Edward Muwanga

Dear Mr Rogers, Thank you for your Regulation 28 Report dated 24 April 2026 concerning the tragic death of Mr Edward Muwanga. I The Metropolitan Police Service (MPS) extends its deepest condolences to the family of Mr Muwanga and we take the concerns you have raised extremely seriously. This letter sets out the formal response of the Commissioner of Police of the Metropolis, addressing each matter of concern and outlining the actions taken and planned to reduce the risk of similar incidents occurring in the future. I can confirm that the matters of concern you. set out within your Regulation 28 report have been carefully considered by senior leaders and practitioners within the MPS and I would now like to formally respond to as follows: The first matter of concern is as follows: A failure by the three police officers attending to understand that their powers under section 136 MHA 1980 applied to persons in a communal space within private accommodation and thereafter a failure to make a more detailed and measured assessment of the Eddie's situation The MPS acknowledges the findings of the inquest and the concerns raised in this report, and we have taken substantive steps fo strengthen training, policy, and operational practice. All officers now receive structured and comprehensive training on sections 135 and 136 of the Mental Health Act. This includes specific instruction on the lawful use of section 136 powers in communal areas, with explicit clarification reinforced through operational notices issued to all frontline staff. Officers are also trained on the purpose and execution of section 135 warrants, including the respective roles of health professionals and the importance of safeguarding considerations. Training is delivered through a blended approach, combining classroom learning, scenario-based exercises, and ongoing professional development to ensure both legal understanding and effective practical application. In addition, officers are expected, as best practice, to conduct intelligence checks when attending ·
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Dear Mr Rogers, Re: Regulation 28 Report to Prevent Future Deaths – Edward Muwanga who died on 7th August 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 24th April 2026 concerning the death of Edward Muwanga on 7th August 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Edward’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Edward’s care have been listened to and reflected upon.

Your report raised concerns around the sharing and visibility of important health care records between medical agencies. In this case, particularly between the treating Trust, in this case South London and Maudsley NHS Foundation Trust (SLAM) and NHS 111, and between the Ambulance Service Trust and SLAM.

NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. As of 2021, all primary and secondary care organisations have been able to share a subset of the patient information they hold, the core information standard, between providers within their own integrated care board footprint through their local Shared Care Record. Building on this and recognising the clinical need, an initiative has been set to achieve national interoperability between shared care records across England. This committed investment aims to enable any authorised health and care professional to have access to safe, reliable, and accurate records, regardless of the patient’s location or where care is provided. It is however, up to local shared care record organisations and participating NHS Trusts, to agree what information, in addition to the core information standard, is held and shared through the local shared care record. It is also up to individual NHS Trusts to negotiate data sharing protocols and agreements to enhance localised information sharing outside of the local shared care record.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

23rd June 2026

NHS England recognises that limited information sharing between care settings can reduce the continuity and effectiveness of care, particularly where patients are receiving support across multiple organisations. NHS England has developed and led the Frontline Digitisation (FD) Programme to support NHS trusts in adopting Electronic Patient Record (EPR) systems, improve digital maturity, and enable better information sharing within and between organisations. In addition to supporting the procurement of EPR systems, the FD Programme provides guidance and oversight to help ensure that implementations are safe and effective. The South London and Maudsley (SLAM) NHS Foundation Trust This trust uses the CareNotes Electronic Patient Record (EPR) system supplied by OneAdvanced (formerly Advanced). As part of the Frontline Digitisation (FD) Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the Digital Capability Framework (DCF). Through the FD Programme, the Trust secured funding to support development of a business case to replace its current EPR system.

London Ambulance Service NHS Trust This Trust uses an electronic Patient Care Record (ePCR) system supplied by Cleric Computer Services Ltd. As part of the FD Programme, the Trust was assessed as having an EPR that did not meet the Programme’s core standards under the DCF. Through the FD Programme, the Trust has secured funding to invest in additional functionality to support its EPR, including:
• A new patient centred Computer Aided Dispatch (CAD) system, linked to its mobile electronic Patient Care Record (ePCR) system
• Improved front-line interoperability with other Ambulance Services and One London Emergency Departments (ED) as a pilot.
• Joining up the patient record by linking with ED systems
• Optimisation of the EPR across the Ambulance Trust and associated treatment centres. Both trusts can already securely share important health care records electronically with health and care partners through the OneLondon Care Record, using a Health Information Exchange (HIE) supplied by Oracle Health. However, while Section 136 status should be recorded within the originating mental health record (in this case SLAM), this would not necessarily be included in the OneLondon Care Record.

Further information about information sharing between providers Local EPR implementations should operate under the oversight of a Trust Clinical Safety Officer (CSO). The CSO is a registered healthcare professional responsible for overseeing the clinical safety and risk management of health IT systems, helping to

ensure that these systems are safe for patient use. Digital safety is a critical component of patient safety. Suppliers and Trusts are jointly accountable for compliance with the two mandatory Clinical Risk Management Standards defined under Section 250 of the Health and Social Care Act 2012:
• DCB0129: Clinical Risk Management: its Application in the Manufacture of Health IT Systems - NHS Digital
• DCB0160: Clinical Risk Management: its Application in the Deployment and Use of Health IT Systems Where multiple digital systems are used within a trust, including EPR systems, robust policies and procedures should be in place to set clear expectations, support appropriate clinical record management, and ensure the timely handover and escalation of abnormal results to the relevant individuals. Responsibility and accountability for the sharing and management of information held within electronic records, including information shared across different systems, rests with each organisation through its established digital governance arrangements. While the FD Programme supports investment in local digital capability, interoperability is generally configured and managed locally, based on agreements between provider organisations and their technology suppliers, with NHS England regional teams taking account of wider catchment areas where appropriate. It is also relevant to consider how the Summary Care Record (SCR) and National Care Records Service (NCRS) may have supported clinical care in this case. Given that Edward had a diagnosis of paranoid schizophrenia, it would be reasonable to expect that this diagnosis, together with any medication prescribed for that condition, would be visible in his SCR, provided that he had not opted out. Brief additional clinical information, for example regarding auditory hallucinations, may also have been included. However, the SCR does not contain correspondence and would therefore be unlikely to include communications between SLAM and the police, nor any recent information relating to sections 135 and 136, unless these were identified by the responsible clinician as explicitly needing to be coded or included as additional information for sharing. Similarly, the National Record Locator, as a separate service within NCRS, is also unlikely to contain that specific correspondence.

National Care Records Service (NCRS) NCRS is the successor to the Summary Care Record application (SCRa) and is designed to address barriers to adoption identified in a number of care settings. The National Care Records Service (NCRS) provides a quick and secure way to access national patient information in order to support clinical decision-making and improve healthcare outcomes. It is free to use and includes additional features and services beyond the legacy SCRa product.

NCRS is internet-based, accessible through a web browser, and is actively used by the London Ambulance Service (LAS) across a range of devices. We would expect both the LAS and NHS 111 to have access to patients’ Summary Care Record (SCR) through NCRS. Any further enquiries about access to SCR through NCRS should therefore be directed to LAS.

Summary Care Record (SCR) NCRS provides access to patients’ Summary Care Records. The SCR is a national record containing key patient information such as current medication, allergies, and details of any previous adverse reactions to medicines. It is generated from GP medical records, and changes made to the GP record are synchronised to the SCR. The SCR can be accessed and used by authorised staff in other parts of the health and care system who are involved in the patient’s direct care but do not require access to the full GP record. Its purpose is therefore to provide a concise summary of the patient’s GP record, including the information most likely to be helpful during an unscheduled care encounter. As a minimum, the SCR contains important information about:
• Current medication
• Allergies and details of any previous reactions to medicines
• The name, address, date of birth and NHS number of the patient In addition, details of long-term conditions, significant medical history, and specific communication needs are now included by default for patients with an SCR, unless they have previously told the NHS that they do not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR Where information is communicated to the GP, for example, via discharge summaries, crisis event notifications, or correspondence, relevant details may be coded or attached within the GP record. If appropriately recorded and coded, this can be visible within the Summary Care Record (SCR) as Additional Information. However, this is not guaranteed, as it depends on:
• Whether the mental health provider shares the information
• Whether the GP system receives and codes it
• Whether it is included within the SCR upload and subsequently viewed

Additional Information in the SCR includes the active problems and significant past problems (from Optum/TPP/Medicus provider systems) for a patient as recorded by their registered GP practice. In relation to SCR, as of 27 April 2026, 88% of the population of England (approximately 59 million patients) had an SCR with Additional Information, 7.3% had

a Core Only SCR (allergies and medications only), and 1.5% had opted out of SCR. In most cases, patients must give Permission to View before their SCR can be accessed. However, an Emergency Access option is available where a patient is unable to provide Permission to View, for example because they are unconscious. National Record Locator NHS England’s National Record Locator (NRL) service allows health and social care professionals to identify and access patient information shared by other health and social care organisations across England in support of direct patient care. It does this by recording the location of digital and paper records within the NHS and providing an index of pointers or bookmarks that can be used to retrieve key patient information from the source. The aim is to improve interoperability across organisational boundaries and support professionals, including care coordinators in mental health trusts, to retrieve information securely and remotely at the point of need. This can help provide a more longitudinal view of a patient’s records and indicate their treatment history. The NRL avoids the need for organisations to create duplicate copies of information across systems by facilitating access to up-to-date information directly from the source. It can also indicate which organisations currently have a care relationship with a patient, enabling users to contact the relevant service in the event of a crisis. Mental health crisis plans are one of the pointer types supported by the NRL service. NRL does not store mental health data, or clinical content itself; rather, it points users to where that information can be found. NRL information can be accessed through the National Care Records Service (NCRS). Where multiple pointers are returned, users can sort the results by creation date. If a mental health provider publishes relevant documents (e.g. care plans, discharge summaries), these may be discoverable via NRL. However, there is no consistent assurance that Section 136 status is explicitly shared or published, and visibility depends on local publishing and role based access and governance practices.

Connecting Care Records NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records, which bring together records from different health and care organisations in one place and connect information around the individual rather than a single organisation. Shared Care Records include prescribed medications and will typically contain more information about an individual than a Summary Care Record. Responsibility for delivering shared care records rests with local Integrated Care Boards (ICBs). Each ICB develops its shared care record in response to local health and care needs, existing systems, and future plans. As a result, some shared care records are accessible to neighbouring ICBs, while others operate only within their own area. Future plans include improving connectivity so that shared care records can be used more consistently across England, regardless of where a person lives or receives care.

Further investigation may be required to determine the extent of the relevant trusts’ access to SCR, NRL and Shared record in this case. More broadly, NHS England and the Department of Health and Social Care have published Fit for the Future: 10 Year Health Plan for England, which sets out the government’s plan for healthcare in England over the next decade. The Plan includes a commitment to give patients ‘a single, secure and authoritative account of their data
– a single patient record’ to support more coordinated, personalised and predictive care.

Regional Response

NHS England have liaised with One London Board who have detailed their response and actions following this Report. As they will be providing a response directly to the Coroner we won’t provide further details here.

I would also like to provide further assurances on the 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 events, such as the sad death of Edward, are shared across the NHS at both a national and regional level and helps us to 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.

Dear Mr Rogers

Re: Inquest into the Death of Edward Muwanga who died 07.08.2023 - Response to Regulation 28 Report

I write in response to the Regulation 28 Report to Prevent Future Deaths in the case of Edward Muwanga. Specifically I write in response to the matters raised which are relevant to (i) NHS England, (ii) OneLondon Board, (iii) London Ambulance Service NHS Trust (“LAS”), and (iv) South London and Maudsley NHS Foundation Trust (“SLaM”), and to provide you with SLaM’s responses to the concerns you have raised.

Evidence was heard at the inquest, and SLaM notes that concerns have been raised as follows:

I. The sharing and visibility of important health care records between medical agencies, (held on multiple platforms by multiple health care agencies) in particular here between the [SLaM] and NHS 111, and between the [LAS] (not NHS 111) and the treating Trust (SLAM).

II. Evidence was heard from LAS that “it is recognised that there remain challenges with the visibility of information from healthcare settings across London. While advances have been made, the visibility of pertinent information depends on technological developments and the coordination of a complex healthcare system.”

III. Written evidence was received from LAS that “...there is currently no single, comprehensive system that provides universal access to all patient records across NHS organisations. Access is influenced by information governance requirements, system interoperability, commissioning arrangements, and the extent to which partner organisations upload information to shared platforms."

IV. Whilst this fragmented situation persists with a multiplicity of systems, platforms, screens, and process in which important patient safety information is embedded the risk such information is not identified or communicated to practitioners making healthcare decisions remains and as such gives rise to a risk of death due to decisions being made on incomplete information where more complete information exists.

1. Review of SLaM information sharing
1.1 Approach to the review In response to the concerns identified by you, Sir, SLaM undertook a comprehensive internal review. The purpose of the review was to examine:
• the information recorded in relation to this patient, and
• the extent to which that information was available to other organisations at the relevant time. South London and Maudsley NHS Foundation Trust Office of the Chief Executive Maudsley Hospital Denmark Hill London SE5 8AZ

The review was led by SLaM’s Chief Clinical Information Officer who was supported by senior clinical, operational, and patient safety staff. The review included a detailed examination of:
• the patient’s clinical records held within the Trust,
• information shared via the London Care Record (LCR), and
• documented interactions between organisations involved in the patient’s care.

1.2 Platforms used to record and share information

Electronic Patient Journey System (“ePJS”)

Within SLaM, patient information is primarily recorded in the Electronic Patient Journey System (“ePJS”), which has served as the Trust’s main electronic health record and central repository for clinical documentation since 2002.

The London Care Record (“LCR”)

Since March 2023, SLaM has adopted a London-wide sharing approach to ensure that appropriate information is available to clinicians at the point of need, regardless of where the patient presents.

The approach to sharing information through the LCR was developed in partnership with service users, families, and carers. This collaborative design prioritised the sharing of up-to-date contextual information about a patient’s current clinical presentation, rather than relying solely on single structured data points, which may not fully reflect the person’s most relevant situation.

Relevant information recorded in ePJS is shared automatically with the LCR in near real time. This includes:
• important alerts
• care team information
• the most recent 15 progress notes
• discharge notification summaries
• key clinical correspondence

Within the LCR, information from ePJS is presented under sections headed ‘Mental Health’ and ‘Clinical Correspondence’. This is consistent with arrangements across other London mental health trusts. The LCR is a secure digital platform that enables authorised health and social care professionals to access key patient information from multiple organisations, providing a shared view to support clinical decision-making.

Crisis plans

Crisis plans provide guidance to support decision-making in anticipated crisis scenarios. They are recorded in ePJS and shared via the National Record Locator Service (known as NRLS or NRL). Taken Crisis Plans and LCR together, these sources can support continuity of care and clinical decision-making at the point of clinical need.

The Universal Care Plan (“UCP”)

The UCP forms part of the broader LCR programme, and it has been developed and implemented incrementally across London, with key shared care record capabilities established by April 2024 as part of a national NHS England initiative.

Within this evolving digital infrastructure, there are ongoing developments to standardise crisis care planning across all London mental health trusts and to incorporate this information into a UCP model within the LCR.

This is intended to provide a more consistent and visible approach to sharing crisis-relevant information across organisations, complementing existing clinical records.

The UCP is also designed to support patient access through the NHS App and, in future, may enable closer integration with core electronic patient record systems. This would facilitate more timely updates as a patient’s clinical presentation changes, reduce duplication across systems, and improve the availability of relevant information to clinicians at the point of need.

The electronic Mental Health Act system (“eMHA”)

The eMHA by Thalamos is a digital platform used by five Mental Health Trusts in London to complete, process, and securely share statutory Mental Health Act documentation across organisations involved in a patient’s care. It was implemented locally in SLaM from 24 March 2025, as part of a London‑wide programme to improve the accuracy, timeliness and accessibility of MHA documentation.

The primary purpose of eMHA is to provide a longitudinal, structured record of Mental Health Act activity, including applications for detention, medical recommendations, treatment and renewal forms, and records of detention. It enables authorised professionals, including AMHPs, doctors and mental health law teams, to complete and share statutory forms electronically, supporting more coordinated and efficient care.

It is important to note that eMHA records formal MHA processes and outcomes, such as detention under the Act and subsequent legal documentation, rather than the earlier clinical decision-making or referral processes leading up to a Mental Health Act Assessment which applied to this case. For this reason, referrals for MHAA and wider clinical context remain recorded within the main clinical record (e.g. ePJS). In addition, while eMHA provides a structured record of MHA activity from its point of implementation, it does not retrospectively capture all historical detentions prior to go live. From 2026, information on current MHA status is also reflected in the London Care Record, to support cross organisational information sharing.

NHS 111 Mental Health

To facilitate timely access to specialist advice, support and triage in mental health crises, the NHS 111 mental health service became available to South London residents in December
2023. From 1 April 2026, the SLaM 24-hour mental health crisis line was transitioned into NHS 111 Mental Health. As a result, NHS 111 Mental Health became the single 24-hour access point for patients, carers, the public, and professionals seeking urgent mental health support.

Clinical safety of information sharing platforms

The information available through shared platforms is intended to support, but not replace, clinical assessment. It provides guidance to clinicians and should be interpreted alongside direct assessment of the individual and, where appropriate, discussion with relevant services. This may include:
• NHS 111 Mental Health services (single point of access),
• conveyance to a health-based place of safety, or
• consultation with the patient’s treating team during working hours.

1.3 Information available for this patient

At the time of the events in question, the patient was under the care of a SLaM Community Mental Health Team and was recognised to be experiencing a deterioration in mental health.

This information was recorded within the ePJS (Electronic Patient Journey System) and shared to the LCR (London Care Record). Information visible within the LCR “Mental Health” section included documentation of clinical deterioration, referral for a Mental Health Act Assessment (MHAA), and ongoing liaison with the Approved Mental Health Professional (AMHP) service and supported accommodation staff. These entries reflected an escalation in clinical concern, including that the patient was awaiting an MHAA. A crisis plan dated 22 April 2023 was also available via the National Record Locator Service (NRLS), providing general guidance for the patient’s management in crisis situations. However, documentation relating to an AMHP warrant reportedly obtained on 2 August 2023 was not present within ePJS and was therefore not available to be shared via the LCR.

It is important to consider the significance and presentation of the information available. A referral for an MHAA reflects professional concern regarding a potential escalation in risk, while the presence of a Section 135(1) warrant represents a further escalation with legal authority for assessment. In this case, key information regarding the patient’s deterioration and level of risk was recorded primarily within free-text clinical notes rather than structured or prominently flagged fields. While this information was available via the LCR, it required active navigation and interpretation to identify the most relevant and recent updates.

At the time (2023), the LCR was in relatively early stages of adoption, and clinicians may also have relied on crisis plans accessed via NRLS. While the LCR provided up-to-date clinical context, crisis plans are inherently more general and may not reflect recent changes such as deterioration or a pending MHAA. In addition, the LCR provides a curated subset of the full clinical record and requires users to actively retrieve and interpret information across multiple entries. As such, while relevant information was available across systems, its visibility and immediate accessibility depended on familiarity with, and active use of, these platforms. Clinical judgement and, where necessary, direct communication between services therefore remained essential.

2. Discussions and joint learning with LAS, NHS England and OneLondon Board

In addition to the internal review, SLaM has engaged with the London Ambulance Service (LAS), NHS England and the OneLondon Board to reflect on the learning from this case, including the concerns raised during this inquest into the death of Edward Muwanga. These discussions have focused on how information is recorded and shared across multiple digital systems, and the risks that may arise from fragmentation, variable visibility of information, and differences in system use across organisations.

These multi-agency conversations have highlighted both the significant progress already achieved in developing shared care records and digital interoperability across London, and the ongoing work required to improve the consistency, visibility and timeliness of critical information. Partners recognised the need to mitigate risks during this period of transformation, including improving the prominence of key risk indicators, strengthening system integration, and supporting staff to effectively access and interpret information across platforms.

It is recognised that where a patient with severe mental illness is awaiting a Mental Health Act Assessment, this represents a period of increased clinical risk. Reflecting on this case, SLaM and LAS have identified that, in such circumstances, additional active information-seeking and clinical assessment may be required to support safe decision-making. It is also acknowledged that digital systems, while supportive, do not replace the need for direct clinical communication

between services, particularly where there are concerns regarding risk or deteriorating presentation. Clinicians have access to NHS 111, including the mental health option, on a 24-hour basis to support advice, triage and escalation where required.

3. Developments with respect to the sharing and visibility of important health care records since 2023 and ongoing

Since 2023, there have been significant developments across London to improve the sharing, visibility and accessibility of mental health information, particularly in crisis situations. The LCR has been implemented across all London mental health trusts, and it is used routinely in clinical practice, enabling organisations such as the London Ambulance Service (LAS) and NHS 111 to access relevant mental health information for direct clinical care. This has improved the ability of clinicians to view key information across organisational boundaries. In addition, from April 2026, the transition of local crisis lines into the NHS 111 mental health service has provided a single, 24-hour access point for crisis support, supporting more consistent triage and escalation across the system.

Alongside these developments, there has been increased focus on training, standardisation and system usability, including the consistent presentation of mental health information within the LCR and improved staff awareness of shared records. However, learning from this case has reinforced that, despite improved availability of information, in complex situations, challenges remain regarding the visibility of key risk indicators across systems, and the need for active information-seeking and interpretation by clinicians in time-critical situations.

Relevant to this case, there is ongoing work within the London Digital Mental Health Forum to standardise crisis care plans across mental health trusts in London, with the intention of incorporating these into a UCP model within the wider LCR (London Care Record). This work seeks to address current fragmentation, whereby crisis plans and clinical information may sit in separate systems, by improving the consistency, visibility and accessibility of crisis-relevant information across organisations. A key aim is for the UCP to integrate with core electronic patient record (EPR) systems such as ePJS, enabling information to be shared without duplication and to reflect changes in a patient’s clinical presentation in a more timely manner. This programme of work is ongoing and aligns with wider NHS ambitions to improve integration between digital systems and move towards a more cohesive and accessible patient record, supporting safer and more efficient care across organisational boundaries.

Learning from this case has been discussed in a multi-agency forum focused on the management of Mental Health Act assessments, involving SLaM, local authority partners and other agencies. These discussions have specifically considered the role of information sharing in supporting timely and safe decision-making during periods of escalating risk. SLaM has also confirmed its willingness to engage with the LCR working group from July 2026, to contribute to system-wide improvements in the sharing and visibility of clinically relevant information across organisations.

4. Concluding remarks

This case highlights the complexity of information sharing across a multi-organisational healthcare system. Since 2023, there have been important advances in how clinical information is shared across organisations in London, in particular, with the established LCR, which enables secure, near real-time access to information from each organisation’s electronic patient record; in addition, crisis plans are also shared via NRLS. There is now greater emphasis within training on both accessing shared information (which is ‘read-only’ via the LCR) and actively sharing relevant information from within each organisation’s electronic patient record, recognising the need to support care beyond organisational boundaries.

More broadly, care pathways are increasingly structured to distinguish between routine care and crisis situations, with clear routes for escalation through the NHS 111 single point of access. In addition, specialist systems, such as the electronic Mental Health Act (eMHA) platform, support information sharing at later stages of the Mental Health Act process following a decision to detain.

While no single system currently provides a fully integrated, real-time view of all patient information, these developments represent meaningful progress in improving visibility of key information and supporting safer decision-making across organisations. The Trust recognises that safe clinical decision-making depends not only on the availability of information, but also on the ability of clinicians to identify and interpret it, alongside effective communication between services in crisis situations.

SLaM remains committed to working with system partners to further strengthen information sharing, improve consistency and usability of shared records, and support safe, coordinated care across organisational boundaries.

Dear Sir

Re: Inquest into the death of Edward Muwanga - Regulation 28 Prevention of Future Death Response

I write in response to the Regulation 28 Prevention of Future Deaths (PFD) Report issued following the inquest into the death of Edward Muwanga. In advance of responding to the specific concerns raised in your report, I would like to extend my sincere condolences to Mr Muwanga’s family and loved ones. London Ambulance Service NHS Trust (“the LAS”) is keen to assure the family and yourself that the concerns raised have been listened to and reflected upon.

Your report has raised the following concerns:

The integration and accessibility of patient health care records which contain important patient safety information about risks they may present to themselves and others, and more generally contain information that will assist a treating clinician with little or no knowledge of the patient to make properly informed decisions about treatment or risk management Following the conclusion of the above inquest, and in consideration of the LAS evidence previously outlined in detail by way of disclosure of a joint Patient Safety Incident Investigation Report, witness statements and live evidence heard during the course of the Inquest hearing, the Trust will address your concerns below. LAS recognises and accept the Coroner’s concerns raised regarding the accessibility and visibility of critical patient information, and the challenges faced by clinicians in identifying key risk factors in time pressured emergency situations.

Current Position:

At present, the platforms that are available to LAS clinicians to facilitate access to patient information are through a range of systems (Appendix 1), which include the London Care Record (LCR), National Care Records Service (NCRS), National Record Locator (NRL) and Universal Care Plan (UCP). All of these facilitate sharing of information on secure platforms.

These systems provide access to extensive clinical information; however, the Trust recognises that:
• Critical risk information may be embedded within lengthy unstructured documentation.
• Clinical information may be not published consistently across different systems (e.g. the availability of Mental Health Crisis Plans published via the National Record Locator are not accessible via the London Care Record).
• Not all care plans or safety plans are consistently recorded in a format designed for rapid identification.
• Records produced by one organisation may not be immediately visible or prioritised in another organisation’s clinical systems.
• Clinicians unfamiliar with a patient or the originating organisation’s record structure may find it difficult to identify key risk information at the point of care.
• There is currently no nationally mandated approach to sharing of key clinical information, nor how patients can access and modify this information – though there is a national Single Patient Record programme in train which may address certain issues. LAS acknowledges that access alone does not guarantee effective use, and that how information is structured, highlighted, and prioritised is fundamental to patient safety. In consideration of this and the Coroner’s concerns raised within the PFD report, the Trust has recently facilitated meetings with participants from NHS England (London Regional ICB’S), OneLondon and South London & Maudsley NHS Foundation Trust (SLaM) to discuss these findings. These meetings were arranged to ensure that all considerations have been explored in relation to the visibility of pertinent information providing an opportunity for improved awareness of the challenges faced by LAS and partner organisations. It also provided an overall understanding that better integration, the ability to surface key critical information quickly and the developments by future digital improvements are essential to the prevention of future harm. The Trust will continue to work closely with partner organisations to ensure patient safety remains central to future developments.

Actions Taken - Planned and Ongoing Work: LAS recognises that improving integration and accessibility of patient risk information requires a system-wide approach and continued collaboration with partner agencies and key stakeholders in digital platforms. Ongoing and planned activities include: Promotion of Universal Care Plans The Trust has and continues to highlight the clear benefits to our partners in the development of UCP for shared care plans across organisations. Digital Flagging and Visual Prompts Enhancements have been implemented (Appendix 2) within clinical systems to alert clinicians when a shared care plan or key document exists, prompting review at the point of care. This is intended to reduce the likelihood that critical information is overlooked due to time pressures in clinical interactions or where patient data records contain a volume of information. Training and Clinical Guidance Training materials and clinical guidance have been reviewed and updated to reinforce expectations regarding:
• When and how shared care records should be accessed.
• The importance of actively seeking documented care plans and safety information. These updates are embedded within induction, mandatory training, and ongoing clinical communications. Improved System Integration The Trust has invested in improved in-context integration between the electronic patient care records (ePCR) and the LCR platform to reduce access time and streamline navigation between systems. Further developments are underway to improve visibility of NCRS held documents (on the National Record Locator) and alerts by the implementation of a flagging indicator which will highlight that a document exists in the patient’s record and prompt the clinician to access NCRS. From the 12th of May, functionality to improve visibility between internal systems has been enabled (notably, the visibility of information currently only visible within the Computer Aided Dispatch [CAD] system in ePCR), which will assist clinicians to access extra incident information, and support decision-making. This will provide the additional benefit of improved visibility of information which has been received by other providers into our CAD (e.g. from the Metropolitan Police Service (MPS) or NHS 111 services).

LAS Mental Health Team - Actions Taken - Planned and Ongoing Work

Recent updates undertaken have strengthened the emphasis on accessing care records and obtaining collateral information in Mental Health assessments. The ePCR Mental Health Documentation Tool (launched in November 2025) now includes embedded Mental Health assessment guidance prompting crews to review care records, with further enhancements to be proposed through planned and ongoing work.

Alongside this, training within LAS has been expanded significantly to include:

• An updated induction session for frontline staff on Mental Health.
• Conference teaching delivered by the LAS Mental Health Practice Lead.
• A new rolling training programme which covers case-based discussions and reinforces these practices.
• Targeted sessions for different staff groups.
• Accessible resources such as the Crisis Management video series which is available to all frontline staff and covers shared decision making, obtaining collateral information and accessing care.

Improved communication with Mental Health Services A further development which has occurred since the conclusion of the inquest has been the introduction of a single point of access for mental health services. This is a relatively new 24/7 NHS 111 telephone service which is delivered by SLaM, and will support LAS clinicians with access to collateral information and direct clinical advice to inform referrals and onward care. Full regional rollout across South London is planned by the end of summer 2026. This development will improve shared decision making and awareness of 999 interaction, which will assist in obtaining pertinent information for patients related to their mental health, current circumstances and offers the opportunity to discuss potential deterioration.

Electronic Mental Health Act (eMHA) Electronic Mental Health Act (eMHA) information is now available in the London Care Record via the eMHA Thalamos system. The system has been introduced at five of London’s Mental Health Trusts and their partner organisations - East London NHS Foundation Trust, North East London NHS Foundation Trust, Oxleas NHS Foundation Trust, South London and Maudsley NHS Foundation Trust and South West London and St George’s Mental Health NHS Trust. LAS clinicians can see whether a patient is or has been detained under the MHA, including dates and the responsible organisation, with data retained for four years after detention ends.

This will assist to support safer, more informed decision-making at the point of care. If an MHA status is shown, this will likely prompt contact with the detaining organisation for further details.

Key points:
• Shows current or past MHA detention status, dates, and organisation.
• Acts as a prompt to gather further information.
• Improves patient oversight, assisting in coordination and improved patient safety.
• It is recognised that currently not all cases will appear, as not all organisations use the system.
• This is a new development which currently is not available pan-London, and is dependent on Trusts who have engaged with the system. Collaboration with System Partners The Trust continues to work collaboratively with the London regional NHS and Integrated Care Boards, Acute Trusts, Mental Health providers, and national programme teams to promote consistent use of shared care planning tools and improve understanding of how information recorded by one organisation is accessed and used by another.
• LAS is actively involved and participates in the One London board, as the only pan- London NHS provider organisation. Other representation is at an ICB and regional level. Consideration will be given to developing further enhancements to improve interoperability between the LCR and the NRL– notably the consumption of NRL records in the LCR in the first instance, with a longer-term view to also share information from the LCR into the NRL. This will be achieved through influence over the direction of procurement and strategic planning of the OneLondon 2.0 programme and approach to London Care Record, UCP and enhanced access and integration.

• At an operational level, LAS has a touchpoint every other month with the Universal Care Plan team and are part of the UCP Clinical Transformation & Advisory Group. The LAS will be collaborating with the UCP team to develop the next two specific personalised care planning use cases – mental health and catheter care. As part of this learning, consideration for how information may be consistently shared across the correct platforms will be made. In addition, the UCP have received confirmation of funding which will allow them to develop integrations into two key Electronic Patient Records (Rio and Mosaic) to support the sharing of mental health information in the UCP. As previously referred to, strategically and operationally, LAS continued to influence this and the wider OneLondon programme to ensure increasing alignment between LCR and UCP – this is informed by the learning access from Mr Muwanga’s case, but also other cases where access to information would support safer, better care.

• LAS’s paramedic Chief Clinical Information Officer and Deputy are part of the NHS England Single Patient Record Programme Clinical Reference Group. The SPR programme aims to create one unified, secure view of a patient’s health and care information across NHS services in England. This intends to bring together data currently held in multiple systems (e.g. GP, hospital, ambulance, mental health etc.) into a single, joined-up record, and is a core part of the NHS 10-year plan. The initial roll-out will focus on two identified priority areas (maternity and frailty) before looking to further areas. It is intended that the first priorities will go live around 2028.

• Some concerns have been raised with the SPR programme from groups including the British Medical Association and Unions about data security, confidentiality and access. This proposal forms part of wider NHS reforms intended to streamline services and improving patient care and outcomes.

Conclusion: London Ambulance Service NHS Trust recognises the seriousness of the concerns raised, and the importance of ensuring that clinicians have access to the right information, at the right time, in a format that supports safe and effective decision-making. LAS remains fully committed to continued collaboration and engagement with partner organisations to strengthen information sharing, improve usability and contribute to system- wide solutions that support safe informed clinical decision making, and prevent future harm. In addition to this, the LAS recognise that further Single Patient Record developments are likely to change the digital landscape in forthcoming years ahead of our continued commitment to collaboration. I hope this information is of assistance in responding to your Regulation 28 concerns.