PFD report

John James JOHNSON · Prevention of Future Deaths report

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Issued 6 May 2025•Gateshead and South Tyneside

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.

View original report
Concerns
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
1

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 raised2

  1. Fragmented clinical information systems requiring users to switch between systems
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionable
  2. Failure of multiple clinical systems to support safe transfers of care
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Failure to communicate clinically important information reliably between care services
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.1

  1. Action

    Establish the Single Patient Record to unify patient data and provide clinicians with accessible patient information.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 19 May 2025.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Each provider organisation is responsible for sharing information across different digital systems through its established local digital governance processes.

    Stated by Department of Health and Social CareRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Fragmented clinical information systems requiring users to switch between systems

Wider context from the report

“(1) During the course of my investigation I heard evidence of the Hospital Trust operating a variety of IT systems to document a patient's stay in hospital. There was not one system which contained all the information generated during a patient’s stay in hospital including, but not limited to, test results. It required clinical users to switch between systems to gather all the necessary information and raised the potential risk of significant findings being overlooked. It also slows down clinical decision making and makes it more difficult to follow a patient's overall care. (2) In Mr Johnson's case, the X Ray report was returned to a department not then involved in his care. The use of multiple systems can create a risk around safe transfers of care for discharge or handover. (3) I was told this issue is not confined to one individual Trust and the use of multiple systems is widespread across the National Health Service. Their use is well known to the national NHS responsible bodies. (4) The Trust in question, has undertaken significant work to make the multiple systems it uses as safe and effective as possible so far as they are able to within their effective control. (5) Given my concerns are not confined to the operations of one NHS Trust, this appears to be a risk that may be present nationally. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable.

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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

Failure of multiple clinical systems to support safe transfers of care

Wider context from the report

“(1) During the course of my investigation I heard evidence of the Hospital Trust operating a variety of IT systems to document a patient's stay in hospital. There was not one system which contained all the information generated during a patient’s stay in hospital including, but not limited to, test results. It required clinical users to switch between systems to gather all the necessary information and raised the potential risk of significant findings being overlooked. It also slows down clinical decision making and makes it more difficult to follow a patient's overall care. (2) In Mr Johnson's case, the X Ray report was returned to a department not then involved in his care. The use of multiple systems can create a risk around safe transfers of care for discharge or handover. (3) I was told this issue is not confined to one individual Trust and the use of multiple systems is widespread across the National Health Service. Their use is well known to the national NHS responsible bodies. (4) The Trust in question, has undertaken significant work to make the multiple systems it uses as safe and effective as possible so far as they are able to within their effective control. (5) Given my concerns are not confined to the operations of one NHS Trust, this appears to be a risk that may be present nationally. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Failure to communicate clinically important information reliably between care services.

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

Establish the Single Patient Record to unify patient data and provide clinicians with accessible patient information.

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

Response from Department of Health and Social Care
Page 5 · response
Published 19 May 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

Each provider organisation is responsible for sharing information across different digital systems through its established local digital governance processes.

Verbatim wording from the response

“Where multiple digital systems, including EPR systems and RIS system are in use across a provider organisation, policies and procedures should be in place to outline expectations, advice, clinical record management, and handover of abnormal results to relevant individuals. Responsibility and accountability for the sharing of information held within electronic records, including across different systems, rests with each organisation through its established digital governance processes.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 19 May 2025

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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