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.
HSSIB recommendation
100match
Access to critical patient information at the bedside
HSIB recommends that NHS England assesses the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the acute hospital setting can be readily and reliably accessed at a patient’s bedside.
Matched on
terms: acces, information, nhs
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
HSSIB recommendation
94match
Electronic patient record (EPR) systems – thematic review
National bodies responsible for providing digital advice and guidance to NHS organisations can improve patient safety by clarifying consistent definitions for design-related IT terms – such as usability and functionality – and sharing guidance on how to apply design principles to electronic patient record system configuration and optimisation.
Matched on
terms: nhs, record, sharing
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
HSSIB recommendation
93match
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care develops a policy and implements a mechanism to enable appropriate NHS patient information to be shared with independent prescribing organisations. This is to ensure independent prescribing organisations can access verified patient information, with patients’ consent, to inform prescribing decisions.
Matched on
terms: acces, information, nhs
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
HSSIB recommendation
90match
Electronic patient record systems – electronic referrals for ongoing care
EPR systems have been implemented to support the transfer of clinical information as part of a referral; this includes in the management of rejected referrals.
Matched on
terms: information, record
HSSIB recommendation
90match
Surgical care of NHS patients in independent hospitals
HSIB recommends that NHSX expands its work programme addressing the challenges associated with interoperability of information systems used in healthcare to include transfer of information between the NHS and independent sector in support of safe care delivery.
Matched on
terms: information, nhs
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
HSSIB recommendation
89match
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June...
HSIB recommends that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record, and also support alerting functionality.
Matched on
terms: information, nhs, record
HSSIB recommendation
89match
Advanced airway management in patients with a known complex disease
HSSIB recommends that NHS England identifies and implements a system for sharing clinical information about people with a known difficult airway. This is to improve access to this information for healthcare professionals and reduce the risk of a person’s known difficult airway not being recognised.
Matched on
terms: acces, information, nhs, sharing
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
HSSIB recommendation
86match
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that HM Prison and Probation Service ensures that the development of the Digital Prison Services system includes interoperability with healthcare IT systems. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing of staff, patients and other prisoners, is available at the point of...
Matched on
terms: information, 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
HSSIB recommendation
85match
Invasive procedures in patients with sickle cell disease
HSIB recommends that NHS England identifies and implements a system for sharing clinical information about patients with sickle cell disease to improve access to this information for clinicians, and reduce the risk of a patient’s sickle cell disease not being treated consistently.
Matched on
terms: acces, information, nhs, 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
Scottish FAI
84match
Erin Casey and Christina Fiorre Ilia
I recommend the following:- (1) The vast majority of patients with epilepsy, or their parents or carers where appropriate, should be advised of the risk of SUDEP on first diagnosis or if , in the particular circumstances of that patient, there are exceptional circumstances for delaying immediate provision of the information, then within a very short time thereafter....
Matched on
terms: acces, information, nhs, record
HSSIB recommendation
83match
Placement of nasogastric tubes
It may be beneficial if national organisations including the Medicines and Healthcare products Regulatory Agency, NHS Supply Chain and NHS England and NHS Improvement review arrangements for ensuring all medical device related incidents, Yellow Card reports, or other device safety related information, including any involving concerns with pH or X-ray in the context of nasogastric tubes, are shared...
Matched on
terms: information, nhs
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
HSSIB recommendation
81match
Healthcare provision in prisons
HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing...
Matched on
terms: information, nhs
HSSIB recommendation
81match
Covid-19 transmission in hospitals: management of the risk - a prospective safety investigation
It is recommended that NHSX considers how technology can assist in mitigating nosocomial transmission in the ward environment with regard to: the use of digital communication technologies in assisting with the deployment of staff and the dissemination and circulation of key information the increased use and availability of personal computing devices and electronic health record systems.
Matched on
terms: information, nhs, record
CQC action
81match
Worthing Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: acces, information, record
CQC action
81match
St Richard's Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: acces, information, record
CQC action
81match
Royal Sussex County Hospital
The trust must ensure that patient record documents and systems are reviewed to ensure staff have access to patient information that is accessible, accurate and up to date across all electronic or paper-based records.
Matched on
terms: acces, information, record
Scottish FAI
81match
Mark John Andrew Smith
However, on the basis that more information allows for a greater ability to make a good decision, the SPS and THB/NHS should consider whether to make it a mandatory requirement for nursing staff to check medical records (if they are available) for a prisoner at the reception assessment. (2) Mr Gilmartin has suggested that more information should be...
Matched on
terms: information, nhs, record
Scottish FAI
81match
N
a. There should be greater communication and co-operation between NHST and NHS Grampian (“NHSG”) in relation to the care of patients who are resident in the geographical area of one authority and subject to treatment in a facility run by the other. b. NHSG should make greater efforts to co-operate in Significant Clinical Event Analysis (“SCEA”) inquiries in...
Matched on
terms: information, nhs
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