PFD report

Andrew Dominic HEYS · Prevention of Future Deaths report

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Issued 24 Jan 2025•Manchester West

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
5

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 raised3

  1. Failure of health information systems to enable authorised cross-provider access to patient records
    Part of recurring concern: Unreliable access to relevant clinical records for safe care
  2. Lack of training for clinicians in accessing patients' GP records
  3. Lack of training for out-of-hours clinicians in following referral pathways
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.2

  1. Action

    Continue rolling out Electronic Patient Records and support trusts to replace, extend, or optimise existing systems.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
  2. Action

    Deliver a single patient record, beginning its rollout from 2028 with maternity care.

    Stated by Department of Health and Social CareStated plannedThe respondent said that this action was planned when they made their response on 7 February 2025.

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

  1. Position

    The concern did not arise from inadequate training or support but from an independent clinical decision by the clinician involved.

    Stated by BARDOC LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 health information systems to enable authorised cross-provider access to patient records

Wider context from the report

“During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. ”

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

Lack of training for clinicians in accessing patients' GP records

Wider context from the report

“During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lack of training for out-of-hours clinicians in following referral pathways

Wider context from the report

“During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call after speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Continue rolling out Electronic Patient Records and support trusts to replace, extend, or optimise existing 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

Response from Department for Health and Social Care
Page 1 · response
Published 7 February 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

Deliver a single patient record, beginning its rollout from 2028 with maternity care.

Verbatim wording from the response

“Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single patient record (SPR). This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place. We have been engaging with the public to help shape our plans, including what information they would like to see included in a single patient record and we will continue to talk to the public and to health and care professionals as we design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028 and be rolled out first in maternity care.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 7 February 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

The concern did not arise from inadequate training or support but from an independent clinical decision by the clinician involved.

Verbatim wording from the response

“We believe that the testimony provided by the GP at the inquest was not factually accurate, and regret that this may have influenced the Coroner’s findings. It is our position that the issue did not arise due to any inadequacy in the training or support provided by BARDOC, but rather due to an unfortunate clinical decision made independently by the clinician involved.”

Source location

Response from BARDOC
Page 1 · response
Published 7 February 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.3

  1. 1

    Refer the matter to the NHS Performance team for further investigation.

    Stated by BARDOC LimitedStated plannedThe respondent said that this action was planned when they made their response on 7 February 2025.
  2. 2

    Continue collaborative work with coroners, regulators and NHS partners to support clinical governance and patient safety.

    Stated by BARDOC LimitedStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.
  3. 3

    Continue engaging the public and health and care professionals while designing the single patient record.

    Stated by Department of Health and Social CareStated in progressThe respondent said that this action was in progress when they made their response on 7 February 2025.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Further investigation of the concerns is assigned to the NHS Performance team following BARDOC’s referral.

    Stated by BARDOC LimitedRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Refer the matter to the NHS Performance team for further investigation.

Verbatim wording from the response

“The BARDOC board has assessed this matter and concluded that a referral to the NHS Performance team is warranted. This decision has been supported by the Coroner. As the Medical Director, I am duty bound to follow the instruction and refer the matter for further investigation due to concerns mentioned earlier in this letter.”

Source location

Response from BARDOC
Page 2 · response
Published 7 February 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

Continue collaborative work with coroners, regulators and NHS partners to support clinical governance and patient safety.

Verbatim wording from the response

“BARDOC takes our duty of care to patients and commitment to continuous improvement extremely seriously. We are proud of our comprehensive training programmes, operational protocols, and the robust support systems available to all clinicians within our services. We will continue to work”

Source location

Response from BARDOC
Page 1 · response
Published 7 February 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

Continue engaging the public and health and care professionals while designing the single patient record.

Verbatim wording from the response

“Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single patient record (SPR). This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place. We have been engaging with the public to help shape our plans, including what information they would like to see included in a single patient record and we will continue to talk to the public and to health and care professionals as we design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028 and be rolled out first in maternity care.”

Source location

Response from Department for Health and Social Care
Page 2 · response
Published 7 February 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

Further investigation of the concerns is assigned to the NHS Performance team following BARDOC’s referral.

Verbatim wording from the response

“The BARDOC board has assessed this matter and concluded that a referral to the NHS Performance team is warranted. This decision has been supported by the Coroner. As the Medical Director, I am duty bound to follow the instruction and refer the matter for further investigation due to concerns mentioned earlier in this letter.”

Source location

Response from BARDOC
Page 2 · response
Published 7 February 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