Fragmented NHS record access and information sharing
Failures to share patient records and clinical information between NHS providers, including at transfer, discharge, and across organisational boundaries, leading to fragmented care and patient safety risks.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
100match
COVID-M4.4 - Proportionate Access to Linked Healthcare Records
The UK government and devolved administrations should work together, with their respective health delivery services, to facilitate and coordinate regulatory bodies' access to healthcare records in order to make the post-authorisation safety monitoring of new vaccines and therapeutics more efficient. In particular, the Medicines and Healthcare products Regulatory Agency should be granted specific and proportionate access to comprehensive...
Matched on
terms: acces, information, record
Committee recommendation
99match
#8 - Twenty-Second Report - Digital transformation in the NHS
NHS England & NHS Improvement (NHSE&I) increasingly seek to plan and coordinate patient care through partnerships of local health and care organisations, known as sustainability and transformation partnerships (STPs) and integrated care systems (ICSs). This makes sharing data between organisations essential to enable electronic patient records to be seen and updated by clinicians in different organisations such as...
Matched on
terms: information, nhs, record, sharing
Inquiry recommendation
98match
F244 - Common information practices shared data and electronic records
There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to be granted user friendly, real time and retrospective access to read their records, and a facility to enter...
Matched on
terms: acces, information, record
Inquiry recommendation
97match
SP50 - Healthcare trust risk information visibility
The Department of Health and Social Care / NHS England should ensure that all healthcare trusts involved in the care of children and young people who are at risk of acts of violence against others have systems that ensure that: 1. Key information regarding current and historic risk information is readily visible to treating clinicians in a summarised...
Matched on
terms: information, nhs, record
PFD report
93match
Leah Ratheram
Fragmented mental health services for young adults, with separate organizations and incompatible record systems, led to uncoordinated care, poor information sharing, and unclear responsibility during patient transfers in crisis.
Matched on
terms: fragmented, information, record, sharing
Committee recommendation
93match
#18 - Twenty-Second Report - Digital transformation in the NHS
Patient records are fragmented across thousands of local organisations that provide patient care, including 227 NHS trusts and NHS foundation trusts, around 7,000 GP practices and around 18,500 adult social care providers.32 NHSX acknowledged that to deliver its digital strategy, local organisations would need the necessary skills and capacity, as well as guidance from the centre, to be...
Matched on
terms: fragmented, nhs, record
PFD report
89match
Timothy Smedley
Fragmented care resulted from out-of-hours services lacking joint access to NHS records. Additionally, patients with alcohol addiction faced difficulties accessing timely mental health services due to an apparent lack of awareness regarding their complex needs.
Matched on
terms: acces, fragmented, nhs, record
Committee recommendation
89match
#7 - 79th Report - Supporting people with frailty outside hospitals
For all patients diagnosed with severe frailty, the GP contract requires GPs to do a clinical review. This includes a review of the patient’s medication, a falls risk assessment and a discussion with the patient of the benefits of having an enriched summary care record that provides healthcare professionals with access to core details about the patient (medications,...
Matched on
terms: acces, information, nhs, record
Committee recommendation
89match
#42 - Fifth Report: Home Office preparedness for COVID-19 (coronavirus): management of the borders
We are concerned that Ministers do not seem to have access to information about prevalence rates internationally, and there is confusion about what information is held by the Department for Health and Social Care, as well as the interaction between different agencies including Public Health England, NHS Test and Trace and the Joint Biosecurity Centre and SAGE. We...
Matched on
terms: acces, information, nhs
Committee recommendation
89match
#9 - Slow progress on data sharing delays essential substance misuse support for prison leavers.
In 2017 this Committee recommended that HMPPS and NHS England (NHSE) improve information-sharing arrangements between health, prison and probation staff following concerns that healthcare records do not follow patients as they enter or leave prisons.18 The NAO found that HMPPS and NHSE have been slow to improve the collection and sharing of prison leavers’ data, limiting their ability...
Matched on
terms: information, nhs, record, sharing
Inquiry recommendation
86match
12b - Information sharing between providers
We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Matched on
terms: information, sharing
Committee recommendation
86match
#2 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Individuals were not formally eligible for the central support of food boxes and medicines delivery offered through the shielding programme until they were on the Shielded Patients List. NHS Digital used national hospital and GP data to identify clinically vulnerable people. However, it took...
Matched on
terms: acces, information, nhs, record
PFD report
85match
Edward Gascoigne
The report identifies that relevant information about the deceased's illness was in disparate records, making it difficult for clinicians, especially the psychiatric team, to access and share.
Matched on
terms: acces, information, record
PFD report
85match
Christiana Pelle
The report identifies a lack of clear guidance for nurses on when to involve a patient’s GP, the absence of a system for sharing information between the Community District Nursing Team and other agencies, and a lack of a system for communicating concerns with the care provider agency.
Matched on
terms: information, sharing
PFD report
85match
Greg Hutchins
Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.
Matched on
terms: information, record, sharing
Committee recommendation
84match
#13 - 6th Report - Palliative Care
Poor data sharing and lack of integration across NHS, social care, voluntary and private providers creates confusion, delays and gaps in continuity for people at the end of life, frequently placing the burden of coordination care on patients and carers during what is an extremely emotional and challenging period. Despite existing systems for data sharing, inconsistent uptake, poor...
Matched on
terms: information, nhs, sharing
Inquiry recommendation
82match
45 - Local diocesan information sharing protocols
The Church of England, the Church in Wales and statutory partners should ensure that information-sharing protocols are in place at a local level between dioceses and statutory partners.
Matched on
terms: information, sharing
Inquiry recommendation
82match
44 - Church of England/Wales information sharing protocol
The Church of England and the Church in Wales should agree and implement a formal information-sharing protocol. This should include the sharing of information about clergy who move between the two Churches.
Matched on
terms: information, sharing
PFD report
81match
John Griffiths
The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.
Matched on
terms: acces, record
PFD report
81match
Adrian Jennings
Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.
Matched on
terms: information, sharing
PFD report
81match
Jacob Sulaiman
Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.
Matched on
terms: information, sharing
Committee recommendation
81match
#4 - Twenty-Second Report - Digital transformation in the NHS
To deliver the digital Vision, NHS organisations’ IT systems must be interoperable. Many of the standards required to enable this are not yet in place, and much work is required before benefits, such as digital-image sharing, can be realised. NHSE&I increasingly seeks to plan and coordinate patient care through local partnerships of health and care organisations, making data...
Matched on
terms: nhs, sharing
Committee recommendation
80match
#12 - Fifty-Third Report - Covid 19: supporting the vulnerable during lockdown
DHSC acknowledged that there are advantages with NHS data systems—such as having large amounts of data—and disadvantages, for example challenges in connecting and using legacy systems.24 We asked NHS Digital what would help to identify patients earlier. NHS Digital told us this would require a technical solution, faster access to GP data would help, while ensuring that the...
Matched on
terms: acces, information, nhs, record
Inquiry recommendation
80match
IHRD-27 - Electronic Patient Information Systems
Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
Matched on
terms: acces, information, record
Committee recommendation
80match
#2 - Thirteenth Report - Initial lessons from the government’s response to the COVID-19 pandemic
Government’s ability to make well-informed decisions and address issues as they arise during the pandemic has been hampered by slow progress in addressing longstanding issues with data and legacy IT. We have repeatedly highlighted longstanding data issues within government, including the lack of data standards, ageing IT systems, fragmented leadership, and a culture that does not support sharing...
Matched on
terms: acces, fragmented, information, nhs
PFD report
77match
Joanne Manning
A severe communication breakdown between GP and psychiatrist led to unsafe methadone prescribing without full patient information, compounded by the absence of a clear inter-agency information-sharing policy.
Matched on
terms: information, sharing
PFD report
77match
Simon McAndrew
Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack of effective care coordination.
Matched on
terms: information, nhs
PFD report
77match
Peter Franklin
Confusion in terminology and lack of information sharing between health teams and the CRISIS team hindered effective care. Significant delays in documentation meant the GP was unaware of crucial hospital admissions and mental health involvement.
Matched on
terms: information, sharing
PFD report
77match
Antony Briggs
Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.
Matched on
terms: acces, information
PFD report
77match
Stephen Leven
The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.
Matched on
terms: acces, information
Committee recommendation
77match
#35 - Second Report - Long-term funding of adult social care
Barriers to data-sharing between health and social care have been a long-standing challenge, so we particularly welcome the Government’s ambition to have shared care records for all citizens by 2024. It is vital that this ambition becomes a reality. 80 Long-term funding of adult social care The Government should set up pilot schemes for shared care records, co-produced...
Matched on
terms: record, sharing
Committee recommendation
77match
#21 - Require Government to detail progress on Pharmacy First digital product rollout and interoperability.
When responding to this report, we ask that the Government sets out what progress has been made on rolling out the full digital product for the documentation of Pharmacy First consultations, including the percentage of community pharmacies that have fully functioning and interoperable read/write access to patient records.
Matched on
terms: acces, record
Inquiry recommendation
77match
F120 - Learning and information from complaints
Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board to undertake the support and oversight role of GPs in this area, and be given the resources to...
Matched on
terms: acces, information, nhs
Committee recommendation
76match
#15 - 1st Report - An analysis of the asylum system
Departments rely on accurate and timely data to understand how people move through the asylum system, but significant gaps remain in the information held across different parts of the process. The NAO found that a reliable, single record is not yet available for each asylum seeker, and that data needed to track cases effectively is inconsistent or unavailable....
Matched on
terms: information, record, sharing
IMB recommendation
76match
Wakefield (2022)
The ACCT ‘system’ remains wholly paper based. This means that ACCT data produced by staff and IMB members in the form of contemporaneous notes and entries into a prisoner's ACCT file are disaggregated from healthcare data contained in NHS SystmOne and operational data in HMPPS Digital Prison Services (formerly C-NOMIS). This inhibits information sharing between prison officers, governors,...
Matched on
terms: information, nhs, sharing
Committee recommendation
75match
#5 - Third Report - The MoD’s tackling of economic crime and misconduct
The fragmented structure of the Department’s counter-fraud and police teams limits its ability to respond effectively to allegations of fraud and economic crime or to understand how cases are progressing. The Department is a large and complex organisation, and it needs strong 5 working relationships and a coordinated approach to deal with fraud properly. However, responsibility for responding...
Matched on
terms: acces, fragmented, information, record
Committee recommendation
74match
#22 - Mandate Pharmacy First evaluation assesses digital systems' data sharing for patient safety and care.
We recommend that the ongoing evaluation of Pharmacy First includes an assessment of the extent to which pharmacy and general practice digital systems are enabling the necessary data sharing to protect patient safety and ensure continuity of care.
Matched on
terms: sharing
PFD report
73match
Daniel Williams
Key concerns include inadequate staff training in record-keeping and communication, absence of clear guidance for checking for self-harm items, and no central summary sheet for key patient information.
Matched on
terms: information, record
PFD report
73match
Graeme Kidd
Locum doctors lacked access to vital electronic records and awareness of mental health services, while GPs faced referral barriers due to mandatory physical checks. Additionally, patients lacked essential medication advice in the prescribing doctor's absence.
Matched on
terms: acces, record
PFD report
73match
Anne Whitworth
Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent treatment.
Matched on
terms: acces, record
PFD report
73match
Brian Francis
A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.
Matched on
terms: acces, record
PFD report
73match
Keith Gallimore
Potentially important patient information documented by one service was not accessible to other services within the same Trust, especially out-of-hours, risking future deaths.
Matched on
terms: acces, information
PFD report
73match
Stephen McDermott
Fragmented electronic record systems and poor record usage led to incomplete mental health assessments, missing critical patient history and suicide risk factors across different teams. Staff also lacked adequate training.
Matched on
terms: fragmented, record
PFD report
73match
Percy Jacks
Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Matched on
terms: information
Inquiry recommendation
73match
F35 - Need to share information between regulators
Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work should be done on a template of the sort of information each organisation would find helpful.
Matched on
terms: information, sharing
Committee recommendation
72match
#18 - 1st Report - An analysis of the asylum system
We also heard evidence on how data is shared with local authorities, who require up-to-date information to plan housing and support services. MHCLG told us that local authorities need timely notice when people are due to enter or leave asylum accommodation, particularly where individuals may be at risk of homelessness.38 Information sharing between the Home Office, local authorities,...
Matched on
terms: information, sharing
Committee recommendation
72match
#33 - Second Report - Long-term funding of adult social care
We welcome the Joining up Care for People, Places and Populations White Paper and commend the Government for making the integration of health and social care a policy priority. We particularly welcome the Government’s ambitions around shared outcomes, workforce integration, and ensuring every citizen has a shared care record by 2024. However, we are concerned that inconsistent geographical...
Matched on
terms: nhs, record
Scottish FAI
71match
Leylan Forte
GP practices to increase use of Key Information Summaries on Emergency Care Summaries to improve information sharing with NHS 24 particularly for vulnerable patients
Matched on
terms: information, nhs, sharing
Inquiry recommendation
70match
R13 - Full staff access to care plans
All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
Matched on
terms: acces
PFD report
69match
Denise Parramore
A lack of open, two-way communication and inability to access shared documentation between primary and secondary care meant psychiatric services were unaware of critical medication prescriptions.
Matched on
terms: acces