Adegboye Mukaila

Dear Ms Wood, Re: Regulation 28 Report to Prevent Future Deaths – Adegboye Prince Azeez Mukaila who died on 23rd March 2024. Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 10th June 2026 concerning the death of Adegboye Prince Azeez Mukaila on 23rd March
2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Adegboye’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Adegboye’s care have been listened to and reflected upon. Your Report raised the following concerns:
1. The Trust does not have an electronic record keeping system, meaning referrals to the haematology team rely on a review of a paper referral form. In this case this took over 34 hours to be reviewed and acted upon.
2. Issues in being able to access records held by other organisations as staff at the hospital did not have access to any previous clinical notes from other organisations to confirm Adegboye’s diagnosis.
1. The Trust’s lack of an electronic record keeping system NHS England recognises that limited electronic record keeping systems can contribute to less effective continuity of care, particularly when the patient has a complex medical history. NHS England also recognises that timely access to relevant patient information across organisational boundaries is an important enabler of safe, effective and coordinated care. The ability for authorised healthcare professionals to identify and access clinical information held elsewhere can support clinical decision-making, reduce reliance on manual information gathering processes and improve continuity of care. NHS England Frontline Digitalisation has reviewed the electronic patient record (EPR) position relating to Darent Valley Hospital and Lewisham NHS Trusts.

[Page 2] As part of the Frontline Digitisation (FD) Programme, the Trust has been assessed against the Digital Capability Framework (DCF) and was identified as not currently meeting the Programme’s core Electronic Patient Record (EPR) standards. The Trust is expected to submit a business case in Quarter 3 of 2026/27 to seek funding for a comprehensive EPR, through the Frontline Productivity Programme. The Trust currently utilises Miya, which was deployed in 2019 and is described by the supplier, Alcidion, as a Fast Healthcare Interoperability Resource (FHIR)-based events platform that supports clinical and operational applications, though it is not a full EPR. In addition, the Trust implemented an Electronic Prescribing and Medicines Administration (EPMA) system in 2024. Lewisham and Greenwich NHS Trust has successfully secured funding to replace its existing Oracle Cerner Electronic Patient Record system as part of the FD programme. The Trust is progressing with the implementation of a new EPIC EPR solution and is currently reported to be on track for a planned go-live date of April 2027. The FD Programme aims to support NHS provider organisations in procuring, implementing and optimising EPR systems, whilst promoting improved digital capability and interoperability, including referral management, across health and care settings. EPR systems are generally configured, managed and governed locally by provider organisations in accordance with their contractual arrangements with technology suppliers. Consequently, the extent and functionality of interoperability between systems may vary between organisations, reflecting local technical architectures, operational requirements and information governance arrangements. However, the new EPRs planned for both trusts should address the specific concerns raised in this tragic case. Until a full EPR is in place, where multiple digital and paper systems are used within an organisation, robust governance arrangements, policies and operational procedures should be in place to support appropriate clinical record management, ensure the effective communication of clinical information, and provide clear accountability for the escalation and handover of referrals, and for abnormal or clinically significant results. Responsibility for the management and sharing of information held within electronic records, including information exchanged between systems, rests with individual provider organisations through their established digital, clinical safety and information governance frameworks. Through the Frontline Productivity Programme, and other enabling programmes such as Single Patient Record Programme, NHS England will continue to promote adherence to applicable clinical safety standards and support providers in improving digital maturity and interoperability across the NHS.
2. Issues accessing records held by other organisations

[Page 3] NHS England has established and continues to develop national interoperability capabilities and standards that support the sharing and discovery of health information across care settings. These initiatives are intended to facilitate appropriate access to patient information where participating organisations have implemented compatible systems, technical integration and associated governance arrangements. The National Record Locator (NRL) forms part of this wider strategic approach to improving information sharing across the NHS. The purpose of such capabilities is to assist clinicians in identifying where relevant patient records may be held and to support access to information needed for direct patient care. This is consistent with the wider NHS objective of reducing fragmented information flows between organisations. The National Care Record Service (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 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. We would expect both Trusts 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 the relevant trusts. Further information on NCRS can be found here: https://digital.nhs.uk/services/national-care-records-service. 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. Further information regarding SCR is available here: Summary Care Record - NHS Digital 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 (such as sickle cell disease), 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

[Page 4] included in an SCR, an example SCR is available here: Additional Information in the SCR. Additional Information in the SCR includes the active problems and significant past problems for a patient as recorded by their registered GP practice. 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 to 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. 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. More broadly, NHS England and DHSC 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

[Page 5] The NHS England South East Regional team have advised that the Trust has confirmed that they are investing in a single EPR across the provider, with business cases due for submission in September 2026. We note that you have addressed your Report to Kent and Medway ICB who will be able to provide more detail on this. 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 Adegboye, 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 Ms Wood Regulations 28 Report regarding Adegboye Prince AZEEZ MUKAILA I write in response to the Prevention of Future Death Report dated 10 June 2026, sent pursuant to paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 concerning the death of Adegboye Prince AZEEZ MUKAILA on 23 March 2024. The Coroner raised the following concern: The Trust (Darent Valley Hospital) does not have an electronic medical records system and staff treating the deceased were unable to access his clinical records from other organisations. We are responding on behalf of NHS Kent and Medway Integrated Care Board (ICB) to the concern raised in your Regulation 28 Report about the risk to patients where important clinical information is not easily available to the staff caring for them at Darent Valley Hospital. NHS Kent and Medway ICB recognise the seriousness of the concern raised within the Prevention of Future Deaths Report and extends its sincere condolences to Mr Mukaila’s family. The ICB has worked with the Trust to review the digital and information-sharing aspects of this case and to identify learning and improvements that may help reduce the risk of similar incidents occurring in future. The purpose of the review has been to understand what happened, identify learning, and ensure that actions are taken to support safer care. In doing so, the ICB has been mindful that this response

[Page 2] Letter reference: 2026.07.30 PFD - Adegboye Prince AZEEZ MUKAILA will be read by Mr Mukaila’s family as well as by the Coroner and has sought to explain the digital issues as clearly as possible. Darent Valley Hospital uses electronic systems to support care. These include systems that hold administrative and some clinical information, such as patient details, appointments, attendances, letters and local records of care. The hospital also has access to shared records, including the Kent and Medway Care Record and the Summary Care Record, which can allow clinicians to view information held by other NHS organisations where it is available and appropriate to access. These arrangements are not the same as a fully integrated Electronic Patient Record (EPR). A fully integrated EPR would bring more information together in one place within the hospital, support clearer recording of clinical decisions and tasks, and help different teams see and act on information more consistently. Under the current arrangements, information may be available through more than one system, but it may not always appear automatically in the clinician’s usual workflow. The ICB recognises that this distinction is important. The issue identified should not be understood as meaning that clinicians at Darent Valley Hospital were unable to access any information held outside the Trust. Rather, the review identified limitations in how information and referrals moved between systems and teams, and in how reliably those referrals were visible, received and acted upon. This is the key area of learning from the review. The ICB has therefore considered both the wider digital position, including the Trust’s future EPR ambitions, and the more immediate question of whether existing referral and information-sharing processes are clear, safe and consistently followed. This included reviewing electronic referral processes, shared care records, clinical alerts, user access arrangements and the governance controls in place to support safe care. The review identified three areas where further improvement and assurance are required:
• Electronic referrals must be consistently seen by the right clinical team, accepted, tracked and acted on in a timely way.
• Staff must be clear about what information can be viewed through shared records, including the Kent and Medway Care Record and the Summary Care Record, and when those records should be checked.
• Existing systems must support teams to share information effectively when a patient’s care involves more than one organisation. The principal learning relates to how a referral was made, received and followed up. While broader digital interoperability remains important, the immediate safety issue is to ensure that referrals made through existing electronic processes are visible to the right teams and are acted upon reliably. The analysis undertaken with the Trust has identified learning relating to referral visibility, responsibility for acting on referrals, staff access to relevant information and the consistent use of existing digital processes. This learning will be taken forward through relevant ongoing work, rather than through the commissioning of further reviews specifically in response to this report.

[Page 3] Letter reference: 2026.07.30 PFD - Adegboye Prince AZEEZ MUKAILA These ongoing activities include the ICB’s continued support to Dartford and Gravesham NHS Trust in progressing the procurement of a modern EPR solution, alongside the use of the ICB’s commissioning role to support safer information-sharing, effective use of shared records and appropriate assurance of commissioned services. These activities form part of existing programmes and established governance arrangements. The learning concerning electronic alerts, clinical flags and access to relevant information will similarly inform ongoing digital, clinical and commissioning activity where applicable. This approach enables the lessons from the case to be considered within the wider work already under way. The findings have been shared with the relevant Trust, digital, governance and clinical leads. The ICB will use its established governance and commissioning arrangements to maintain appropriate oversight as the learning is taken forward through relevant ongoing work. The ICB remains committed to learning from this case and to supporting improvements that reduce the risk of similar incidents occurring in future. The analysis completed for this response will inform the ICB’s continuing work with the Trust and its wider responsibilities as commissioner, with appropriate governance in place to support safer care for patients and families.