Glennis CONNELLY · Prevention of Future Deaths report

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Issued 31 May 2024•Staffordshire and Stoke-on-Trent

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
9

Described in responses

Recipients and published responses

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 electronic patient records to automatically share renal team entries between hospitals
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Unreliable inter-agency information sharing for coordinated carePart of recurring concern: Unreliable operation of the Lorenzo clinical information system
  2. Failure of allergy information to automatically cross-populate between records
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Unreliable cross-referencing of related patient recordsPart of recurring concern: Unreliable recording and communication of patient allergy information

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.9

  1. University Hospitals of Derby and Burton NHS Foundation Trust

    Establish a multidisciplinary allergy working group to ensure robust systems for managing allergies and alerts.

  2. University Hospitals of Derby and Burton NHS Foundation Trust

    Prompt staff during pharmacy reconciliation to compare allergies, sensitivities and adverse reactions with the GP Summary Care Record.

  3. University Hospitals of Derby and Burton NHS Foundation Trust

    Disseminate learning about discordant allergy records through Trust-wide articles, bulletins, computer-screen messaging, leadership discussion and divisional case presentations.

  4. University Hospitals of Derby and Burton NHS Foundation Trust

    Audit medicines reconciliation, including correct allergy recording, every six months from the next quarter until the new electronic patient record is fully implemented.

  5. University Hospitals of Derby and Burton NHS Foundation Trust

    Provide cross-record patient links between the two electronic patient records and links to the GP Summary Care Record through the Master Patient Index.

  6. University Hospitals of Derby and Burton NHS Foundation Trust

    Provide patients with tubulointerstitial nephritis caused by medication allergy an alert card describing their adverse medication reaction.

  7. University Hospitals of Derby and Burton NHS Foundation Trust

    Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.

  8. University Hospitals of Derby and Burton NHS Foundation Trust

    Add Summary Care Record allergy-check prompts to both electronic patient record clerking forms for assessing clinicians.

  9. University Hospitals of Derby and Burton NHS Foundation Trust

    Amend electronic patient record training scripts and implement a quick-reference guide explaining Summary Care Record access and related learning resources.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. University Hospitals of Derby and Burton NHS Foundation Trust

    The Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. Department of Health and Social Care

    The University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  3. Department of Health and Social Care

    The Care Quality Commission will assess the incident and determine whether further regulatory action is needed.

    Redirects 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 electronic patient records to automatically share renal team entries between hospitals

Wider context from the report

“Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Unreliable inter-agency information sharing for coordinated care; Unreliable operation of the Lorenzo clinical information system.

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 allergy information to automatically cross-populate between records

Wider context from the report

“Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, "allergies" do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Unreliable cross-referencing of related patient records; Unreliable recording and communication of patient allergy information.

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 a multidisciplinary allergy working group to ensure robust systems for managing allergies and alerts.

Verbatim wording from the response

“4. Setting up an allergy working group”

Source location

Response from Derby and Burton NHS
Page 4 · response
Published 6 June 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

Prompt staff during pharmacy reconciliation to compare allergies, sensitivities and adverse reactions with the GP Summary Care Record.

Verbatim wording from the response

“Acknowledging that a wholesale EPR change takes time to tender for, develop and implement, we have sought to improve our interim solutions. We already have a medicines reconciliation process, but arising directly from Ms Connelly's case, we implemented a specific pharmacy prompt to staff to compare allergies, sensitivities and adverse reactions with the GP SCR. Alongside our wider awareness raising, we hope this prompt will deliver real impact arising from the circumstances of this incident.”

Source location

Response from Derby and Burton NHS
Page 3 · response
Published 6 June 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

Disseminate learning about discordant allergy records through Trust-wide articles, bulletins, computer-screen messaging, leadership discussion and divisional case presentations.

Verbatim wording from the response

“• An article specific to Ms Connelly's case was written and posted on the Trust's intranet page. This is available across all sites, all divisions and all specialities.”

Source location

Response from Derby and Burton NHS
Page 4 · response
Published 6 June 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

Audit medicines reconciliation, including correct allergy recording, every six months from the next quarter until the new electronic patient record is fully implemented.

Verbatim wording from the response

“We also plan to audit against the wider medicines reconciliation process starting in the next quarter and will be conducted every six months until such time that our new EPR system is fully implemented. This will include an assessment of whether the patient's allergy status has been recorded correctly. The medicines reconciliation process includes checking both systems.”

Source location

Response from Derby and Burton NHS
Page 3 · response
Published 6 June 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 cross-record patient links between the two electronic patient records and links to the GP Summary Care Record through the Master Patient Index.

Verbatim wording from the response

“Pending implementation of a unified system, the Trust has created a Master Patient Index, enabling us to create a patient context link from each EPR to the other, meaning that staff would be able to click a link to be taken to a mobile version of the other EPR/eCasenote systems without needing to log in or search for the patient again. Similarly, access was created to link the GP surgery held Summary Care Record (SCR). Patients have to agree to share their information on SCR in order for the information to be accessible.”

Source location

Response from Derby and Burton NHS
Page 2 · response
Published 6 June 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 patients with tubulointerstitial nephritis caused by medication allergy an alert card describing their adverse medication reaction.

Verbatim wording from the response

“6. Allergy card for TIN”

Source location

Response from Derby and Burton NHS
Page 4 · response
Published 6 June 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

Implement the unified electronic patient record across Trust sites, with staged rollout underway and allergy functionality planned for the first phase.

Verbatim wording from the response

“Whilst the incident was multifactorial, the unification of the EPR systems is something the Trust is working hard to remedy. As noted, the Trust currently has two enterprise wide systems which include all patient administrative and clinical functionality, appointments, waiting lists, test results, medications, emergency care, maternity and clinical noting.”

Source location

Response from Derby and Burton NHS
Page 2 · response
Published 6 June 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

Add Summary Care Record allergy-check prompts to both electronic patient record clerking forms for assessing clinicians.

Verbatim wording from the response

“Medical clerking is an important initial step on a patient journey through the hospital and represents a key opportunity to capture relevant clinical history. We would always ask a patient about relevant history, including allergy information but analysing Ms Connelly's case we felt that this is a better opportunity to check allergy information, rather than expecting a doctor to read all available information on the system or external systems during a busy ward round. As such we added a prompt to both EPRs to each clerking forms to prompt the user to check the patient's SCR. All assessing clinicians are expected to check this regardless of the patient provided information.”

Source location

Response from Derby and Burton NHS
Page 4 · response
Published 6 June 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

Amend electronic patient record training scripts and implement a quick-reference guide explaining Summary Care Record access and related learning resources.

Verbatim wording from the response

“To support in the delivery of this we have reviewed and amended the training scripts for both EPRs, specifically referencing that the two systems do not automatically talk to one another.”

Source location

Response from Derby and Burton NHS
Page 4 · response
Published 6 June 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 Trust cannot extend an existing EPR across all sites because of contractual, technical, support-life and specialist-function constraints.

Verbatim wording from the response

“Implementing an entirely new system is not a small undertaking. It is important to get this right for the five hospital sites now and into the future. These EPR systems are not created by the Trust, but rather bought under contracting arrangements with their associated contractual periods, support and shelf life. As was heard at inquest, it has not been possible to extend one of the existing systems to the whole site as they need to function effectively across all specialisms. In the case of one system it is reaching the end of its support life. Any system has to be then integrated into the wider Trust in a safe way, operating alongside our other systems.”

Source location

Response from Derby and Burton NHS
Page 2 · response
Published 6 June 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 University Hospitals of Derby and Burton NHS Foundation Trust will address specific local actions in its separate response.

Verbatim wording from the response

“I understand that the University Hospitals of Derby and Burton NHS Foundation Trust will be separately responding to the report and commenting on specific local action in their response.”

Source location

Response from DHSC
Page 2 · response
Published 6 June 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 Care Quality Commission will assess the incident and determine whether further regulatory action is needed.

Verbatim wording from the response

“Where there is any death or serious injury at a provider or service registered by the CQC, the CQC will consider this in line with their specific incident guidance to identify if a patient has suffered avoidable harm or they were placed at significant risk of avoidable harm. This includes when there are issues relating to digital systems, and a specific incident review would consider the role of the system, as well as the registered providers involved.”

Source location

Response from DHSC
Page 2 · response
Published 6 June 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