PFD report

Suzanne EDWARDS · Prevention of Future Deaths report

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Issued 1 Aug 2025•Milton Keynes

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
4

Named on the report

Responses found
3

Of 4 recipients

Stated actions
8

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. Unreliable access to patients' primary care records in Emergency Departments
    Part of recurring concern: Unreliable access to relevant clinical records for safe carePart of recurring concern: Unreliable consolidation and access to patients’ cross-service clinical risk information
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.6

  1. Action

    Continue working with healthcare partners to ensure necessary patient data sharing occurs for effective treatment.

    Stated by Bedfordshire Hospitals NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025.
  2. Action

    Provide Emergency Department clinicians access to Shared Care Records, GP Connect and Summary Care Records for patient care.

    Stated by Bedfordshire Hospitals NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.
  3. Action

    Establish Health Information Exchange links with providers serving significant numbers of common patients.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Expanding the patient information shared through existing records is outside the Trust’s control.

    Stated by Bedfordshire Hospitals NHS Foundation TrustOutside 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

Unreliable access to patients' primary care records in Emergency Departments

Wider context from the report

“Emergency Departments at hospitals in this and surrounding jurisdictions do not have reliable access to patients' primary care records, including recent GP consultations, investigations or concerns. This means that clinicians are frequently treating acutely unwell patients without full access to their recent medical history, which can delay or misdirect diagnosis and undermine patient safety and continuity of care and lead to avoidable deaths. Without access to a patients full records further lives may be put at risk. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care; Unreliable consolidation and access to patients’ cross-service clinical risk information.

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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 working with healthcare partners to ensure necessary patient data sharing occurs for effective treatment.

Verbatim wording from the response

“Thank you for bringing this important patient safety concern to my attention. As a Trust we are committed to working closely with our healthcare partners to ensure that data sharing happens, we all recognise the vital information sharing that is needed to effectively treat our patients.”

Source location

Response from Bedfordshire Hospitals NHS Trust
Page 3 · response
Published 4 August 2025

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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 Emergency Department clinicians access to Shared Care Records, GP Connect and Summary Care Records for patient care.

Verbatim wording from the response

“I do of course recognise the risk you have identified that can result when primary and secondary healthcare providers cannot access each other's medical records. I welcome the opportunity to explain what access to Shared Care Records (including GP records) our A&E clinicians have at both the Bedford and Luton & Dunstable hospital sites. I hope this will assure you that Bedfordshire Hospitals NHS Foundation Trust clinicians do, as far as is possible, have access to primary care records to assist them in the diagnosis of conditions thus reducing the overall risk to patient safety and further mitigating the risk of future deaths.”

Source location

Response from Bedfordshire Hospitals NHS Trust
Page 2 · response
Published 4 August 2025

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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

Establish Health Information Exchange links with providers serving significant numbers of common patients.

Verbatim wording from the response

“MKUH has developed HIE linkages with many other providers.”

Source location

Response from Milton Keynes University Hospital
Page 2 · response
Published 4 August 2025

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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

Encourage other providers to share more pertinent record content through the Health Information Exchange.

Verbatim wording from the response

“At MKUH, we continue to:”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 4 August 2025

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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

Optimise the eCare record for sharing through the Health Information Exchange.

Verbatim wording from the response

“At MKUH, we continue to:”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 4 August 2025

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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

Link Summary Care Record visibility into the Acute Electronic Patient Record front screen when it launches.

Verbatim wording from the response

“In Buckinghamshire we are fortunate to have a Summary Care Record which contains a record of encounters with all health services. This includes primary care diagnosis codes and lists, medication lists and brief summaries of primary care appointment outcomes. The Summary Care Record is visible to all hospital colleagues and access will be linked into our Acute Electronic Patient Record front screen when this launches in September / October 2025. This visibility would I believe mitigate against the issues noted in the Report although at the moment some patients have opted out across the system as a matter of personal choice.”

Source location

Response from Buckinghamshire Healthcare NHS Trust
Page 1 · response
Published 4 August 2025

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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

Expanding the patient information shared through existing records is outside the Trust’s control.

Verbatim wording from the response

“It is not within the Trust's control to expand upon what patient information is shared on the services outlined above as the record is taken from the Summary Care Record and GP Connect. The extent of what is contained in the Summary Care Record is regulated by NHS Digital which forms part of NHS England.”

Source location

Response from Bedfordshire Hospitals NHS Trust
Page 3 · response
Published 4 August 2025

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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 regulates the extent of information contained in the Summary Care Record.

Verbatim wording from the response

“It is not within the Trust's control to expand upon what patient information is shared on the services outlined above as the record is taken from the Summary Care Record and GP Connect. The extent of what is contained in the Summary Care Record is regulated by NHS Digital which forms part of NHS England.”

Source location

Response from Bedfordshire Hospitals NHS Trust
Page 3 · response
Published 4 August 2025

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 Summary Care Record visibility and some EMIS access are considered sufficient to mitigate concerns about hospital clinicians’ visibility of primary care records.

Verbatim wording from the response

“In Buckinghamshire we are fortunate to have a Summary Care Record which contains a record of encounters with all health services. This includes primary care diagnosis codes and lists, medication lists and brief summaries of primary care appointment outcomes. The Summary Care Record is visible to all hospital colleagues and access will be linked into our Acute Electronic Patient Record front screen when this launches in September / October 2025. This visibility would I believe mitigate against the issues noted in the Report although at the moment some patients have opted out across the system as a matter of personal choice.”

Source location

Response from Buckinghamshire Healthcare NHS Trust
Page 1 · response
Published 4 August 2025

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

    Educate internal and external clinicians about the benefits and capabilities of the Health Information Exchange.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 4 August 2025.
  2. 2

    Roll out the Oracle Health Millennium eCare electronic record across the Trust.

    Stated by Milton Keynes University Hospital NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 August 2025.

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

Educate internal and external clinicians about the benefits and capabilities of the Health Information Exchange.

Verbatim wording from the response

“At MKUH, we continue to:”

Source location

Response from Milton Keynes University Hospital
Page 3 · response
Published 4 August 2025

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

Roll out the Oracle Health Millennium eCare electronic record across the Trust.

Verbatim wording from the response

“It is perhaps useful to consider the historic position of paper-based notes where all different care providers maintained a physically separate clinical record. Primary Care and some hospitals have moved decisively towards electronic records. Electronic records have many benefits including the potential to share content across providers (at least in a ‘read-only’ manner). Concerns do naturally persist in relation to the legal status of the record (and a reluctance therefore to have ‘third parties’ edit or write into the record) and information governance (in terms of ensuring that access to confidential personal data is appropriate and has a legal basis). MKUH is relatively advanced in terms of its digital infrastructure and has rolled out Oracle Health’s Millennium product incrementally since 2018 (known locally as eCare). Our tertiary”

Source location

Response from Milton Keynes University Hospital
Page 1 · response
Published 4 August 2025

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