PFD report

Akhona MOYO · Prevention of Future Deaths report

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Issued 28 Jan 2026•Northamptonshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
13

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Lack of hospital doctors’ electronic access to detailed primary care medical notes
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.11

  1. Action

    Implement the Single Patient Record to unify patient data from multiple sources and provide clinicians access through existing clinical systems.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 29 January 2026.
  2. Action

    Implement the Frontline Productivity Programme to improve access to patient information and develop digital workflow capabilities.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 29 January 2026.
  3. Action

    Work across the health system to support greater integration and awareness of medical-record sharing between providers.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Access to the Northamptonshire Care Record is determined locally and falls outside NHS England’s remit to comment on.

    Stated by NHS EnglandOutside remitThe respondent said that this matter was outside its role or authority.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of hospital doctors’ electronic access to detailed primary care medical notes

Wider context from the report

“Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc. At Northampton General Hospital, a new electronic system known as “Nerve Centre” contains only hospital notes. Hospital doctors also have access to the “Northamptonshire Care Record” which contains basic lists of GP visits and medication, but no detailed entries. All the doctors that gave evidence to the Inquest stated that access to primary care records would undoubtedly assist them in delivering better patient treatment and care. It was felt that access to such information was particularly important in cases such as the present when a patient is autistic and non-verbal. There may be a multitude of other reasons why a patient or their family may not be able to relay to doctors a full and accurate medical history. Access may also enable doctors to have a more global view of a patient’s medical condition rather than, as it was put at Inquest, “working in silos”. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care.

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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

Implement the Single Patient Record to unify patient data from multiple sources and provide clinicians access through existing clinical systems.

Verbatim wording from the response

“I agree that ensuring health and care professionals have access to a single source of digital information about the patients they are treating and caring for is vitally important to delivering the best care possible. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue.”

Source location

2026-0045 - Response from DHSC
Page 1 · response
Published 29 January 2026

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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

Implement the Frontline Productivity Programme to improve access to patient information and develop digital workflow capabilities.

Verbatim wording from the response

“Further digital investment has been confirmed for the Frontline Productivity (FP) Programme, a four-year initiative which is beginning in April 2026. The programme aims to help NHS organisations realise the full benefits of digitised patient information by developing the capabilities enabled through EPR systems, building on the successful implementation funding provided through the FD Programme.”

Source location

2026-0045 - NHS England
Page 2 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work across the health system to support greater integration and awareness of medical-record sharing between providers.

Verbatim wording from the response

“NHS England is aware of the challenge in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.”

Source location

2026-0045 - NHS England
Page 2 · response
Published 29 January 2026

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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

Lead the Frontline Digitisation Programme to support adoption and safe deployment of electronic patient record systems.

Verbatim wording from the response

“NHS England recognises that limited information sharing between care settings can contribute to delays in discharge, incomplete handovers and less effective continuity of care, particularly when patients receive support across organisational or geographical boundaries. NHS England has developed and led the Frontline Digitisation (FD) Programme, which has supported provider organisations to adopt Electronic Patient Record (EPR) systems which support increased consistency in digital maturity but also improve information sharing within and between organisations.”

Source location

2026-0045 - NHS England
Page 1 · response
Published 29 January 2026

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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

Work with the Summary Care Record Programme to support wider access to relevant patient information.

Verbatim wording from the response

“NHS England is aware of the challenge in sharing medical records between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.”

Source location

2026-0045 - NHS England
Page 2 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Continue advocating for access to full GP consultation notes through appropriate national forums.

Verbatim wording from the response

“I trust that the above information and progress to date demonstrates the substantial improvements to primary care information access since November 2022. I acknowledge that full GP consultation notes remain unavailable and that achieving this would require national actions on data standards and information governance frameworks. I can provide assurance that we will continue to advocate this through the appropriate national forums.”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 3 · response
Published 29 January 2026

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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

Provide clinicians with Northamptonshire Care Record access containing expanded primary care information, with Summary Care Record information migrated into it.

Verbatim wording from the response

“• Northamptonshire Care Record (NCR) This is now available at NGH, providing clinicians with access to GP data including medications, allergies, diagnoses, and lists of GP consultations. This has single sign-on integration from our clinical system (Nervecentre) into NCR and this element is currently in final testing and expected to be available within weeks, removing the need for separate logins.”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 2 · response
Published 29 January 2026

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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

Provide clinicians with GP Connect access to structured primary care data, including medications and allergies.

Verbatim wording from the response

“• GP Connect This is now available at NGH, providing structured data from GP records including medications and allergies.”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 2 · response
Published 29 January 2026

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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

Raise the requirement for GP free-text access with the National Record Locator and Shared Patient Record Programme Boards.

Verbatim wording from the response

“• By the end of March 2026, we will raise the requirement for GP free text access with the National Record Locator and Shared Patient Record Programme Boards;”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 3 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Work with Northamptonshire Integrated Care Board to explore enhanced primary-care data-sharing options.

Verbatim wording from the response

“• We are continuing to work with Northamptonshire Integrated Care Board to explore options for enhanced data sharing within primary care;”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 3 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Complete single-sign-on integration from Nervecentre into the Northamptonshire Care Record to remove separate logins.

Verbatim wording from the response

“• Northamptonshire Care Record (NCR) This is now available at NGH, providing clinicians with access to GP data including medications, allergies, diagnoses, and lists of GP consultations. This has single sign-on integration from our clinical system (Nervecentre) into NCR and this element is currently in final testing and expected to be available within weeks, removing the need for separate logins.”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 2 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Access to the Northamptonshire Care Record is determined locally and falls outside NHS England’s remit to comment on.

Verbatim wording from the response

“Access and information contained within the local ‘Northamptonshire Care Record’ is determined by local policy and procedures and therefore falls outside of NHS England’s remit to comment upon.”

Source location

2026-0045 - NHS England
Page 2 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

The Trust is responsible for, and better placed to answer, questions about local EPR integration and hospital information access.

Verbatim wording from the response

“As part of the FD Programme, Northampton General Hospital secured funding and went live with the Nervecentre Electronic Patient Record (EPR) on 27 June 2025. Prior to adoption, patient information was recorded through a range of non-standardised processes rather than a single integrated EPR. NHS England are unable to state the ability of Nervecentre to integrate or view GP primary care records as this would be dependant on the local trust and organisation. We would suggest that the Coroner directs this query to the Trust.”

Source location

2026-0045 - NHS England
Page 2 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Full GP free-text consultation notes cannot currently be accessed because they are outside the scope of national shared-care-record programmes.

Verbatim wording from the response

“We are working within the national boundaries of what is currently achievable in terms of being able to access general practitioner consultation notes and free text entries within primary care. We share the views of our clinicians that such access would benefit patient care, but there are currently significant national barriers to overcome before this is possible.”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 2 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation

Direct access to GP systems is constrained by the need for agreements with numerous practices, including cross-boundary practices, and previous negotiations did not progress.

Verbatim wording from the response

“• Information governance Direct read access to GP clinical systems (EMIS and SystmOne) has been explored previously in Northamptonshire. This requires individual data sharing agreements with each of the 66 GP practices in the county, plus consideration of practices across county boundaries whose patients attend our hospitals. Previous attempts to negotiate these agreements did not progress. Additionally, 20% of Northamptonshire patients are registered with practices using EMIS rather than SystmOne, and any solution would need to ensure equitable access for all patients.”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 2 · response
Published 29 January 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. 1

    Discuss Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 29 January 2026.
  2. 2

    Share Accident and Emergency attendance summaries and discharge notifications from Northampton General Hospital with the Northamptonshire Care Record.

    Stated by University Hospitals of Northamptonshire NHS GroupStated in progressThe respondent said that this action was in progress when they made their response on 29 January 2026.

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 Prevention of Future Deaths reports through the Regulation 28 Working Group and share resulting learning across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Akhona, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.”

Source location

2026-0045 - NHS England
Page 3 · response
Published 29 January 2026

Open published response

Source evidence

How this respondent action was interpreted

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

PFD Monitor interpretation

Share Accident and Emergency attendance summaries and discharge notifications from Northampton General Hospital with the Northamptonshire Care Record.

Verbatim wording from the response

“• We are ensuring that Accident and Emergency Department attendance summaries and discharge notifications from NGH are shared with the NCR to improve information available in other care settings. We will review progress during June 2026;”

Source location

2026-0045 - Response from University Hospitals of Northamptonshire NHS Group
Page 3 · response
Published 29 January 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026