Suzanne Edwards

Dear Mr Osborne, Bedford Hospital Kempston Road Bedford MK42 9DJ Re: Suzanne Edwards - Regulation 28 Report to Prevent Future Deaths I am writing in response to your Regulation 28 Report to Prevent Future Deaths (hereafter "Report") issued on 1st August 2025 following the Inquest into the death of Suzanne Edwards held on 24th July
2025. I would like to begin by extending my sincere condolences to the family of Mrs Edwards for their loss. I appreciate this will still be a very difficult time for the family. In response to evidence heard at the Inquest you raised a concern in relation to Accident and Emergency Department clinicians not being able to access primary health care records, in this case GP records, upon a patient arriving at an Emergency Department. The Bedfordshire Hospitals NHS Foundation Trust (the Trust) would like to assure both you and the family that the concern raised in your report has been listened to and reflected upon. This letter sets out the Trust's formal response. Regulation 28 Concern The matter of concern raised and responded to is as follows:
1. Emergency Departments at hospitals in this and surrounding jurisdictions do not have reliable access to patients' primary care records, including recent GP consultations, investigations or concerns. This means that clinicians are frequently treating acutely unwell patients without full access to their recent medical history, which can delay or misdirect diagnosis and undermine patient safety and continuity of care and lead to avoidable deaths. Without access to a patients full records further lives may be put at risk. I understand that thankfully the care Mrs Edwards received at the Bedfordshire Hospitals NHS Foundation Trust was not affected by the concern you raise in the report. As a prompt diagnosis of a kidney stone was made and the clinical teams swiftly began treating the infection that had been caused by the obstructed kidney; including inserting a stent to relieve the blockage. Sadly, despite appropriate pre-operative care, surgery and optimal post-operative treatment in our Critical Care Complex, Mrs Edwards succumbed to septic shock. Bedfordshire Hospitals incorporating: Bedford Hospital, Luton and Dunstable Hospital

I do of course recognise the risk you have identified that can result when primary and secondary healthcare providers cannot access each other's medical records. I welcome the opportunity to explain what access to Shared Care Records (including GP records) our A&E clinicians have at both the Bedford and Luton & Dunstable hospital sites. I hope this will assure you that Bedfordshire Hospitals NHS Foundation Trust clinicians do, as far as is possible, have access to primary care records to assist them in the diagnosis of conditions thus reducing the overall risk to patient safety and further mitigating the risk of future deaths. Clinicians have access to three services:- The Shared Care Record (ShCR) The Shared Care Record (previously known as the Clinical Portal,) represents a collaborative effort between Bedfordshire Hospitals NHS Foundation Trust and the Bedfordshire, Luton and Milton Keynes Care Partnership (BLMK), originating in late 2019 and early 2020 in response to NHS England's mandate for regional Integrated Care Boards. This platform facilitates the exchange of data among all BLMK health providers in a "read-only" capacity. The Shared Care Record consolidates healthcare information from various organisations into a unified, confidential electronic record. Only relevant and accessible healthcare data is shared on this platform for direct care purposes. Essentially, this provides a broader view of the patient's history to support joined up care. It is important to note that patients can, through their GP practice opt out of data sharing which subsequently means that our clinicians will not be able to see their GP records. However, patients are automatically opted in unless they make the conscious decision to opt out. GP Connect This is a national NHS service that allows authorised clinicians to view the patient's primary care record so that they can review medications, allergies and any recent GP interactions. It also allows for the sending and receiving of data, for example, booking appointments or sharing information between services. Our A and E clinicians have access to this part of the service via an internal hospital system called Viper and the Shared Care Record. Summary Care Record (SCR) This is a national NHS service which is automatically created from GP records. It contains key patient information such as medications, allergies and any previous adverse reactions a patient may have had. The SCR is primarily used in urgent or emergency care when GP records are not accessible. It is important to note that the patient has the option to opt out of their data being put on to the SCR. These services have clear benefits for both the patients attending our hospital sites and the clinicians working within the Emergency Medicine setting. Benefits of the three system to our patients include:-
• There are fewer steps for patients, this reduces the repetition of relaying information multiple times to different clinicians with the attached risk of missing something vital. Bedfordshire Hospitals incorporating: Bedford Hospital, Luton and Dunstable Hospital

• Medication safety improvements; patients do not need to remember their full list of medication which may be extensive.
• Improved communication between referrers and service providers.
• Improved healthcare outcomes for patients, including patient experience. Benefits to our Clinicians include:-
• Clinicians are able to make a better informed decision with more extensive information available at their fingertips.
• Increased productivity and efficiency as clinicians may not need to contact other sources, departments or services.
• An improved user experience and clinical satisfaction; our clinicians are able to do their job with the right information available to them resulting in positive interactions with patients. It is not within the Trust's control to expand upon what patient information is shared on the services outlined above as the record is taken from the Summary Care Record and GP Connect. The extent of what is contained in the Summary Care Record is regulated by NHS Digital which forms part of NHS England. There are unfortunately certain limitations to what can be accessed and shared without a single system for medical records which could be used nationally by all NHS Care providers; but we strive to ensure that what is available is easily accessible to our treating clinicians. Thank you for bringing this important patient safety concern to my attention. As a Trust we are committed to working closely with our healthcare partners to ensure that data sharing happens, we all recognise the vital information sharing that is needed to effectively treat our patients.

Dear Mr Osborne

Regulation 28 Report following Inquest into the death of Mrs Suzanne Edwards

I am writing following receipt of a Regulation 28 report dated 01 August, relating to the Inquest concluded on 24 July 2025. Mrs Edwards died from septic shock secondary to pneumonia and urosepsis, the latter associated with a calculus. I was sorry to learn of Mrs Edwards’ death. I understand that MKUH was not named as an interested party prior to the Inquest, the Trust was not legally represented, and Trust witnesses were not called to provide oral testimony. Over a period of 48 hours, Mrs Edwards had contacts with her GP and the MKUH Emergency Department and had then been admitted to Bedford Hospital under urology where she subsequently died. MKUH and Bedford Hospital operate a shared urology ‘out of hours’ service at Consultant level.

Whilst the Record of Inquest suggests that you were satisfied that management was appropriate at each specific step, you were concerned that there had been a failure to recognise signs of urinary tract obstruction resulting in a lost opportunity to treat this prior to the onset of sepsis.

The Regulation 28 report (sent to MKUH and separately to neighbouring hospitals) articulates a concern that staff in Emergency Departments do not have reliable access to patients’ primary care records. You expressed the view that this lack of access can delay or misdirect diagnosis and undermine patient safety and continuity of care and lead to avoidable deaths.

Whilst challenging to provide a comprehensive response having not been party to the Inquest, I shall outline the issues in this area as seen by MKUH and the actions we have taken and continue to take on this issue.

It is perhaps useful to consider the historic position of paper-based notes where all different care providers maintained a physically separate clinical record. Primary Care and some hospitals have moved decisively towards electronic records. Electronic records have many benefits including the potential to share content across providers (at least in a ‘read-only’ manner). Concerns do naturally persist in relation to the legal status of the record (and a reluctance therefore to have ‘third parties’ edit or write into the record) and information governance (in terms of ensuring that access to confidential personal data is appropriate and has a legal basis). MKUH is relatively advanced in terms of its digital infrastructure and has rolled out Oracle Health’s Millennium product incrementally since 2018 (known locally as eCare). Our tertiary

provider (Oxford University Hospitals) uses a separate instance of the same product. Neighbouring providers use other systems including SystmOne (Primary Care, CNWL community and Buckinghamshire Hospitals), Nerve Centre (Bedfordshire Hospitals NHS Foundation Trust) and EMIS / System C (Primary Care in Oxfordshire and Buckinghamshire).

One important element of Oracle Health’s product is the Health Information Exchange (HIE). The HIE acts as an interface between the MKUH instance of Oracle Health’s Millennium and other instances, or third-party products (including SystmOne, System C and Nerve Centre). In some cases (specifically Nerve Centre), some ‘middleware’ known as Intersystems is required for this connection. The HIE acts as a ‘window’ through which selected content of one record system can be seen from within another system. This works in both directions: for example, selected content from SystmOne can be seen from within Millennium, and selected content from Millennium can be seen from within SystmOne. The entire record is not typically visible through HIE, rather a selected subset of documents and data items within the record. The range of documents and data items that can be seen through HIE is determined by the owner of the clinical record: in other words, MKUH determines what information to render visible to others through the HIE window. Only a subset of the record is shared for several reasons: the volume of data which is collected during a relatively short secondary care inpatient episode is very large (as you are aware from records provided to assist in your coronial inquiries); some parts of the record would be of no discernible use to those outside the hospital; some of the data are such that interpretation is required in order to generate usable information; and, the ability to structure records within HIE is very limited (such that there is limited ‘search functionality’, and it can be difficult to find the desired information within ‘background noise’).

The information shared by Primary Care through HIE is variable but can offer a more complete view of the primary care record. The patient can have limited input into determining how much of their Primary Care record is visible through HIE. There remain challenges as to how HIE users locate important and pertinent information within the view that they are afforded. The way in which information is arranged is not intuitive. Whilst key information may be accessible in theory, it can be less so in practice.

MKUH has developed HIE linkages with many other providers.

Specific challenges in the MKUH footprint include:

1. Variable maturity of digital records (meaning that in some instances there is still relatively little digital information to share). Bedfordshire Hospitals NHS Foundation Trust is still in the implementation phase of its electronic record (Nerve Centre).

2. Variable willingness of other providers to establish HIE links. This is a particular challenge with Primary Care in Oxfordshire and Buckinghamshire (including

Aylesbury Vale / Buckingham from where patients frequently access urgent and emergency care at MKUH). Leaders in the Thames Valley have a strategic preference for sharing the content of care records via the Thames Valley Shared Care Record. Whilst this is rational (from the perspective of wanting to drive real patient benefits from this shared care record), it does lead to gaps in the HIE environment described above. Discussions are ongoing.

At MKUH, we continue to:

 optimise our eCare record for sharing via HIE;  establish HIE links with all providers with whom we have a significant number of common patients;  educate clinicians internally and externally about the benefits and possibilities of HIE; and,  encourage other providers to share more pertinent content from their records with us via HIE.

I append several illustrations to demonstrate our activity and energy in this area.

Fig. 1 HIE Connections to other provider record systems set up by MKUH

MKUH Health Information Exchange (HIE) Connections Connection Type BLMK GP Practices Primary Care Willen Hospice Community MK Urgent Care Urgent Care CNWL Community Community One London Various Oxford University Hospitals Tertiary Bedfordshire Hospitals Acute MKCC – Adult Social Care Social Care MKCC – Children’s Services Social Care Connection available but not activated

Swan and North Bucks PCNs Primacy Care Thames Valley Shared Care Record Primary Care / Various

Fig. 2a HIE Interface as seen in MKUH’s eCare (Oracle Health’s Millenium)

Fig. 2b HIE Interface as seen in Primary Care’s SystmOne

Fig. 3a Upsurge in HIE usage by sector, 2020-23

Fig. 3b Items accessed through HIE, 2020-23

I trust that this response is helpful.