PFD report

Rachelle Naomi Ross · Prevention of Future Deaths report

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Issued 17 Feb 2023•Newcastle upon Tyne and North 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.

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Concerns
1

Raised in this report

Recipients
4

Named on the report

Responses found
4

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. Lack of automatic GP-record alerts for smear-test non-responders
    Part of recurring concern: Unreliable clinical safety-alert systems
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.3

  1. Action

    Undertake an internal review of the concerns raised in the report.

    Stated by EMIS GroupStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
  2. Action

    Provide an automatic home-screen alert when a patient is due for a cervical smear, regardless of prior attendance.

    Stated by The Phoenix Partnership (Leeds) LtdStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
  3. Action

    Provide a report listing patients due for cervical screening so practices can issue letters, reminders or SMS messages.

    Stated by The Phoenix Partnership (Leeds) LtdStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.4

  1. Position

    Existing System alerts and functionality already meet required specifications and the recommendation for automatic cervical screening alerts.

    Stated by EMIS GroupExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 automatic GP-record alerts for smear-test non-responders

Wider context from the report

“1. During the course of the inquest I heard evidence from ████████, GP Partner at the Collingwood Health Group who informed me that GP practice records do not include an alert from EMIS or System 1 IT systems to provide an automatic flag on a patient's GP medical records if they are classed as a non-responder for a smear test by the National Screening Service. 2. The alert system is only triggered after a patient attends a smear test. For a non-responder, they go back into the three or five year waiting list for a National Screening invitation for a smear test. 3. An automatic flag or alert when a patient fails to attend for a smear test as part of the National Screening Service, would mean that a GP surgery would not have to manually add a warning as an entry onto an individual’s GP records. It would standardise the approach across all GP surgeries and could increase patient safety. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems.

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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

Undertake an internal review of the concerns raised in the report.

Verbatim wording from the response

“As a company, we work very hard to support health care services across the UK and patient safety is of paramount importance to us. We have reviewed and considered your concerns raised in the Report and have undertaken an internal review.”

Source location

Response from EMIS
Page 1 · response
Published 28 February 2023

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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 an automatic home-screen alert when a patient is due for a cervical smear, regardless of prior attendance.

Verbatim wording from the response

“SystmOne has a built in report in support of the Quality Outcomes Framework that alerts GPs on the home screen (the screen that is first seen when a patient record is opened) when a patient is due a cervical smear. This is not dependent on the patient having had a cervical smear. The list of patients who are requiring a smear are also available in the reporting system as a list of patients ready for letters / reminders / SMS messages to be sent as the practice decides.”

Source location

Response from TPP
Page 1 · response
Published 28 February 2023

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 a report listing patients due for cervical screening so practices can issue letters, reminders or SMS messages.

Verbatim wording from the response

“SystmOne has a built in report in support of the Quality Outcomes Framework that alerts GPs on the home screen (the screen that is first seen when a patient record is opened) when a patient is due a cervical smear. This is not dependent on the patient having had a cervical smear. The list of patients who are requiring a smear are also available in the reporting system as a list of patients ready for letters / reminders / SMS messages to be sent as the practice decides.”

Source location

Response from TPP
Page 1 · response
Published 28 February 2023

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 System alerts and functionality already meet required specifications and the recommendation for automatic cervical screening alerts.

Verbatim wording from the response

“However, we feel it important to note that in the case of a patient failing to respond to an invitation for a Cervical Screening Event, an automatic alert (triggered by the absence of a code indicating completion of Cervical Screening Event), which reads “Cervical Smear due or outstanding”, will display each time the patient’s record is opened in the System. This alert is triggered regardless of whether the patient has historically attended for a Cervical Screening Event or not (in accordance with the NHS Cervical Screening Programme). The alert remains visible on the patient record until the patient is recalled by the National Screening Programme in 3 or 5 years depending on age.”

Source location

Response from EMIS
Page 1 · response
Published 28 February 2023

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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

CQC lacks statutory powers over clinical system providers and therefore cannot directly require improvements in this area.

Verbatim wording from the response

“In our discussions with CQC, they agree that the concerns raised by the coroner have highlighted an important area. Although CQC does not have statutory powers in relation to clinical system providers they will consider engaging with them to enquire and encourage an improvement in this area.”

Source location

Response from Department of Health and Social Care
Page 2 · response
Published 28 February 2023

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

GP IT systems automatically display overdue cervical-screening alerts, including for non-responders, so the concern that records lack an alert is incorrect.

Verbatim wording from the response

“GP IT software systems typically have inbuilt alerts to notify users when a person’s cervical screening is overdue. Such alerts appear automatically in the person’s record without any further manual input, when they reach their 25th birthday. Once a person has had a cervical screening test done, the alert next appears if that person is overdue their next test. This alert stays present even if the national service has recorded the person as a non-responder and has set their recall to the next screening cycle date. These alerts appear to the user when in a patient’s records in an alert tab. This is visible in EMIS (bottom right-hand side of the screen) and in TPP (top right-hand side of the screen) along with other alerts pertinent to that person’s health status.”

Source location

Response NHS England
Page 2 · response
Published 28 February 2023

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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

The system cannot alert GPs to non-response because the National Screening Service does not provide that information directly to electronic patient records.

Verbatim wording from the response

“With regard to your specific point about an alert when a patient has not responded to an invitation by the National Screening Service - my understanding is that GPs are not informed of this, and there is no mechanism for this information to be sent directly into the electronic patient record. As a result that computer cannot alert the GP as it does not hold this information.”

Source location

Response from TPP
Page 1 · response
Published 28 February 2023

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.5

  1. 1

    Continue investigating similar cases and reviewing the effectiveness of current and ongoing mitigations.

    Stated by EMIS GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
  2. 2

    Continue reviewing solutions to identify changes that could improve their performance.

    Stated by EMIS GroupStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
  3. 3

    Share key learnings and insights from reports across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.
  4. 4

    Monitor emerging trends that may require further review and action.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 28 February 2023.
  5. 5

    Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 28 February 2023.

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 investigating similar cases and reviewing the effectiveness of current and ongoing mitigations.

Verbatim wording from the response

“EMIS will continue to review and investigate any cases of a similar nature, and review effectiveness of any current and ongoing mitigations.”

Source location

Response from EMIS
Page 2 · response
Published 28 February 2023

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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 reviewing solutions to identify changes that could improve their performance.

Verbatim wording from the response

“At EMIS we are proponents of continuous improvement, and we will continue to review our solutions to determine whether there are changes to be made which would improve their performance.”

Source location

Response from EMIS
Page 2 · response
Published 28 February 2023

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

Share key learnings and insights from reports across national and regional NHS services.

Verbatim wording from the response

“I would like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response NHS England
Page 3 · response
Published 28 February 2023

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

Monitor emerging trends that may require further review and action.

Verbatim wording from the response

“I would like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response NHS England
Page 3 · response
Published 28 February 2023

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

Discuss all Prevention of Future Deaths reports through the Regulation 28 Working Group.

Verbatim wording from the response

“I would like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response NHS England
Page 3 · response
Published 28 February 2023

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