Recipient

BARDOC Limited

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First report 24 Jan 2025•Latest report 24 Jan 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
2

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found
2stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from BARDOC Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester West

    AI-generated summary

    Andrew Dominic HEYS · 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 Dominic HEYS received a Covid-19 booster vaccination in December 2021 and subsequently suffered from Auto-Immune Encephalopathy. On 12 March 2024, he fell into the Manchester Ship Canal from a bridge, and his body was discovered four days later. Concerns included inadequate training for an out-of-hours GP in following referral pathways and accessing patient records, as well as incompatible health-record IT systems that prevented health professionals from accessing records held elsewhere in the NHS.

    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. The report was sent to BARDOC Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of health information systems to enable authorised cross-provider access to patient records

    Wider context from the report

    “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BARDOC Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for clinicians in accessing patients' GP records

    Wider context from the report

    “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to BARDOC Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for out-of-hours clinicians in following referral pathways

    Wider context from the report

    “During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. ”
    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

    The concern did not arise from inadequate training or support but from an independent clinical decision by the clinician involved.

    Verbatim wording from the response

    “We believe that the testimony provided by the GP at the inquest was not factually accurate, and regret that this may have influenced the Coroner’s findings. It is our position that the issue did not arise due to any inadequacy in the training or support provided by BARDOC, but rather due to an unfortunate clinical decision made independently by the clinician involved.”

    Source location

    Response from BARDOC
    Page 1 · response
    Published 7 February 2025

    Open published response
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
50%50%
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026