PFD report

Amy Rose COOPER · Prevention of Future Deaths report

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Issued 25 Feb 2016•Liverpool and the Wirral

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
2

Named on the report

Responses found
0

Of 2 recipients

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

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Concerns and recipient responses

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Concerns raised1

  1. Lack of compatible digital record-keeping and medical note systems enabling information sharing between maternity services
    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 servicesPart of recurring concern: Failure to reliably transfer medical records between healthcare organisationsPart of recurring concern: Unreliable communication and coordination across maternity care providersPart of recurring concern: Unreliable inter-agency information sharing for coordinated care
Responses linked to these concerns

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No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 compatible digital record-keeping and medical note systems enabling information sharing between maternity services

Wider context from the report

“It was clear at the inquest that maternity services which had been commissioned in this region had not been required to have a specification for record keeping, notes and scans which could be digitally available to other maternity services operating in the same area. Such that Arrowe Park Hospital needed to have the paper notes from One to One North West Ltd. to ensure continuity of care. This does not appear to be the most efficient system for continuity of patient care and could have been remedied by the commissioners of the services requiring compatible record keeping and medical note systems to ensure the easy sharing of information. This would also enable community based midwives to refer a patient to a consultant without the patient necessarily having to attend the maternity unit in the first place. Further access to notes would make the admission to the maternity unit safer and seamless, delivering what should be a better patient experience and outcome. ”

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; Failure to reliably transfer medical records between healthcare organisations; Unreliable communication and coordination across maternity care providers; Unreliable inter-agency information sharing for coordinated care.

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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