondent positions 2
1. Position
  SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.
  Stated by Central and North West London NHS Foundation TrustRedirects responsibility
1. Position
  Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.
  Stated by Central and North West London NHS Foundation TrustDisputes the concern
AI-generated summary

Andrew Goldstraw · 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

Andrew Goldstraw was found hanging in a cell at HM Prison, Winchester, on 14 November 2018, having taken his own life using a ligature made from torn bed linen. The report raised concerns that relevant information about his previous suicidal ideation and self-harm attempts was difficult for healthcare staff to identify in SystmOne, that the system could hinder effective risk assessment, and that staff training may have been inadequate. The inquest jury found that an ACCT should have been opened and that its absence would have more than minimally helped to prevent his death.

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
SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information
Wider context from the report
“B. SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT. Too much reliance is placed on the individual prisoners presentation and how he answers a series of pre-set questions. C. At best, SystmOne makes it difficult for a mental health nurse to ascertain the relevant information and at worst it actively misleads them. For example, a search can be made of the "journal" section but this would rely on the exact words being searched (such as "suicide" or "deliberate self-harm") and it would then be necessary to go through the various entries (in Mr Goldstraw's case spread over 111 pages) using the "Key Word Search" function. Further, the functions that would (on the face of it) serve to assist in this situation (such as the "Summary" page or "Active Problems" section) were not populated with the information relevant to an accurate assessment. It was conceded by the legal representatives acting on behalf of CNWL that the "Summary" section is "very limited in its contents" and is not routinely used by healthcare staff within the prison in order to gain an insight into a prisoner's past medical history. D. The "Active Problems" section of SystmOne is subdivided in to a number of distinct areas and it appears to be wholly inadequate in terms of identifying key areas of concern such as the risk of suicide or deliberate self-harm. The only information contained in the "Active Problems" section of SystmOne in Mr Goldstraw's case was four years out of date. None of the relevant information was contained in "Active Problems" but a great deal of irrelevant information was there! E. The "Communications" section of SystmOne contains a chronological record of correspondence with the hospital, GP surgery and psychiatric units. However, the "Key Word Search" facility does not function at all and short of going through all of the correspondence there is no way of identifying the key information needed to undertake an effective risk assessment. The "Communications" section in Mr Goldstraw's case amounted to 83 pages. Although the relevant information concerning Mr Goldstraw's mental health issues was contained within the "Communications" section of SystmOne there was no way of easily extracting it. F. Accordingly, a busy, under pressure mental health nurse or doctor is very likely to struggle to find the relevant entries using SystmOne, which may explain why (in Mr Goldstraw's case) too much reliance was placed on how he presented during interview. A prisoner who chooses not to disclose his true state of mind or suicidal ideation is unlikely to come to the notice of the healthcare staff whose job it is to identify the risk that he may pose to himself because SystmOne does not facilitate this. ”
Source location
Andrew Goldstraw · 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
Distribute guidance to offender-care sites on using SystmOne searches to identify suicide and self-harm history.

Verbatim wording from the response
“The Trust has sent out guidance to all offender care sites in relation to the search function. Whilst this is a function owned by SystmOne CNWL has given staff directions on how to best utilise this function. For instance, when trying to get a history of suicide attempts rather than searching suicide the clinician should search ‘suic’ which will bring up results for suicide, suicidal, suicidal thoughts.”

Source location
2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Page 3 · response
Published 9 March 2020
Open published response
Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation
Remind staff to use SystmOne search tools when information entered by other organisations is difficult to locate.

Verbatim wording from the response
“We will also remind staff that other organisations use SystmOne and that they may not enter data in an easy to view way. Staff have been advised to use search functionality to find data that may have not been entered properly by staff from other organisations.”

Source location
2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Page 3 · response
Published 9 March 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
SystmOne’s contract is managed by NHS England, while system developments are for NHS England and TPP to consider.

Verbatim wording from the response
“SystmOne is the medical records system for all prisoners and this contract with TPP is managed by NHS England and not directly by CNWL. However, with internal training and audit we hope to be able to overcome a significant proportion of the limitations identified. We will also be raising the Coroner’s concerns and our work around with TPP so that they can consider them in any future developments of the system”

Source location
2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Page 1 · response
Published 9 March 2020
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Clinicians are not reliant solely on patients’ disclosed answers or presentation when assessing suicide and self-harm risk.

Verbatim wording from the response
“Whilst the risk assessment template on SystmOne does ask pre-set questions the clinician is not reliant solely on the information disclosed during the assessment. When completing the risk assessment there is a section on the right hand side of the template with previous values that have been entered in relation to these questions. This allows the clinician to have an understanding of previous answers to these questions and gives them some context when considering a response to a question. For instance if a patient’s response contradicts a previous statement they have made the staff will be able to ascertain this and ask appropriate follow up. When the cursor is put in the box relating to risk incidents and triggers previous entries about this come up on the right hand section of the template.”

Source location
2020-0041-Response-from-Central-and-North-West-London-Foundation-Trust
Page 2 · response
Published 9 March 2020
Open published response
2 Nov2015
Cumbria
Concerns raised1
1. Failure of SystmOne to provide usable search and clear flagging of important historical information
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 3
1. Action
  Re-procure the electronic healthcare system with improved sharing of risk indicators between healthcare services and NOMS.
  Stated by NHS EnglandStated planned
2. Action
  Implement an interface between healthcare services and NOMS to share risk indicators and support proactive risk management.
  Stated by NHS EnglandStated planned
3. Action
  Provide full training and regular training updates for the new electronic healthcare system.
  Stated by NHS EnglandStated planned
AI-generated summary

Richard Scott Green · 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

Richard Scott Green was found hanged in his cell at Haverigg Prison on 9 May 2014, using a ligature made from a torn bed sheet. The jury found that bullying and debt had contributed to his death but was not satisfied that he intended to kill himself. The report raised concerns that his documented history of self-harm and apparent suicide attempts was not recognised or acted upon by prison medical professionals, with missed opportunities to assess and manage the risk he presented.

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 SystmOne to provide usable search and clear flagging of important historical information
Wider context from the report
“I was clear that serious incidents of self-harm/suicide attempts from 2007 and 2013 were recorded on his SystmOne records. These do not appear to have been recognised or acted upon by various medical professionals in the prison system. This meant that a nurse at screening had not read the records, neither had a GP or a mental health nurse who later carried out an assessment. The result was that throughout his prison term at Haverigg no one was aware of the history and the risk he presented. As a result, there were missed opportunities which might have made a difference. Evidence showed that a) there appeared to be no reliable tool to help assess depression in a prisoner (community tools being unsatisfactory). b) Although entries were there to be seen on System One, none of the clinicians saw them. Pressure of work and the time needed to check were reasons cited, together with lack of resources. It seems SystmOne was not easy to use, some staff being unaware they could “search” and an absence of a way to clearly flag important historical information to ensure it was at the clinicians’ finger tips. ”
Source location
Richard Scott Green · 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
Re-procure the electronic healthcare system with improved sharing of risk indicators between healthcare services and NOMS.

Verbatim wording from the response
“In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

Source location
2015-0456 - Response from NHS England
Page 2 · response
Published 2 November 2015
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 an interface between healthcare services and NOMS to share risk indicators and support proactive risk management.

Verbatim wording from the response
“In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

Source location
2015-0456 - Response from NHS England
Page 2 · response
Published 2 November 2015
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 full training and regular training updates for the new electronic healthcare system.

Verbatim wording from the response
“In relation the second recommendation NHS England are re-procuring the healthcare electronic healthcare system, SystmOne. This system will include improvements on the current system such as the sharing of risk indicators (e.g. ‘increased risk of suicide’) between healthcare & NOMS and there is a joint commitment between NHS England and NOMS to implement the interface to show that proactive steps are being taken to address this issue in the longer term. The implementation of the new system will include a full training programme along with regular training updates undertaken.”

Source location
2015-0456 - Response from NHS England
Page 2 · response
Published 2 November 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to record and clearly flag family history of sudden cardiac death in SystmOne

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

Concerns raised1

SystmOne failing to facilitate retrieval of key suicide and deliberate self-harm risk information

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

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

Concerns raised1

Failure of SystmOne to provide usable search and clear flagging of important historical information

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.3

Respondent positions 1

Actions described in response 2

Respondent positions 2

Actions described in response 3