NHS England
NHS / Health Body
Noted
NHS England acknowledges concerns about accessing Summary Care Records and allergy information but primarily describes existing requirements and procedures. They highlight national work to share learnings from PFD reports. (AI summary)
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Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Stephen William Cassidy who died on 5 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18 September 2023 concerning the death of Stephen William Cassidy on 5 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Stephen’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Stephen’s care have been listened to and reflected upon.
Following several meetings with colleagues at North Bristol Trust (NBT), NHS England offer the following responses to each of the points raised.
1. There was no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily.
The Summary Care Record (SCR) have nationally established Pre-requisites for access which are known to organisations. These include:
▪ access to the internet or a Health and Social Care Network (HSCN) connection. ▪ to ensure your organisation has completed a Data Security and Protection Toolkit. (DSPT) self-assessment and or reviewed the latest updates to it. (DSPT - formerly known as the Information Governance Toolkit). ▪ local technical configuration including Identity Agent and NHS Credential Management as per Warranted Environment Specification on all user computers. ▪ an assigned privacy officer for alert and audit purposes when viewing SCR. ▪ agreed local processes to ensure robust governance - when viewing SCR the user is informed of the need to follow the Permission to View guidelines. ▪ to have prepared training for users covering the features the organisation plans to use. The National Care Records Service (NCRS) is the improved successor to the Summary Care Record application that allows health and social care professionals to access and update a range of patient and safeguarding information across regional Integrated Care Services (ICS) boundaries. The service is a web-based application and can be accessed regardless of what IT system an organisation is using, providing a summary of health and care information for care settings where the full patient record is not required to support their direct care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
9 November 2023
Access to SCR or NCRS requires a web link which can be bookmarked or added to relevant desktop machines. Alternatively, access can be via a SCR 1-Click/NCRS Integration, which allows local access to the National Care Records Service.
Authentication is required to ensure that only relevant healthcare professionals are able to access special category personal identifiable information / clinical records. Smartcards have been a common method to support authentication and access to Spine services over the last few years for healthcare professionals. Spine allows information to shared securely though national health services such as the Electronic Prescription Services, the Personal Demographics Service, the Summary Care Record and the e-Referral Service.
Staff require a smartcard to authenticate to Spine services, it is however acknowledged that only a limited number of staff at NBT have and carry a smartcard. NHS England are working with NBT to identify suitable alternative solutions to the use of Smartcards.
While NBT staff have access to clinical records for patients who live within the footprint of their local detailed care record, for patients who reside or are registered with a GP outside of this footprint, the National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes and it is free to use.
2. This was despite provision existing for South West Ambulance clinical staff to do so before a patient arrived at hospital.
It is understood that South West Ambulance Trust have the technical ability to access Spine services including SCR and have embedded organisational procedures to access this information routinely.
A paramedic from South West Ambulance Trust accessed this patient’s SCR and noted that this patient had an allergy to Ceftriaxone in their record. The paramedic included information that this patient had an allergy to Ceftriaxone, in their handover to A&E staff at SMH.
3. There was no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appeared in SMH’s electronic patient record;
NHS England Summary Care Records team and digital safety experts within the National Patient Safety Team have worked collaboratively with North Bristol Trust to discuss and identify suitable options to access SCR.
The implementation of National Care Records Service (NCRS) will address two of these points: ▪ The NCRS Integration ‘Deep Link’ is a quick and easy way of integrating NCRS into local clinical systems.
▪ CIS2 (the authentication mechanism used by NCRS) permits a variety of authentication methods in addition to Smartcards.
SCR is fully integrated with EMIS, a provider GP IT system for 60% of GP Practices in England. EMIS update the data which is displayed in SCR every time the information in the SCR is updated (approximately 1 million updates per day).
In addition, there is the ability to view SCRs within the EMIS system, which multiple practices routinely do to support the care of temporary resident patients and newly registered patients.
The SCR viewing requirements require clinical systems and organisations that consume the SCR to only present the information as human readable and not machine processed i.e., a human must read the information, assimilate this, and transcribe relevant content in the correct way, into their local patient record.
NHS England is committed to other programs of work (e.g., GP Connect / MIG) which are currently delivering solutions that convey allergy information end to end in a machine processable way.
4. As a result none of the emergency department doctors, the trauma and orthopaedics team or the anaesthetist who administered the antibiotic with induction were able to ascertain Mr Cassidy’s Ceftriaxone allergy;
All healthcare providers are required to perform medicines reconciliation during relevant patient contacts. Medicines reconciliation includes obtaining an accurate allergy history for each patient, this requires at least two sources of information e.g., from the patient / carer, and from the SCR.
In the case presented it appears that Mr Cassidy did not self-report the Ceftriaxone allergy or the patient was only able to report vague details about an allergy which could not be matched to a unique drug when they were asked about allergies by NBT staff.
It is recognised that some NBT staff may not have been aware that out of area patients may not have their allergy information recorded on local NBT systems.
5. This led to an avoidable fatal anaphylactic reaction.
NHS England is fully committed to working with provider organisations to improve access to all available sources of critical patient information. I would also 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.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.
Re: Regulation 28 Report to Prevent Future Deaths – Stephen William Cassidy who died on 5 March 2023.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18 September 2023 concerning the death of Stephen William Cassidy on 5 March 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Stephen’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Stephen’s care have been listened to and reflected upon.
Following several meetings with colleagues at North Bristol Trust (NBT), NHS England offer the following responses to each of the points raised.
1. There was no provision for clinical staff at SMH to access patients’ Summary Care Record routinely or easily.
The Summary Care Record (SCR) have nationally established Pre-requisites for access which are known to organisations. These include:
▪ access to the internet or a Health and Social Care Network (HSCN) connection. ▪ to ensure your organisation has completed a Data Security and Protection Toolkit. (DSPT) self-assessment and or reviewed the latest updates to it. (DSPT - formerly known as the Information Governance Toolkit). ▪ local technical configuration including Identity Agent and NHS Credential Management as per Warranted Environment Specification on all user computers. ▪ an assigned privacy officer for alert and audit purposes when viewing SCR. ▪ agreed local processes to ensure robust governance - when viewing SCR the user is informed of the need to follow the Permission to View guidelines. ▪ to have prepared training for users covering the features the organisation plans to use. The National Care Records Service (NCRS) is the improved successor to the Summary Care Record application that allows health and social care professionals to access and update a range of patient and safeguarding information across regional Integrated Care Services (ICS) boundaries. The service is a web-based application and can be accessed regardless of what IT system an organisation is using, providing a summary of health and care information for care settings where the full patient record is not required to support their direct care. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
9 November 2023
Access to SCR or NCRS requires a web link which can be bookmarked or added to relevant desktop machines. Alternatively, access can be via a SCR 1-Click/NCRS Integration, which allows local access to the National Care Records Service.
Authentication is required to ensure that only relevant healthcare professionals are able to access special category personal identifiable information / clinical records. Smartcards have been a common method to support authentication and access to Spine services over the last few years for healthcare professionals. Spine allows information to shared securely though national health services such as the Electronic Prescription Services, the Personal Demographics Service, the Summary Care Record and the e-Referral Service.
Staff require a smartcard to authenticate to Spine services, it is however acknowledged that only a limited number of staff at NBT have and carry a smartcard. NHS England are working with NBT to identify suitable alternative solutions to the use of Smartcards.
While NBT staff have access to clinical records for patients who live within the footprint of their local detailed care record, for patients who reside or are registered with a GP outside of this footprint, the National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes and it is free to use.
2. This was despite provision existing for South West Ambulance clinical staff to do so before a patient arrived at hospital.
It is understood that South West Ambulance Trust have the technical ability to access Spine services including SCR and have embedded organisational procedures to access this information routinely.
A paramedic from South West Ambulance Trust accessed this patient’s SCR and noted that this patient had an allergy to Ceftriaxone in their record. The paramedic included information that this patient had an allergy to Ceftriaxone, in their handover to A&E staff at SMH.
3. There was no provision for the Summary Care Record to be integrated with SMH’s hospital electronic patient record (known as Careflow/Connect) or the primary care electronic patient record (EMIS – Egton Medical Information System) – such that the Ceftriaxone allergy automatically appeared in SMH’s electronic patient record;
NHS England Summary Care Records team and digital safety experts within the National Patient Safety Team have worked collaboratively with North Bristol Trust to discuss and identify suitable options to access SCR.
The implementation of National Care Records Service (NCRS) will address two of these points: ▪ The NCRS Integration ‘Deep Link’ is a quick and easy way of integrating NCRS into local clinical systems.
▪ CIS2 (the authentication mechanism used by NCRS) permits a variety of authentication methods in addition to Smartcards.
SCR is fully integrated with EMIS, a provider GP IT system for 60% of GP Practices in England. EMIS update the data which is displayed in SCR every time the information in the SCR is updated (approximately 1 million updates per day).
In addition, there is the ability to view SCRs within the EMIS system, which multiple practices routinely do to support the care of temporary resident patients and newly registered patients.
The SCR viewing requirements require clinical systems and organisations that consume the SCR to only present the information as human readable and not machine processed i.e., a human must read the information, assimilate this, and transcribe relevant content in the correct way, into their local patient record.
NHS England is committed to other programs of work (e.g., GP Connect / MIG) which are currently delivering solutions that convey allergy information end to end in a machine processable way.
4. As a result none of the emergency department doctors, the trauma and orthopaedics team or the anaesthetist who administered the antibiotic with induction were able to ascertain Mr Cassidy’s Ceftriaxone allergy;
All healthcare providers are required to perform medicines reconciliation during relevant patient contacts. Medicines reconciliation includes obtaining an accurate allergy history for each patient, this requires at least two sources of information e.g., from the patient / carer, and from the SCR.
In the case presented it appears that Mr Cassidy did not self-report the Ceftriaxone allergy or the patient was only able to report vague details about an allergy which could not be matched to a unique drug when they were asked about allergies by NBT staff.
It is recognised that some NBT staff may not have been aware that out of area patients may not have their allergy information recorded on local NBT systems.
5. This led to an avoidable fatal anaphylactic reaction.
NHS England is fully committed to working with provider organisations to improve access to all available sources of critical patient information. I would also 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.
Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.