PFD report

Alix Elizabeth Knowles · Prevention of Future Deaths report

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Issued 2 Oct 2024•Staffordshire and Stoke-on-Trent

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
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
9

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. Failure of bank staff to access patient notes before assessments
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
  2. Failure of computer systems to enable different NHS Trusts to access patient notes
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionable
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.7

  1. Action

    Support increased electronic patient record convergence across Integrated Care Boards.

    Stated by NHS EnglandStated plannedThe respondent said that this action was planned when they made their response on 4 October 2024.
  2. Action

    Support NHS and foundation trusts to acquire modern electronic patient record systems and improve their effectiveness after deployment.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2024.
  3. Action

    Provide UHDB with a list of liaison bank and Crisis Home Treatment staff requiring patient-notes access.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Individual healthcare providers, not NHS England, determine bank staff access levels to electronic patient records under local policies and risk assessments.

    Stated by NHS EnglandRedirects 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

Failure of bank staff to access patient notes before assessments

Wider context from the report

“1. Bank Staff are not able to access patient notes before assessments; ”

Is this part of a recurring concern?

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

Open source report

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 computer systems to enable different NHS Trusts to access patient notes

Wider context from the report

“2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this. ”

Is this part of a recurring concern?

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

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

Support increased electronic patient record convergence across Integrated Care Boards.

Verbatim wording from the response

“The next phase of optimising digitisation in England is for the FLD programme to support increased EPR convergence across Integrated Care Boards (ICBs).”

Source location

Response from NHS England
Page 1 · response
Published 4 October 2024

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

Support NHS and foundation trusts to acquire modern electronic patient record systems and improve their effectiveness after deployment.

Verbatim wording from the response

“As a response to this, NHS England set up the Frontline Digitisation Programme (FLD) in 2021 and has been supporting NHS and Foundation Trusts in acquiring modern EPR systems and helping them develop their system’s effectiveness once deployed. The FLD programme comes with substantial financial and specialist IT support to bring all Trusts to an optimum level of digital maturity.”

Source location

Response from NHS England
Page 1 · response
Published 4 October 2024

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

Provide UHDB with a list of liaison bank and Crisis Home Treatment staff requiring patient-notes access.

Verbatim wording from the response

“Following this inquest, several meetings have taken place between MPFT and UHDB to consider the most efficient way for bank staff to obtain access to patient notes. As a result of these meetings, it has been agreed that a list of all liaison bank staff and Crisis Home Treatment staff have been provided to UHDB who will allow them access to their patient notes system V6. A joint Standard Operating Procedure for the ‘Referral Process to Liaison Psychiatry Team and Crisis Resolution and Home Treatment Team for patients 16 years old and over within the Emergency Department’ has also been developed to outline the referral process for all staff.”

Source location

Response from Midlands Partnership University NHS
Page 1 · response
Published 4 October 2024

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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 other NHS trusts to maintain processes and safeguards that enable staff to access necessary patient records for safe care.

Verbatim wording from the response

“2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this. While MPFT recognises this as an ongoing issue, we work closely with other trusts to ensure we have processes and safeguards in place to allow staff to access patient notes when required. We are unable to comment on the”

Source location

Response from Midlands Partnership University NHS
Page 1 · response
Published 4 October 2024

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 MPFT to arrange Meditech V6 access for current short-term Liaison Psychiatry bank staff who lack it.

Verbatim wording from the response

“We are also working together with MPFT to arrange access to Meditech V6 for any of their current short term bank staff in the Liaison Psychiatry team who do not already have access.”

Source location

Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024

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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

Reiterate to MPFT the available routes for obtaining emergency Meditech V6 access for bank staff.

Verbatim wording from the response

“If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.”

Source location

Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024

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

Develop a written standard operating procedure with MPFT formalising emergency access arrangements for bank staff.

Verbatim wording from the response

“If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.”

Source location

Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024

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

Individual healthcare providers, not NHS England, determine bank staff access levels to electronic patient records under local policies and risk assessments.

Verbatim wording from the response

“The first concern raised in your Report was that bank staff are not able to access patient notes before assessments. Individual healthcare providers determine the access levels that different members of staff have to different parts of their electronic patient record systems. This decision will be in line with each Trust’s access policy and risk assessment, and is determined solely by individual healthcare providers. I note that you have also addressed your Report to Derby and Burton Hospital (Royal Derby Hospital) and Royal Stoke University Hospital and refer you to their responses on this matter.”

Source location

Response from NHS England
Page 1 · response
Published 4 October 2024

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

Local healthcare providers decide which electronic patient record systems to procure and deploy, based on local operational and financial factors.

Verbatim wording from the response

“For information, local healthcare providers make the decision on which Electronic Patient Records (EPR) system to procure and deploy, and their decision may apply to either a single NHS organisation or across multiple NHS organisations within a single Integrated Care System (ICS) where convergence of EPR systems across an ICB or ICS is seen as the most beneficial model. These decisions are based on many factors including the required functionality, a system’s suitability for the service specialities on offer, user experience, cost, and ease of information sharing. Today, there are already many examples where EPR records are shared seamlessly between provider organisations to enhance care provision.”

Source location

Response from NHS England
Page 2 · response
Published 4 October 2024

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 response cannot comment on national NHS patient-record access arrangements, while addressing access locally with other trusts.

Verbatim wording from the response

“2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this. While MPFT recognises this as an ongoing issue, we work closely with other trusts to ensure we have processes and safeguards in place to allow staff to access patient notes when required. We are unable to comment on the”

Source location

Response from Midlands Partnership University NHS
Page 1 · response
Published 4 October 2024

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

Bank staff access risk is mitigated by working with an authorised colleague and using established emergency access processes when required.

Verbatim wording from the response

“As was confirmed by MPFT in court, their substantive staff in Liaison Psychiatry do have access to Meditech V6 records at UHDB, and they have subsequently confirmed that long-term bank staff also have access to Meditech V6. The issue that arose in this case is that the individual MPFT bank nurse from the Liaison Psychiatry team did not have access to the Meditech V6 records as UHDB had not been notified of the need for access on this occasion and therefore UHDB were not aware of until after Miss Knowles' death. As we heard during the inquest hearing, MPFT explained that they mitigate the risk of bank staff not having access to Meditech V6 by always ensuring that they are on shift with a member of staff who does have access. The bank nurse confirmed in her evidence that the Meditech V6 notes were accessed by a colleague from MPFT Liaison Psychiatry team on the night in question.”

Source location

Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024

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

Cross-organisation record access is addressed where possible through access arrangements and information-sharing protocols, despite wider interoperability limitations.

Verbatim wording from the response

“Across the NHS in England there are health and care services using different clinical systems that do not interact with each other, and it is accepted that there is a need for interoperability across the system. This is a national issue whose feasibility is being looked at as part of the long-term plan for the NHS. Given the broader context that applies and the complexities around digital infrastructure and transformation, we are unable to comment any further on this, except to say that we recognise the importance of effective information sharing between organisations. It is for this reason that we arrange access where possible and having sharing protocols in place as described above.”

Source location

Response from University Hospitals of Derby and Burton
Page 2 · response
Published 4 October 2024

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 key learning across NHS national and regional levels.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 4 October 2024.
  2. 2

    Develop a joint standard operating procedure covering Emergency Department referrals to liaison psychiatry and crisis resolution and home treatment teams.

    Stated by Midlands Partnership University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 4 October 2024.

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 key learning across NHS national and regional levels.

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 Alix, 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

Response from NHS England
Page 2 · response
Published 4 October 2024

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

Develop a joint standard operating procedure covering Emergency Department referrals to liaison psychiatry and crisis resolution and home treatment teams.

Verbatim wording from the response

“Following this inquest, several meetings have taken place between MPFT and UHDB to consider the most efficient way for bank staff to obtain access to patient notes. As a result of these meetings, it has been agreed that a list of all liaison bank staff and Crisis Home Treatment staff have been provided to UHDB who will allow them access to their patient notes system V6. A joint Standard Operating Procedure for the ‘Referral Process to Liaison Psychiatry Team and Crisis Resolution and Home Treatment Team for patients 16 years old and over within the Emergency Department’ has also been developed to outline the referral process for all staff.”

Source location

Response from Midlands Partnership University NHS
Page 1 · response
Published 4 October 2024

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