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.
Source spread
Where this theme appears
This theme appears across 14 independent accountability sources, so the source mix matters as much as the headline total.
43 inquiry recs
156 PFD reports
97 committee recs
101 HSSIB recs
19 CQC actions
3 HMICFRS recs
9 PPO recs
48 IMB recs
21 Scottish FAIs
6 Article 2 learning points
1 detention investigation rec
16 PHSO decisions
23 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(43)
R2 — Coroners to send post mortem reports to consultants
Recommendation: We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984 …
Unknown
R93 — Regional service map with vacancies
Recommendation: There needs to be a clear regional view of all services available in the community, especially given the variety of services and providers of services now available. The service map recommended in 2022 must be regularly updated to reflect available …
Response Pending
R24 — Clear records and disclosure policies
Recommendation: Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with learning disabilities and autistic people themselves where possible.
Response Pending
R13 — Full staff access to care plans
Recommendation: All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
Response Pending
45 — Local diocesan information sharing protocols
Recommendation: 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.
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it would develop template information-sharing agreements which may be adapted and used …
Accepted
44 — Church of England/Wales information sharing protocol
Recommendation: 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.
Gov response: On 24 June 2021, the Church of England announced that the updated version of the House of Bishops' handling of Clergy Personal Files policy covers data sharing between the Church of England and the Church …
Accepted
32 — Send internal safeguarding reviews to national body
Recommendation: If religious organisations have undertaken internal reviews or enquiries into individual safeguarding incidents, their findings should be sent to the national review body (set up under the Children and Social Work Act 2017).
Gov response: On 27 June 2019, the Church of England stated that its National Safeguarding Team would liaise with the Child Safeguarding Practice Review Panel to ensure that 'the right cases' are reported to them in accordance …
Accepted
COVID-M4.4 — Proportionate Access to Linked Healthcare Records
Recommendation: 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. …
Gov response: No formal response published by this government.
Unknown
SP50 — Healthcare trust risk information visibility
Recommendation: 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: …
Gov response: The Department of Health and Social Care (DHSC) and NHS England are the lead organisations. Progress and next steps: - The Single Patient Record is currently being designed and scoped. - This is part of …
Accepted
R6 — Sickness records available to occupational health
Recommendation: We recommend that the possibility be reviewed of making available to Occupational Health departments any records of absence through sickness from any institution which an applicant for a nursing post has attended or been employed by (para 5.5.14).
Unknown
SP54 — National guidance on SMART action points
Recommendation: Nationally, the Department of Health and Social Care and NHS England should consider whether nationwide guidance should be issued on the importance of action points from all relevant meetings involving healthcare agencies, discharge plans and management plans after risk assessments …
Gov response: The Department of Health and Social Care (DHSC) and NHS England are the lead organisations and expect to complete the implementation of this recommendation by 31 March 2027. Progress and next steps: - DHSC and …
Accepted
SP53 — GMMH and Alder Hey joint SMART audit
Recommendation: At the local level, Greater Manchester Mental Health NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust should by no later than 13 October 2026 carry out and report on a joint audit to ensure that for cases involving …
Gov response: DHSC has limited powers to direct NHS Foundation Trusts to implement recommendations 51 and 53. The Secretary of State for Health and Social Care has written to Greater Manchester Mental Health NHS Foundation Trust and …
Accepted
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in …
Gov response: No formal response published by this government.
Unknown
LAMI-73 — Require inquiry and review of previous hospital admissions for suspected deliberate harm.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be …
Unknown
12b — Information sharing between providers
Recommendation: We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Gov response: Accepted in principle. Government supports principle of sharing concerns between employers. CQC registration conditions require providers to share relevant information. GMC guidance requires doctors to disclose concerns about their practice. NHS England working with independent …
Accepted in Part
F244 — Common information practices shared data and electronic records
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F120 — Learning and information from complaints
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F36 — Use of information for effective regulation
Recommendation: A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F35 — Need to share information between regulators
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
SP31 — Response officer access to case information technology
Recommendation: 1. Lancashire Constabulary should ensure response officers have access to effective technology providing clear, essential case information. 2. The National Police Chiefs’ Council, College of Policing and Home Office should review whether current policing information systems, particularly the limitations on …
Gov response: The Home Office is the lead department for central government and has completed the recommended review. Progress and next steps: - The Home Office, jointly with the National Police Chiefs' Council and the Association of …
Accepted
IBI-7f(iii) — Blood Tracking Systems Funding
Recommendation: Establishing the outcome of every transfusion: That funding for the provision of enhanced electronic clinical systems in relation to blood transfusion be regarded as a priority across the UK.
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted in Part
IBI-7f(ii) — NHSBT Transfusion Outcome Funding
Recommendation: Establishing the outcome of every transfusion: To the extent that the funding for digital transformation does not already cover the setting up and operation of this framework, bespoke funding should be provided.
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted
IBI-7f(i) — Transfusion Outcome Framework
Recommendation: Establishing the outcome of every transfusion: That a framework be established for recording outcomes for recipients of blood components. That those records be used by NHS bodies to improve transfusion practice (including by providing such information to haemovigilance bodies). Success …
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted
IBI-6a(vi) — Commissioning Hepatology Services
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
IBI-6a(v) — Consultant Hepatologist Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
IBI-6a(iv) — Fibroscan for Liver Imaging
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be used for liver imaging, rather than alternatives
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
IBI-6a(iii) — Uncertainty About Fibrosis
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
IBI-6a(ii) — Specialist Hepatology Centre Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
IBI-6a(i) — Hepatologist Oversight and Fibroscan Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
BRIS-18 — Provide parents of young children with copies of all inter-professional healthcare letters
Recommendation: Parents of those too young to take decisions for themselves should receive a copy of any letter written by one healthcare professional to another about their child’s treatment or care.
Unknown
BRIS-17 — Ensure patients receive copies of all inter-professional letters about their care
Recommendation: Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Unknown
IHRD-47 — Post-Mortem Reporting Standards
Recommendation: In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) Work in liaison with the clinicians involved. (iii) Provide preliminary …
Gov response: Post-mortem reporting standards updated in line with these requirements.
Accepted
IHRD-46 — Clinician Attendance at Post-Mortem Discussions
Recommendation: Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.
Gov response: Guidance issued on clinician attendance at clinico-pathological discussions.
Accepted
IHRD-27 — Electronic Patient Information Systems
Recommendation: Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
Gov response: Electronic care record and digital health programmes progressing across Northern Ireland.
Accepted
IHRD-11 — Patient Transfer Protocol
Recommendation: There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Gov response: Transfer protocols developed and implemented across HSC Trusts.
Accepted
F123 — Responsibility for monitoring delivery of standards and quality
Recommendation: GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
IBI-7b — Transfusion 2024 Review Progress
Recommendation: Review of progress towards the Transfusion 2024 recommendations: Progress in implementation of the Transfusion 2024 recommendations be reviewed, and next steps be determined and promulgated; and that in Scotland the 5 year plan is reviewed in or before 2027 with …
Gov response: UK Government Progress against Transfusion 2024 recommendations has been initially reviewed jointly by NHS England and NHSBT and a wider four nations stakeholder review is being scheduled. The draft report was discussed with key stakeholders …
Accepted
IBI-7a(iii) — Transfusion Performance Benchmarking
Recommendation: Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management
Gov response: In relation to the recommendation on standardising and benchmarking, a review of current benchmarking practices and associated data collection and ongoing intelligence and analysis requirements, including model health dashboard and national clinical audit, has been …
Accepted
IBI-4c(ii) — Safety Management Systems Coordination
Recommendation: Regulation: That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation of safety management systems (“SMS”s) through SMS coordination groups (as recommended by the HSSIB), and do so as …
Gov response: UK Government In relation to Recommendation 4c) ii., DHSC agrees that it is important to explore approaches for enhancing the safety of services. In 2023, NHS England established an SMS coordination group with partners from …
Accepted
IBI-4c(i) — Simplify External Regulation
Recommendation: Regulation: That external regulation of safety in healthcare be simplified. As a first step towards this, there should be a UK wide review by the four health departments of the systems of external regulation, with the aim of addressing all …
Gov response: UK Government In relation to recommendation 4c) i. the Secretary of State for Health and Social Care asked Dr Penny Dash to conduct a review of patient safety in the health and care landscape. The …
Accepted
BRIS-19 — Require effective communication among healthcare professionals to avoid conflicting patient advice
Recommendation: Healthcare professionals responsible for the care of any particular patient must communicate effectively with each other. The aim must be to avoid giving the patient conflicting advice and information.
Unknown
1 — Single consultant data repository
Recommendation: We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data – for example, how many times a consultant has performed a particular …
Gov response: Accepted in principle. The government is improving data flows to CQC and GMC to give them better oversight of consultants' full scope of practice. NHS England is developing a workforce repository and working with partner …
Accepted in Part
AC-2b — Share Clinical Assessor Advice
Recommendation: In respect of any case in which the advice of a clinical assessor has been given, in relation to the person concerned (and no more widely except with the consent of that person): that person should be told the factual …
Gov response: The remaining 11 recommendations focus on IBCA delivery. Further detail on these will be set out by IBCA in due course.
Accepted
Prevention of Future Deaths reports(156)— showing 50 strongest matches
Felix Cembrowicz
Concerns: The electronic patient record system failed to migrate complete histories for discharged mental health patients, leaving current staff unaware of crucial past contact and relapse management plans.
Response (Avon and Wiltshire NHS Trust): Avon and Wiltshire NHS Trust will establish if re-referred patients have historic relapse management plans and an additional check should be undertaken in the RiO clinical records/documents to establish if …
Responded
Joanne Manning
Concerns: 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.
Overdue
Keith Fleming
Concerns: The provided text indicates that matters of concern were revealed but does not detail what these specific concerns are.
Overdue
Chloe Grace Flavell
Concerns: The reception area management, prior to triage, creates significant and dangerous delays in providing immediate care and treatment, particularly for children.
Overdue
Daniel Williams
Concerns: 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.
Response: The Trust has implemented a patient record development programme which provides alerts to staff, states a patient centred approach, and has rolled out training for staff and improved patient handovers. …
Responded
James Withers
Concerns: Key concerns include significant delays in specialist consultation, missing medical notes, and poor communication with family regarding the Do Not Attempt Resuscitation (DNAR) status. A doctor also assumed an incorrect DNAR.
Overdue
Andrew John Fallon
Concerns: Emergency Department staffing levels were critically insufficient, causing excessive delays for seriously ill patients as staff were overwhelmed by patient volume, including minor complaints.
Overdue
Grace Mary Bates
Concerns: The hospital lacked a specialist diabetic nurse available over the weekend, posing a risk to patients requiring specific care.
Response: A business case for the appointment of a minimum of one WTE IPDSN to complement the current diabetes team, to provide improved cover for the Hospital across the calendar week …
Response: The Secretary of State for Health acknowledges the coroner's concerns regarding diabetes management at Barnet Hospital and refers to existing NICE quality standards and NHS England initiatives for improving patient …
Responded
Simon McAndrew
Concerns: 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.
Overdue
Matthew Simmonds
Concerns: An effective local action plan for commissioning complex care pathways for ventilated patient discharges is not shared nationally, posing a risk that other Clinical Commissioning Groups may not adopt it.
Overdue
Audrey Kelly
Concerns: The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic notes, describing this as a serious lapse in procedures that could lead to future loss of life.
Response (Department of Health2): Stockport CCG is seeking formal assurance from Mastercall regarding processes for new starters and contingency plans when practitioners lack smartcards. They will also work with Mastercall to map and analyze …
Response (Department of Health): Stockport CCG are investigating the attempted access to the patient's record at the time of the incident and are working with suppliers to understand the root cause and whether it …
Responded
Janet Blackman
Concerns: Psychiatric units fail to provide essential physical health care, including DVT prophylaxis, indicating a need for seamless, integrated care delivery for both physical and mental health.
Overdue
Stephen Widman
Concerns: The provided text does not detail any specific concerns.
Overdue
Mary Wanya
Concerns: Significant delays in urgent psychiatric assessments, an inadequate system for mentally ill patients in medical units, and a flawed investigation report by unqualified staff raise serious safety concerns.
Overdue
Peter Franklin
Concerns: 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.
Response (Kent Medway NHS Trust): Kent and Medway NHS Trust has developed a joint action plan with Maidstone and Tunbridge Wells NHS Trust, extending Liaison Psychiatry service hours, introducing a recovery card for patients on …
Response (Tunbridge Wells Hospital): Tunbridge Wells Hospital is implementing a SMART tool, working towards electronic discharge summaries by October 2014, holding frequent attenders' meetings, and adding a 3-hour Mental Capacity Act session to the …
Responded
Denise Parramore
Concerns: 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.
Overdue
Graeme Kidd
Concerns: 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.
Overdue
Anne Whitworth
Concerns: Incompatible computer systems prevented out-of-hours doctors from accessing GP records, leading to a missed opportunity to escalate urgent treatment.
Overdue
John Shelley
Concerns: The inquest revealed unstated circumstances that pose a continued risk of future deaths if action is not taken.
Response: Since the event, all staff in the residential units have been trained in Basic Life Support. The University Health Board is evaluating options for training healthcare support staff in managing …
Responded
William Jackson
Concerns: The hospital lacked a formal system to record specialist advice given during informal interactions, leading to critical advice being given without reviewing patient images, which risks lives.
Response (Newcastle upon Tyne Hospital NHS Trust): An electronic system is now in place within Cardiothoracic Surgery to record details of advice given when medical opinion is sought by a healthcare professional in another hospital.
Responded
Shannon Gee
Concerns: Delays in mental health treatment occurred due to unaddressed gaps between organisational treatment thresholds and difficulties transferring medical notes, raising concerns about seamless patient care.
Overdue
Brian Francis
Concerns: 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.
Response: The Health Board provided an action plan prior to the inquest and has updated it in response to concerns. Actions include enhanced senior clinician review of emergency medical patients, reinforced …
Overdue
Keith Gallimore
Concerns: 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.
Response (Camden and Islington NHS Trust): IAPTUS training will be provided to a small number of front-line staff in the Acute Division to enable routine checks on all new patients against the IAPTUS system, expected to …
Responded
Olive Darbyshire
Concerns: An urgent CTPA procedure was delayed and miscategorised, exacerbated by a lack of follow-up from the clinical team, radiology department errors, and potential impact of reduced Christmas staffing levels.
Response (Olive Darbyshire): Blackpool Teaching Hospitals NHS Foundation Trust has held meetings and created a Standard Operating Procedure (SOP) to improve the recording, tracing, and follow-up of diagnostic requests, ensuring all changes are …
Responded
John Lloyd
Concerns: Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.
Overdue
Jean Hannon
Concerns: A critical diagnosis (autonomic dysreflexia) was not sufficiently highlighted in medical records, leading to a consultant's unawareness during a later admission and potentially inappropriate management.
Response (East Lancashire Hospitals NHS Trust): The Trust now uses 'EMIS web' to include a printed summary of the patient's GP record for urgent and emergency admissions (since April 2015). A consultant geriatrician is also piloting …
Responded
Edward Gascoigne
Concerns: 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.
Response (Response ny Department of Health): The Department of Health describes the Summary Care Record (SCR) system and planned enhancements, stating that it is designed to improve access to patients’ GP records.
Responded
Thomas Collins
Concerns: The attending paramedic lacked confidence in making a clinical decision and inappropriately deferred to an out-of-hours service, indicating a potential training or support gap.
Response (North West Ambulance Service NHS Trust): The North West Ambulance Service describes its existing 'Paramedic Pathfinder' algorithm and referral process to Acute Visiting Services, asserting it is a considered and auditable system.
Response (Haughton Thornley Medical Centres): The practice will ensure that when accidents happen with Thomas and Amy Senior and Tony Swales, they will obtain more information surrounding the circumstances of the fall and will clearly …
Responded
Antony Briggs
Concerns: 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.
Response (A Briggs): The Trust will strengthen communication between secretarial teams at Stepping Hill and Buxton to ensure radiology reports are available at both sites simultaneously. They will develop a standard operating procedure …
Responded
Norma Holden
Concerns: The inquest identified matters of concern presenting a risk of future deaths if not addressed, requiring action by the relevant authorities.
Overdue
Anthony Fraser
Concerns: Summary medical information was not conveyed to the receiving A&E department upon transfer, and there is no system for ensuring such information is sent; a system needs to be implemented to convey such information for every inmate transferred with an acute illness.
Response (Nottinghamshire Healthcare NHS Trust): Following concerns raised, the Trust co-authored a procedure with HMP Lindholme to convey summary medical information to A&E departments during inmate transfers, and the procedure has been issued to staff …
Responded
Anielka Jennings
Concerns: No lead professional was identified for a child transitioning to adult services with multiple agency involvement, leading to a breakdown in communication and continuity of care.
Overdue
Stephen McDermott
Concerns: 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.
Overdue
Leah Ratheram
Concerns: 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.
Overdue
Christiana Pelle
Concerns: 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.
Overdue
David Birtwistle
Concerns: A patient diverted from A&E meant crucial tests for pulmonary embolism were missed, compounded by unavailable 111 referral information at the emergency department.
Overdue
Constance Connolly
Concerns: The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Response (The Royal College of Emergency Medicine): The Royal College of Emergency Medicine has issued guidance to Fellows and Members regarding follow-up of test results in two documents, and is preparing a safety alert reminding them to …
Response (King's College Hospital NHS Foundation Trust): King's College Hospital NHS Foundation Trust is setting up a "virtual review" of self-discharged patients to ensure any investigations or follow-ups can be appropriately actioned.
Responded
Stephen Leven
Concerns: The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.
Response (Stephen Leven): The response outlines the Summary Care Record (SCR) system and NHS England's plans to mandate SCR access for 111, 999 services, and hospital acute admission areas by March 2016, including …
Responded
Sam Crick
Concerns: Missed neuroradiological findings and a critical report's unavailability to the neurosurgeon led to undetected brain herniation and rising intracranial pressure. The absence of a Serious Incident Report further hindered learning from this preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): The Trust will review externally reported deaths weekly as part of a Morbidity and Mortality session to identify lessons and feedback to referring hospitals, as part of the ongoing SIR …
Response (CQC): The CQC has requested written confirmation and evidence from Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) regarding actions taken following the death and any additional actions they intend …
Response (NHS England): NHS England will work with the Society of British Neurological Surgeons (SBNS) and the Royal College of Emergency Medicine to produce and distribute a guidance statement nationally within the next …
Responded
John Griffiths
Concerns: 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.
Response (UHSM): UHSM acknowledges concerns regarding checking for recent patient presentations in the emergency department. They state the ED system alerts clinicians to previous attendances and that the Electronic Patient Record System …
Overdue
Frances Greenhalgh
Concerns: A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical records and computer system, leading to a lack of awareness and follow-up.
Overdue
Percy Jacks
Concerns: Communication breakdowns between hospital, GP, and care homes, including incorrect information transfer and inadequate medication review systems, led to poor DVT management.
Response (Welsh Government): Healthcare Inspectorate Wales (HIW) has noted the inquest findings and will use the information to inform their ongoing review of discharge arrangements, focusing on communication and documentation between secondary and …
Response (Rhayader Group Practic): Rhayader Group Practice has implemented a system to record and follow up DVT referrals, inform patients with positive DVT results and prescribe Rivaroxiban, and fast-track medical records for new patients …
Response: Hywel Dda Health Board has streamlined the process for managing potential DVT patients with a direct referral pathway to the Radiology Department, a pre-printed letter from on-call physicians to the …
Response (CQC): CQC had no prior knowledge of the death. They contacted Pencombe Hall care home and Cantilupe Surgery in Herefordshire, reviewed information transfer procedures, and consider their current inspection methodology covers …
Responded
Timothy Smedley
Concerns: 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.
Response (Department of Health): The Department of Health acknowledges the concerns regarding access to NHS records and services for individuals with co-occurring mental health and substance misuse conditions. They reference existing guidance and reviews …
Responded
Paul Mullen
Concerns: The "red flag system" for reporting uncollected methadone prescriptions is ineffective; reports don't reach key workers directly, delaying intervention. Lack of shared systems between partner organisations further hinders communication.
Response: This response is not classifiable as it consists of nonsensical characters and cannot be understood.
Overdue
Peter Stojilkovic
Concerns: Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online sources.
Response (NHS England): The Medical Director will review the case with the practice to identify any further learning and will discuss the provision of medication at discharge with Pennine Care to identify any …
Overdue
Adrian Jennings
Concerns: 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.
Response (Tameside Glossop CCG): Tameside and Glossop CCG acknowledges the need to expand mental health support and is investing in additional services, but does not recognize a gap in provision for individuals with high …
Response (Department of Health): The Department of Health acknowledges the concerns raised and refers to national policy expectations and guidance, including the Mental Health Act 1983 Code of Practice and the Global Digital Exemplar …
Response (NHS England): NHS England notes the concerns and describes actions taken to address disparate IT systems (Global Digital Exemplar programme), joined-up discharge plans (national framework), and capturing when police bring in individuals …
Responded
Greg Hutchins
Concerns: 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.
Overdue
Grahame Searby
Concerns: The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
Overdue
Robert Power
Concerns: A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.
Response (North Bristol NHS Trust): The Trust acknowledges receipt of the coroner's letter and confirms that the Trust now works under different systems than in 2008 with processes to arrange follow-up appointments; they have no …
Responded
Jacob Sulaiman
Concerns: Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.
Response (London Borough of Camden): The London Borough of Camden is migrating records to a new IT system for Careline, to be in place by the end of 2018, including a checklist for referring to …
Responded
Select committee recommendations(97)— showing 50 strongest matches
#7 —
Recommendation: 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 …
Gov response: The government agrees with the Committee’s recommendation. Framework Delivery Plan’s progress by the end of the current Spending Review period in 2025. Treasury Minutes Archive1 Treasury Minutes are the government’s response to reports from the …
Response Pending
#31 —
Recommendation: The government should commit to wherever possible using UK-owned and UK-based suppliers to develop and implement the NHS Single Patient Record, and to awarding all associated contracts via open and transparent procurement processes. (Recommendation, Paragraph 97)
Response Pending
#42 —
Recommendation: 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 …
Gov response: Replied together with 44. We note that the COVID-19 Operations committee appears to be taking the decisions on border policy and we welcome a cross-Government process to coordinate different departments and ensure that decisions are …
Not Addressed
#35 —
Recommendation: 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 …
Gov response: We welcome the committee’s interest in the government’s ambition to have shared care records for all citizens. The Digital Health and Care Plan, published in June 2022, sets out our expectation that by April 2025, …
Position Not Stated
#14 —
Recommendation: If the Government intends for the introduction of the Single Patient Record to address concerns about a lack of service integration for palliative and end of life care, then this record must be available to all providers—including social care, the …
Gov response: Accept Integrated palliative care and end-of-life care services are central to the shift towards community-based care. They enable care to be delivered closer to people’s homes. NHS England’s statutory guidance for palliative care and end-of-life …
Position Not Stated
#22 — Mandate Pharmacy First evaluation assesses digital systems' data sharing for patient safety and care.
Recommendation: 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.
Gov response: Accept NHS England is committed to ongoing monitoring of all services, including Pharmacy First to understand ways we can improve access and support provided. For Pharmacy First, this includes oversight of medicine supply, claims systems …
Accepted
#21 — Require Government to detail progress on Pharmacy First digital product rollout and interoperability.
Recommendation: 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 …
Gov response: The full suite of digital capabilities for Pharmacy First is designed to make it easier for frontline staff to refer, consult, record outcomes, and report. NHS England policy is not to enable community pharmacies to …
Accepted
#14 —
Recommendation: The Home Office and the police should be added to the list of public bodies subject to the statutory ‘duty to refer’ and included in the forthcoming proposals for a ‘duty to collaborate’. (Recommendation, Paragraph 75)
Response Pending
#25 —
Recommendation: We raised concerns that local authorities often do not receive early notice of accommodation decisions. We referred to previous examples, including Northeye and the Bibby Stockholm, where local authorities had not been consulted early enough.61 The Home Office told us …
Response Pending
#20 —
Recommendation: Planning across the asylum system has had to respond to shifting pressures at different stages of the process, and departments’ ability to model demand and plan ahead has been limited by the absence of shared data and a single, end-to-end …
Response Pending
#18 —
Recommendation: 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 …
Response Pending
#17 —
Recommendation: Officials from both departments described ongoing challenges joining up information across systems. The MoJ explained that achieving fuller interoperability “needs money and a focused effort,” and that enabling systems to “talk to each other and share data” is difficult given …
Response Pending
#15 —
Recommendation: 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 …
Response Pending
#30 —
Recommendation: In its response to this report the government should confirm the exact nature of Palantir’s access to identifiable and non-identifiable patient data, on what statutory basis this was authorised, when, and by whom; and whether the Information Commissioner was consulted. …
Response Pending
#8 —
Recommendation: 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 …
Gov response: 22 Digital Transformation in the NHS Department of Health and Social Care and NHSX
Not Addressed
#22 —
Recommendation: The Government must share all the available data with local areas in as much detail as possible, ideally to patient level. Data which will be key to decision making on the road map should be shared immediately, and ahead of …
Gov response: The Secretary of State for Health and Social Care wrote to the Committee on 24 March 2021, setting out the Government’s response to this recommendation.
Position Not Stated
#20 —
Recommendation: Vital information which might have helped local leaders to respond quickly to outbreaks simply did not move quickly enough through the system. Central Government was initially unwilling to share granular data on the spread of the virus, systems were fragmented, …
Gov response: The Secretary of State for Health and Social Care wrote to the Committee on 24 March 2021, setting out the Government’s response to this recommendation. As a result of the Government’s actions and those taken …
Response Not Attributed
#12 —
Recommendation: 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 …
Gov response: 2.3 Work is already underway on this. NHS Digital has developed a strategic national GP dataset alongside the profession. This will allow faster access to GP information that will be more regularly updated and more …
Accepted
#10 —
Recommendation: NHS Digital created the first iteration of the list of some 900,000 people within two days using readily accessible data sources—hospital, maternity and prescribed medicines data. By 12 April 2020, three weeks after shielding began, a further 420,000 people had …
Gov response: 2.2 Whilst the government agrees with the Committee’s recommendation, it does not agree with the conclusion that DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Given the data available …
Not Addressed
#5 —
Recommendation: We further recommend that the CQC rating includes progress ICSs make on the integration of information technology between primary care, secondary care and the social care sector.
No Published Response
#5 —
Recommendation: Protocols to share data between public bodies involved in the response were too slow to establish and to become functional. This was especially true in the data flows from national to local government.
Gov response: The government partially accepts this recommendation. The government recognises the importance of establishing arrangements that allow immediate flows of data between relevant bodies with a mechanism to resolve any disputes swiftly and decisively. The government …
Partially Accepted
#62 —
Recommendation: Protocols to share data between public bodies involved in the response were too slow to establish and to become functional. This was especially true in the data flows from national to local government.
Gov response: The government partially accepts this recommendation. The government agrees that there is positive learning and engagement to be had with other countries, practitioners, and disciplines, as it has done since the start of the pandemic …
Under Consideration
#5 —
Recommendation: Protocols to share data between public bodies involved in the response were too slow to establish and to become functional. This was especially true in the data flows from national to local government.
Gov response: The government accepts this recommendation.
Under Consideration
#62 —
Recommendation: Protocols to share data between public bodies involved in the response were too slow to establish and to become functional. This was especially true in the data flows from national to local government.
Gov response: Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.
Accepted
#23 —
Recommendation: We also heard that the DVLA’s decisions often require information from GPs and other medical professionals, which is requested and returned using paper documentation. 40 Q 47; Letter from DVLA to PAC dated 8 December; Driver & Vehicle Licensing Agency, …
Gov response: 5.4 The government disagrees with the Committee’s recommendation. 5.5 The department is currently unable to agree to this recommendation as Ministers will need to decide whether and how any strategic review or alternative action is …
Not Addressed
#13 —
Recommendation: 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 …
Gov response: Accept Integrated palliative care and end-of-life care services are central to the shift towards community-based care. They enable care to be delivered closer to people’s homes. NHS England’s statutory guidance for palliative care and end-of-life …
Response Not Attributed
#10 —
Recommendation: Out of area placements can remove vulnerable people from their support networks at a time when they most need them and have a devastating impact on people’s healthcare and education. Reports of the disproportionate use of these placements for Black …
Response Pending
#14 —
Recommendation: In response to this report DWP should clearly outline indicative delivery and rollout arrangements for WorkWell. This should include referral readiness and the point at which full delivery is expected in each Integrated Care Board (ICB), as well as how …
Response Pending
#13 —
Recommendation: We support the national rollout of WorkWell. By strengthening coordination between health and employment services, WorkWell has the potential to support clearer pathways between programmes, including Connect to Work, and to contribute to wider system change. Effective arrangements for information …
Response Pending
#6 —
Recommendation: We found evidence of misaligned expectations which contributed to the decision to discontinue the case. In particular, the Deputy National Security Adviser (DNSA) said he was clear from the outset that he would only provide evidence in line with Government …
Gov response: The Government welcomes the Committee’s conclusion that the witness statements provided by the Deputy National Security Adviser (DNSA) were clear that China posed a range of threats to the United Kingdom’s national security. The Committee …
Not Addressed
#29 —
Recommendation: The government should commit to exercising the February 2027 break clause in the Federated Data Platform contract and either develop an in-house replacement or seek an alternative developed by UK-owned and UK-based providers that are more compatible with UK values, …
Response Pending
#18 —
Recommendation: 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, …
Gov response: 7.1 The government agrees with the Committee’s recommendation. Target implementation date: Spring 2021 7.2 DHSC and NHSX fully recognise the critical importance of ensuring the right digital skills, capacity and capabilities are in place across …
Accepted
#4 —
Recommendation: 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 …
Gov response: 2021. The department will use the annual update to keep the Committee informed of the success of the Fund with evidence from the monitoring and evaluation process.
Under Consideration
#30 —
Recommendation: Lockdown decisions have been met with confusion because the data has been unclear. Data was not initially available for local leaders to understand the tiering decisions and there were no adequate frameworks for escalation and de-escalation in place. While this …
Gov response: The Secretary of State for Health and Social Care wrote to the Committee on 24 March 2021, setting out the Government’s response to this recommendation. As a result of the Government’s actions and those taken …
Response Not Attributed
#23 —
Recommendation: The Department of Health and Social Care, with support from UKSA, should undertake an urgent review of health data systems in England. The review should include consideration of the role of the Department of Health and Social Care in bringing …
Gov response: We agree that cross-organisational working is more important than ever given the large number of organisations across health and social care and the nature and impact of COVID-19. As a result of the Government’s actions …
Position Not Stated
#21 —
Recommendation: In May 2020, this Committee heard that local data would be key to the response, enabling local leaders to move quickly, stem small outbreaks and potentially 50 Government transparency and accountability during Covid 19: The data underpinning decisions stop a …
Gov response: The Secretary of State for Health and Social Care wrote to the Committee on 24 March 2021, setting out the Government’s response to this recommendation. As a result of the Government’s actions and those taken …
Response Not Attributed
#19 —
Recommendation: The message from the evidence received to this inquiry is frustratingly clear. The Government knew the response would need to be localised and there were local systems in place to manage infectious diseases already (including statutory duties on Public Health …
Gov response: The Secretary of State for Health and Social Care wrote to the Committee on 24 March 2021, setting out the Government’s response to this recommendation. As a result of the Government’s actions and those taken …
Response Not Attributed
#9 —
Recommendation: The list of medical conditions that the chief medical officers developed to define clinically extremely vulnerable people was shared with NHS Digital on 18 March 2020. DHSC tasked NHS Digital to use patient data to identify those affected and create …
Gov response: 2.2 Whilst the government agrees with the Committee’s recommendation, it does not agree with the conclusion that DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Given the data available …
Accepted
#2 —
Recommendation: 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 …
Gov response: agree with the conclusion that DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Given the data available at the time, and the novelty of shielding policy, NHS Digital, DHSC, …
Under Consideration
#4 —
Recommendation: We recommend that NHS England reviews the way in which it collates data about concussion and concussion-related brain injury and ensures that doctors have a full history available to better inform patient treatments.
Gov response: The Government agrees in part with this recommendation. NHSX will continue to work with NHS England, NHS Improvement and NHS Digital to improve data quality and reporting by recommending the creation of codes for concussion …
Partially Accepted
#2 —
Recommendation: 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 …
Gov response: 2: PAC conclusion: 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. 2a: PAC …
Accepted
#11 —
Recommendation: Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.
Gov response: The government accepts this recommendation. The government recognises the importance of immediate flows of data between bodies relevant to an emergency response and is committed to ensuring that information is shared quickly and effectively. The …
Accepted
#188 —
Recommendation: Despite this, it appeared that there was a disconnect between the testing operation in the Lighthouse Laboratories and NHS labs. For example, the Institute of Biomedical Science suggested that there was a “lack of integration and collaboration” between the laboratories …
Gov response: The government accepts this recommendation. The government agrees that it is important to proactively collaborate with other organisations, to study and emulate international best practice with urgency and agility, and that a culture that does …
Response Not Attributed
#11 —
Recommendation: Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.
Gov response: The government accepts this recommendation. The government recognises the importance of data sharing across relevant bodies. Existing legislation, such as the Civil Contingencies Act 2004, provides a framework for emergency preparedness and response, including duties …
Accepted
#188 —
Recommendation: Despite this, it appeared that there was a disconnect between the testing operation in the Lighthouse Laboratories and NHS labs. For example, the Institute of Biomedical Science suggested that there was a “lack of integration and collaboration” between the laboratories …
Response Not Attributed
#18 —
Recommendation: Many savers have multiple pension pots with different providers and schemes. At the moment, it is not possible for providers and regulators to aggregate data on individual savers, rather than individual pension pots. This makes it more difficult to ensure …
Gov response: We will consider this recommendation in more detail. DWP is part funding, and sits on the steering group of, a Pensions Policy Institute DC data project to provide individual-level data of pension provision across a …
Under Consideration
#33 —
Recommendation: 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, …
Gov response: Whilst strategic, at-scale planning and commissioning is at integrated care system (ICS) level, the government recognises much of the activity to integrate care should be driven by collaboration between commissioners and providers over smaller geographic …
Position Not Stated
#15 —
Recommendation: The Department acknowledged that while an IT system that allows information to be shared between provider employment advisors and Department work coaches would be “perfect” and is something it would think about for future programmes, it also told us that …
Gov response: 3. PAC conclusion: The Department and providers are not working together and sharing information as effectively as they might to support participants into work. 3a. PAC recommendation: The Department should ensure work coaches and Restart …
Accepted
#9 — Slow progress on data sharing delays essential substance misuse support for prison leavers.
Recommendation: 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 …
Not Addressed
#5 —
Recommendation: 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 …
Response Pending
HSSIB safety recommendations(101)— showing 50 strongest matches
Mental health: attempted suicide while under the care of community services
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area of Improvement
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 …
Safety Observation
Electronic patient record (EPR) systems – thematic review
How does your organisation share learning from the implementation and ongoing optimisation of EPR systems to support other organisations?
Learning Prompt
Electronic patient record (EPR) systems – thematic review
How does your organisation identify whether an EPR system meets relevant standards, such as those that support clinical risk management and interoperability?
Learning Prompt
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 …
Safety Recommendation
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, …
Safety Recommendation
Healthcare provision in prisons: continuity of care
Prison healthcare departments and operational staff in prisons can improve patient safety by working together to develop internal policies in relation to clinical holds, to include a requirement for communication with any receiving healthcare team about a patient’s health needs. …
Safety Observation
Healthcare provision in prisons: continuity of care
HSSIB recommends that HM Prison and Probation Service updates Prison Service Order 3050, ‘Continuity of healthcare for prisoners’, including guidance on communication of information about prison patients when transferring between prisons, and on the process when prison patients are released …
Safety Recommendation
Medication not given: discharge from an acute hospital to the community
How does your organisation enable staff to understand that a patient referral has been received, actioned, and completed?
Learning Prompt
Medication not given: administration of time critical medication in the emergency department
How does your organisation support staff to access information (including information from primary care and specialty teams) about patients’ time critical medications?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure consistency in how data is collected and shared across different organisations, including with integrated care boards?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you support interoperability of electronic systems to enable effective information sharing across different organisations?
Learning Prompt
Patient safety across regional care pathways: learning from an HSSIB investigation pilot
How do you ensure information and documentation used to support the care pathway are aligned across different organisations?
Learning Prompt
Online prescribing: challenges and opportunities to improve patient safety
National healthcare organisations and independent prescribing organisations can improve patient safety by working together to design mechanisms for receiving information held by independent prescribing organisations. Such data may help to inform NHS care and provide insights into the safety profile …
Safety Observation
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care works with relevant organisations, including Digital Clinical Excellence and the Coalition for Responsible Digital Health, to develop a framework to enable the sharing of safety critical information relating to patients …
Safety Recommendation
Online prescribing: challenges and opportunities to improve patient safety
HSSIB recommends that the Department of Health and Social Care undertakes a review to explore the options and determine an appropriate mechanism for write access to health records for independent prescribing organisations. This would inform future developments such as the …
Safety Recommendation
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 …
Safety Recommendation
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.
Investigation Scope
Mental health: investigating under the Patient Safety Incident Response Framework (PSIRF)
Making information about service users easily available and accessible across providers to support effective initial engagement and decision making.
Area of Improvement
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that NHSX develops a method of digitally notifying patients of results. This should be used to inform patients of unexpected significant radiological findings after an agreed timeframe. It should be developed in conjunction with the Royal College …
Safety Recommendation
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that NHS England and NHS Improvement’s patient safety team takes steps to ensure providers are aware of the safety recommendations in this report and act to implement the key findings regarding risk controls such as a monitored …
Safety Recommendation
Failures in communication or follow-up of unexpected significant radiological findings
It is recommended that the Royal College of Radiologists, working with the Society and College of Radiographers and other relevant specialties through the Academy of Royal Medical Colleges, develops: principles upon which findings should be reported as ‘unexpected significant’, ‘critical’ …
Safety Recommendation
Wrong patient details on blood sample
It is recommended that NHSX should take steps to ensure the adoption and ongoing use of electronic systems for identification, blood sample collection and labelling.
Safety Recommendation
Electronic prescribing and medicines administration systems and safe discharge
It is recommended that NHSX supports the development of interoperability standards for medication messaging.
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that NHSX develops a standardised care passport, which should include sections to support patients with autism, learning disabilities or learning difficulties.
Safety Recommendation
Undiagnosed cardiomyopathy in a young person with autism
It is recommended that NHSX develops a system for sharing care plans for patients with autism, learning disabilities or learning difficulties to enable reasonable adjustments to be made. It is recommended that NHSX develops a standardised care passport, which should …
Safety Recommendation
Unplanned delayed removal of ureteric stents
The NHS Summary Care Records (SCR) system is being developed to allow for specific patient groups to be flagged. It may be beneficial for the British Association of Urological Surgeons to liaise with NHSX should opportunities arise in the future …
Safety Observation
Unplanned delayed removal of ureteric stents
It is recommended that the British Association of Urological Surgeons encourages members to include information in discharge letters and other communication sent to GPs and patients regarding patients’ stent status, potential complications and the possibility of a retained stent.
Safety Recommendation
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 …
Safety Recommendation
Placement of nasogastric tubes
It would be beneficial for the Department of Health and Social Care to consider post-Brexit arrangements for sharing patient safety incident data with Europe.
Safety Observation
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 …
Safety Observation
Management of chronic asthma in children aged 16 years and under
It may be beneficial if suspected or possible asthma diagnosis is communicated by secondary care services to children, families, and other care sectors, when asthma is being considered as a possibility (but not formally diagnosed).
Safety Observation
Management of chronic asthma in children aged 16 years and under
HSIB recommends that NHS England and NHS Improvement and NHSX identify and integrate data items into information technology systems to develop a greater understanding of the risk factors present in the community.
Safety Recommendation
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
Telephone triage Difficulties in communication were identified, relating to the availability and presentation of clinical records, documentation and communication of information from triage calls, and availability of interpretors particularly in urgent circumstances. The usual reliance on family members to provide …
Learning Prompt
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April …
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 …
Safety Recommendation
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.
Safety Recommendation
Local integrated investigation pilot 1: Incorrect patient identification
It may be beneficial if the Acute Trust considers the interoperability of its IT systems (that is, the ability of different IT systems to communicate and share information) as part of its digital strategy and in future procurement.
Safety Observation
Medicine omissions in learning disability secure units
It may be beneficial if electronic prescribing and medicines administration (ePMA) systems were interoperable with electronic patient records (EPR) systems to allow details of medicines omissions to be alerted to staff automatically from the ePMA system to the EPR system.
Safety Observation
Access to critical patient information at the bedside
It may be beneficial for healthcare organisations to provide guidance to support decisions in clinical areas that balance confidentiality and the visibility of critical patient information for patient safety.
Safety Observation
Access to critical patient information at the bedside
HSIB recommends that the Royal College of Nursing develops guidance for ward-based nursing handovers with consideration of the following: how handovers are organised, their content, the environment in which they take place and the technology needed to support them.
Safety Recommendation
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 …
Safety Recommendation
Access to critical patient information at the bedside
HSIB recommends that NHS England, during review of relevant Health Building Notes and Technical Memoranda, includes, as a consideration, that bedside patient information should be consistently visible.
Safety Recommendation
Access to critical patient information at the bedside
HSIB recommends that NHS England provides guidance to healthcare organisations to support local design and configuration of electronic patient records to enable end users to access critical patient information (such as patient identifiers and cardiopulmonary resuscitation status).
Safety Recommendation
Access to critical patient information at the bedside
HSIB recommends that NHS England develops guidance to providers, via any digital maturity assessments that are developed, to help ensure critical patient information (such as patient identifiers and cardiopulmonary resuscitation status) is available to clinical staff when accessing electronic patient …
Safety Recommendation
Access to critical patient information at the bedside
HSIB recommends that the Office of the National Data Guardian supports local interpretation of the Caldicott Principles to give organisations and staff the confidence to display full patient names at the bedside to support correct patient identification for safer care.
Safety Recommendation
Invasive procedures in patients with sickle cell disease
It may be beneficial if trusts included a sickle cell disease notification within their electronic patient record systems, to ensure that clinicians treating patients with the disease consider it and seek advice from haematology teams about the impact of any …
Safety Observation
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 …
Safety Recommendation
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 …
Safety Recommendation
Patients at risk of self-harm: continuous observation
Is there a process to ensure staff undertaking continuous observation who are new to an acute hospital ward are introduced to staff and the environment, including rest facilities and access to relevant patient records?
Learning Prompt
Patients at risk of self-harm: continuous observation
Is there comprehensive, clear, and accessible documentation available to both mental and physical healthcare staff?
Learning Prompt
CQC inspection actions(19)
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.
Must Do
The Princess Royal Hospital
The trust should ensure all staff caring for patients receive a handover to enable them to provide safe care and treatment.
Should Do
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.
Must Do
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.
Must Do
Royal Shrewsbury Hospital
The trust should ensure all staff caring for patients receive a handover to enable them to provide safe care and treatment.
Should Do
King George Hospital
The service should continue to work on implementing a standard patient electronic records system. The system should have the capacity to integrate with other records systems such as those used for mental health patients.
Should Do
Kettering General Hospital
The servicemust ensure robust systems and processes are in place to ensure key safety and safeguarding information is handed over when transferring patients between departments.
Must Do
Crowborough Birthing Centre
The service should ensure all women and birthing people booked into Crowborough Birthing Centre from the local NHS trust are put on to the electronic bookings system.
Should Do
Warrington Hospital
The serviceshouldensurethatelectronicpatientrecordsareintegratedasfarasispossibletoavoidtheriskofmissed information.
Should Do
St Helier Hospital and Queen Mary's Hospital for Children
The service should ensure staff use the ‘situation, background, assessment, recommendation’ handover format when handing over care of women, birthing people and babies.
Should Do
Epsom General Hospital
The service should ensure staff use the ‘situation, background, assessment, recommendation’ handover format when handing over care of women, birthing people and babies.
Should Do
Bridgwater Community Hospital
The service must ensure where responsibility for the care and treatment of women and birthing people is transferred to timely sharing of information and care planning takes place.
Must Do
Birmingham Children's Hospital
The trust should ensure that records are accessible to both emergency department staff and the mental health team.
Should Do
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.
Must Do
The Princess Royal Hospital
The trust should ensure that the service use electronic system for patient’s records.
Should Do
Countess Mountbatten House
Staff have training in the use of the electronic patient recordsystem to enable them to access information as needed.
Should Do
Royal Shrewsbury Hospital
The trust should ensure that the service use electronicsystem for patient’s records.
Should Do
Doncaster Royal Infirmary
The trust must ensure it maintains securely an accurate, complete, and contemporaneous record in respect of each service user, including a record of the care and treatment provided to the service user and of decisions taken in relation to the …
Must Do
Trent Lodge Residential Care Home
The provider must ensure service users are protected against the risks associated with effective communication with other healthcare professionals.
Must Do
HMICFRS recommendations(3)
FRS 2021-22 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service still does not have effective systems in place to manage risk-critical information to make sure it is collected, shared and reviewed in a consistent and timely manner. Recommendation: By 31 August 2021, make sure that …
Recommendation
FRS 2018-19 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: We have serious concerns about Cornwall FRS’s response to incidents. The service consistently doesn’t meet target response times for fires, especially in remote areas served by on-call stations. It is sometimes slow to update mobile data terminals …
Recommendation
FRS 2021-22 CoC Recommendations: Cornwall Fire and Rescue Service
Cause of concern: The service still does not have effective systems in place to manage risk-critical information to make sure it is collected, shared and reviewed in a consistent and timely manner. Recommendation: By 31 August 2021, make sure that …
Recommendation
PPO death in custody recommendations(9)
The Head of Healthcare and the lead for CGL
The Head of Healthcare and the lead for CGL should ensure that CGL’s records are also recorded on SystmOne so that healthcare staff can access them.
The Head of Healthcare
The Head of Healthcare should ensure that significant information is shared promptly between healthcare services and where appropriate with wider prison staff.
The Head of Healthcare and the Lead GP (HMP Oakwood)
The Head of Healthcare and the Lead GP should review the terms of reference of the multi-professional complex case clinic/conference (MPCCC) process to ensure that: • crucial information is appropriately reviewed and shared at meetings, and • patients receive continuity …
The Head of Healthcare
The Head of Healthcare should ensure that a clear plan is documented within the patients SystmOne records following self–discharge from the hospital acute Trust to ensure that all outstanding care/treatment is re-initiated as soon as possible.
The Head of Healthcare
The Head of Healthcare should ensure staff request prisoners’ community medical records at the earliest opportunity.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners with ongoing treatment needs are identified and referred back into relevant specialist services to ensure that continuity of healthcare is maintained.
The Head of Healthcare at Lewes
The Head of Healthcare at Lewes should ensure that a formal clinical handover is arranged for all complex mental health prisoners before transfer to a new prison.
The Head of Healthcare
The Head of Healthcare should ensure that prisoners are kept informed of the status of their referrals to healthcare services, particularly when referrals are rejected. Information about repeated referrals should be clearly recorded and identify follow-up action.
The Head of Healthcare
The Head of Healthcare should ensure that medication reconciliations are made in accordance with the community prescriber of that medication and where this is the community mental health team, they must confirm they are prescribing that medication and support this …
IMB individual recommendations(48)
Highpoint (2020)
In order for mental health practitioners to provide timely interventions, there is a requirement for prisoner records to be transferred between establishments when a prisoner is relocated. The Board asks for a co-ordinated and regulated procedure to be established to ensure this happens.
HMPPS
Implemented
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, registered nurses …
HMPPS
Partially Accepted
Erlestoke (2022)
What is the solution to improve the IT infrastructure so medical records can be accessed across the estate to ensure prisoners are not put at risk?
NHS / Healthcare Provider
In Progress
Erlestoke (2023)
What is the solution to improve the IT infrastructure so medical records can be accessed by healthcare staff across the estate to ensure prisoners are not put at risk?
Governor / Director
Downview (2023)
There seems to be some limitations in communication between HMP Bronzefield and the prison (for example, with regards to transferred prisoners with significant mental health conditions and with missing property and medication issues). Is this because HMP Bronzefield is a private prison, and systems and processes may not be compatible?
HMPPS
Gatwick IRC (2024)
Establish suitable mechanisms with relevant other parties to ensure that information regarding men's medical conditions/medication, vulnerabilities or security risks arrives with them or is shared in a timely way.
Governor / Director
In Progress
North East Midlands, Yorkshire & Humber STHF (2025)
The IMB should be given its own direct, independent access to electronic records. It is not adequate for IMB access to records to be dependent on Border Force or other facility staff gathering and curating print-outs of records. Such a system is inefficient, it hinders the IMB’s ability to get a full picture of cases and, in a worst case …
Ministry of Justice
Usk and Prescoed (2020)
The Board notes that sometimes prisoner records are very slow in reaching the open estate. Assessment records which are locked or unavailable to the receiving establishment cause delay in the smooth transition of prisoners, on a fourfold basis: 1. in terms of liaison with statutory agencies 2. the assessment of risk 3. planning for ROTL and eventual release into the …
HMPPS
In Progress
Portland (2020)
Checks need to be put in place to ensure that critically unwell prisoners, suffering significant health problems, cannot be unilaterally transferred. Should this ever be necessary, it should not happen without prior negotiation with the receiving establishment and the provision of up to date and comprehensive medical records.
HMPPS
Noted
Erlestoke (2020)
Communication between Prison Reception Staff and Healthcare Reception Staff is unsatisfactory (see paragraph 8.7). Will this problem be addressed?
Governor / Director
Styal (2021)
There has been some improvement in communications with the mental health team and other areas of the prison, which has led to a more holistic approach to mental health treatment. However, there is still not enough dialogue between healthcare and other staff in the prison, and the Board have been unable to access any analysis of complaints made by prisoners …
Governor / Director
Wakefield (2022)
We repeat our request in the 2020-21 annual report to ask HMPPS to clarify progress on the integration of the SystmOne project led by the Ministry of Justice’s digital team.
HMPPS
In Progress
Springhill (2022)
Leverage the link with HMP Winchester to improve property transfers and reduce complaints, and benefit from improved communication between the two prisons’ offender management units (OMUs) and healthcare departments.
Governor / Director
Woodhill (2023)
To work with colleagues in the Department of Health and Social Care to consider how the pathway through secondary care could be streamlined for prisoners who are transferred after their referral.
Ministry of Justice
Noted
Rochester (2023)
Property losses on transfer: yet again, there appears to have been no progress in resolving the problems which occur when a prisoner and their property are transferred between establishments, and property goes missing. Volumetric control introduced via the new property guidance is being ignored, as prisoners arrive at Rochester with excessive amounts of property. Lack of ownership over this reoccurring …
HMPPS
Gartree (2023)
The following question is repeated from last year’s annual report: will the Prison Service work with the Board to ensure that it has access to necessary information, such as healthcare data, for example, so that the Board is able to monitor more effectively how well the prison is meeting the standards and requirements placed on it and what impact these …
HMPPS
Gartree (2023)
The Board has continued to struggle to obtain meaningful data about healthcare provision to enable monitoring of waiting lists and patients’ clinics, etc, so that we can ascertain whether or not they are being provided at a satisfactory level.
Ministry of Justice
Exeter (2023)
Ensure robust and timely arrangements are in place to facilitate inter-prison transfers for prisoners with specific needs that cannot be met at Exeter?
HMPPS
In Progress
Downview (2023)
We routinely see unnecessary disruption when women transfer prisons (to their monies; telephone access to family and friends; their property; and educational progress). Transferring between prisons is a stressful event which is being exacerbated by basic administrative processes not functioning.
HMPPS
Bedford (2023)
The lack of a suitable computer in the healthcare rooms in reception means that healthcare staff cannot access the personal escort records.
Governor / Director
Hollesley Bay (2024)
The Board suggests that there is a need to review the handling of prisoners’ post, in particular where healthcare appointments are concerned.
Governor / Director
Norwich (2025)
To assist the Board monitor health and wellbeing in the prison, could the Governor please ensure that copies of the following reports are provided: • HCRG quality reports and clinical governance reports. • Minutes from Norfolk Prison Health and Partnership board meetings. • Social care reports. • Minutes from medicines management meeting.
Governor / Director
Thorn Cross (2020)
An additional concern is the healthcare needs of prisoners who transfer to Thorn Cross while in the process of hospital and other clinical treatment at their current establishment. These prisoners, who require ongoing treatment at specialist centres, cannot easily or quickly be referred to local medical facilities. To enable these prisoners to continue their treatment, significant additional resource requirements are …
HMPPS
Noted
Gartree (2021)
Will the Prison Service work with the Board to ensure that it has access to necessary information, for example healthcare data, so that the Board is able to monitor more effectively how well the prison is meeting the standards and requirements placed on it and what impact these have on those in its custody?
HMPPS
Thameside (2023)
Please can those in HMPPS with responsibility for contracted out prisons ensure that all IMBs in those prisons have access to the same resources as our colleagues in the public sector, as there is much discrepancy and full access to NOMIS has been an issue for a number of years and is still not fully resolved.
HMPPS
In Progress
Gartree (2024)
The Minister has previously advised that healthcare provision is monitored and reviewed by NHS England Midlands Clinical and Quality Team. Despite numerous requests by the Board, the healthcare provider has steadfastly declined to provide any meaningful quantitative data for monitoring the healthcare provision and benchmark against the community equivalent. Again, we ask the Minister to explain how the Ministry of …
Ministry of Justice
Accepted
Erlestoke (2024)
Just over 60% of first Assessment Care in Custody and Teamwork (ACCT) reviews do not have the benefit of healthcare input. This negates the multidisciplinary ethos behind the intended strategy of the ACCT process and which impacts on the safety of prisoners – how will this important issue be addressed?
Governor / Director
In Progress
Bronzefield (2024)
How does NHS England plan to improve the integration of the healthcare services in Bronzefield? (6.1)
NHS / Healthcare Provider
In Progress
Bronzefield (2024)
How does the Minister plan to improve the integration of the healthcare services (under NHS England commissioning) within Bronzefield? (6.1)
Ministry of Justice
In Progress
Stoke Heath (2025)
The Board recommends that the Prison Service acts on findings by the IMB and the Prisons and Probation Ombudsman (PPO) to improve the transfer of property between prisons.
HMPPS
In Progress
Lancaster Farms (2025)
When will the Prison Service review healthcare contracts to monitor the delivery of services and ensure that prisoners transferring between prisons are not disadvantaged in their healthcare status?
HMPPS
Implemented
Wormwood Scrubs (2020)
Will the minister instigate, at a national level, a policy which will ensure that prisoners who have had their hospital appointments cancelled, through no fault of their own, are not returned to the start of the appointments process?
Ministry of Justice
In Progress
Bedford (2020)
Ensure that the healthcare team provides information to prisoners (and families) regarding the Northamptonshire Healthcare Foundation Trust (NHFT) Patient Advice and Liaison Service (PALS) and complaints process, and, if necessary, that they are helped to understand when, and how, they should use it.
Governor / Director
Huntercombe (2021)
To develop a process with healthcare to ensure there is documented sharing of appropriate health information with prison staff (paragraph 6.1.8.).
Governor / Director
Erlestoke (2021)
Will steps be taken to enhance IT capabilities in this regard?
NHS / Healthcare Provider
In Progress
Grendon (2022)
Improved governance of healthcare data and outcomes (6.1.2) and overseeing delivery of health champions and improved communication with men (6.1.7).
Governor / Director
Belmarsh (2022)
Will HMPPS stand by their commitment to introduce a nationwide approach to prisoners’ property, and implement a digitalised process to reduce the amount of property lost on transfer (see section 5.8 Property)? (A new Property Framework has now been produced but still with no digitalisation).
HMPPS
Thameside (2023)
Address the continued deficiencies of on wing CMS which have a major impact on prisoners’ lives.
Governor / Director
In Progress
Rye Hill (2023)
The Board is concerned that processes designed to ensure prisoners have sufficient prescribed medication with them when transferring to Rye Hill are not being consistently applied across the prison estate.
HMPPS
Morton Hall (2024)
Our communication with the prison personnel is hampered due to the use of two different email systems within the prison service. Can a solution be found (8.1.1)?
HMPPS
Noted
Hewell (2024)
Enables prisoners transferring to other establishments to take with them a record of progress and achievement in education and vocational activities.
Governor / Director
Gartree (2024)
The Board is still aware of issues with property lost on transfer and remains concerned that current rules for possession of property vary amongst prisons. As a national issue, are rules covering transfer and possession of property belonging to prisoners in the LTHSE to be standardised?
HMPPS
In Progress
Dovegate (2024)
Is there a way for property that is authorised in possession in one prison to be recorded, to allow a prisoner to retain the item following transfer to another prison?
HMPPS
Noted
Chelmsford (2025)
Launchpad has been a great success in allowing prisoners to check and verify personal information. Will the Prison Service commit to adding a feature so prisoners can book and manage their medical appointments? If so, what timeline do you anticipate for implementation?
HMPPS
Wakefield (2021)
Clarify progress on the integration of the SystmOne project led by the Ministry of Justice’s digital team.
HMPPS
Hewell (2024)
Could you establish a process to ensure that prisoners can take a record of progress and achievement in educational and vocational activities with them when moving between prisons.
HMPPS
Implemented
Foston Hall (2024)
Many prisoners experience problems in relation to their property when transferring between establishments, with property going missing or being delayed. When will this be addressed?
HMPPS
In Progress
Erlestoke (2024)
What additional measures are in place to address the continual loss of property between establishments, as the re-issued Prisoners’ Property Policy Framework has not offered a solution to this matter?
HMPPS
In Progress
Scottish Fatal Accident Inquiries(21)
Roderick McIntosh Donnet
Changes must be made utilising modern technology to end this unacceptable state of affairs to ensure that GPs are made aware as soon as possible, and in any event within no more than seven days, by a doctor who played an active role in the patient's in-patient treatment, what was the basis for the discharge, what was the diagnosis and …
Aug 2007
Daryl Malcolm Shearer
But the point here is that it could easily have been avoided if Dr Campbell had written, or better still printed or typed, clear instructions in duplicate to the police to the effect that Mr Shearer should be taken to Raigmore Hospital the following morning to have his cheek x-rayed. But I should have thought that a single form incorporating …
Jul 2011
Michael Peter Cameron
However, if they have information which they consider could be safely shared then, in my view, they ought to be reminded that such information can and should be entered into the prison computer system PR2.
Jun 2006
Andrew Hamilton
1. That a number of defibrillator machines are made available in HMP Dumfries for emergency use by prison staff when the prison medical centre is closed. 2. That Scottish Prison Service (SPS) install and maintain a system of individual cell emergency alarms which is effective at all times. 3. That consideration should be given by SPS to enabling a prison …
Sep 2016
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 physically transferred …
Sep 2017
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 NHST where …
Jan 2018
Clark James Isard
It seems to me that consideration should be given to ensuring a copy of that form accompany a prisoner to prison.
Jul 2008
Lee Russell
In terms of Section 6(1)(e) of the said Act, that the following were further facts relevant to the circumstances of the death namely, in the event of a person who is in custody being seen by a medical practitioner, the reasons for that person being seen by that practitioner and any treatment and medication received by that person should be …
May 2009
Dylan Evan Brian Stickle
I realise that the doctor’s ACT risk assessment is but a part of a general health assessment but recommend that consideration be given to making the PER together with any accompanying information relevant to the issue of suicide or self harm (such as social work department or procurator fiscal letters) available to the examining doctor at least in cases where …
Oct 2009
Angela Smith
[51] Although I do not find established that system failures contributed to Angela Smith’s death, I consider the evidence which emerged in this long inquiry should be examined by the police service and NHS to ensure at-risk prisoners are flagged up with all relevant information known about the risk. Where a nursing assessment is indicated this should be carried out …
Dec 2009
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. Advice about …
Aug 2011
Christian Douglas McIntosh
Where credible information is received by a prison official that a prisoner has threatened to commit suicide the Scottish Prison Service should review their procedures to ensure that the information:- (i) is recorded in the prisoner’s record together with the details of any action taken and the reasons for any decision not to invoke the ACT 2 CARE procedure; (ii) …
Jun 2013
John Paul Pratt
I have therefore recommended that the DVLA institute a practice whereby in cases where the examining doctor is not the applicant’s general practitioner that the general practitioner is asked to verify from his records that the applicant has no condition likely to adversely affect his fitness to hold a relevant licence.
Aug 2014
J.K. Sweeney, L. Sweeney, E.P. McQuade, S.C. Tait, G.M. Ewing and J. Morton
5.1 Doctors generally, and general practitioners in particular, should take steps to ensure that medical notes are made and kept in such a way as to maximise their ability to identify repeated episodes of loss of consciousness, loss of or altered awareness, in the case of patients who are or may become drivers. 5.2 When a doctor is advising an …
Apr 2010
John Perry
I consider that it would be helpful if that information was provided. In a similar vein, I consider that it would be beneficial if the Doctor carrying out the assessment the day after admission had a copy of the Prisoner Escort Form. It seems to me that if there are still issues with accessing that data base as a result …
Jan 2013
Raygen Merchant
I would express a hope that such information, provided it is significant and relevant to the care of a prisoner in custody, would be communicated to those who are responsible for the prisoner’s care. Further, it seems to me that if the prison authorities have information which is potentially relevant to the care of a prisoner either because of the …
Aug 2018
Christina Anne Wilson
That being said, I think it is important that there should be full dialogue between the lead professional in the patient’s care in the hospital and the care home manager before any patient is transferred from hospital to a care home. This dialogue should include the patient and, if possible, a family member and should be fully documented.
Jan 2019
Chloe McIver
The Health Board, therefore, should review its procedures in this regard. This dichotomy of view between a Consultant Paediatrician and the Director of Nursing must be resolved and the appropriate protocol put in place. (c)It was clear from the evidence at the Inquiry that the midwives were not certain as to how they instigated the transfer of a sick baby …
Sep 2005
Martin Jamieson
a) that all personnel, both police officers and civilian staff, involved in the initial processing of a person in custody must ensure that all relevant information about the person is communicated to the Custody Officer; b) that Custody Officers must ensure that during initial processing they undertake a risk assessment of the person based on all relevant information provided to …
Feb 2010
Leylan Forte
GP practices making greater use of Key Information Summaries on Emergency Care Summaries where appropriate to improve information sharing between GP practices and NHS 24 might realistically prevent other deaths in similar circumstances.
Dec 2021
Health
Leo Lamont; Ellie McCormick; Mira-Belle Bosch
1. Recommendation 1: Greater Glasgow & Clyde Health Board (“GGCHB”) should develop a trigger list or similar system to (a) aid in the identification and assessment of symptoms that might be indicative of preterm labour and (b) inform a decision as to whether a patient should attend for clinical assessment. When a telephone assessment is carried out with a patient …
Mar 2025
Health
Article 2 learning points(6)
— LP 1
A brief review of the available SystmOne medical record should be made by staff prior to performing initial health-screening to validate the answers made to the template-driven questions.
PPG
Accepted
— LP Healthcare 4
The date and time of an individual’s transfer to secondary care and discharge back to prison should be documented in the clinical record. This should include any required actions which are identified on discharge from secondary care.
Healthcare Provider
— LP 12
Staff employed by Birmingham and Solihull Mental Health NHS Foundation Trust should be reminded of the specific requirements in PSI 73/2011, P-NOMIS to add case notes about behavioural issues or which detail specific issues that might help the care of the offender by staff generally.
PPG
Accepted
— LP 10
There should be an effective system for following up requests for medical records if these fail to arrive.
PPG
Accepted
— LP 14
Greater priority should be given to seeking back records from previous establishments, particularly for those prisoners with complex needs or challenging behaviour, where assessments from a previous sentence may be particularly useful.
The Governor
Accepted
— LP 3
We recommend that more effective models of clinical care are developed for prisoners with diagnosed mental illness and that ways are found to ensure that diagnostic assessments undertaken for the courts are swiftly and systematically used to inform decisions about day to day medical care in prison.
PPG
Accepted
Detention investigations(1)
PHSO casework decisions(16)
P-004644 — Royal Free London NHS Foundation Trust
Miss A complained Moorfields failed to properly transfer her care and records to Royal Free, causing significant delays and affecting her eyesight. She also cited poor complaint handling.
NHS in England
Partly Upheld
Jan 2026
P-001379 — County Durham and Darlington NHS Foundation Trust
Mr G complained he was left unattended for long periods, prescription details weren't sent to his GP, and a cannula was left in his hand on discharge.
NHS in England
Apr 2022
P-004727 — An independent provider in the Redbridge area
Ms N complained the Provider added another patient's notes to her medical records, leading to a referral for unnecessary surgery, delayed check-ups for her eye disease, and increased stress.
NHS in England
Jan 2026
P-003437 — University Hospitals of Derby and Burton NHS Foundation …
Mr Z complained the Trust failed to share information about his wife's cancer progression, delaying the option for alternative treatments and contributing to her premature death.
NHS in England
Upheld
Mar 2025
P-003418 — University College London Hospitals NHS Foundation Trust
Mr W complained his mother contracted COVID-19 on a ward, the Trust lacked communication, and failed to effectively treat her leg ulcer, leading to its deterioration and affecting her health.
NHS in England
Mar 2025
P-003423 — An independent provider in the Hammersmith and Fulham …
Mrs F complained two Trusts failed to provide appropriate care for her father's mobility, nutrition, medication reviews, safeguarding, and antipsychotic medication, causing his condition to deteriorate.
NHS in England
Upheld
Mar 2025
P-004459 — Northern Care Alliance NHS Foundation Trust
Mrs B complained the Trust provided inappropriate care to her husband, Mr B, alleging issues like mixed records, cancelled tests, and poor communication, which she believes contributed to his death.
NHS in England
Dec 2025
P-001220 — Royal Free London NHS Foundation Trust
Mrs G and Mr G complained about inadequate care for Mrs S, citing poor condition assessment, delayed response to low blood pressure/confusion, and issues with both operations.
NHS in England
Partly Upheld
Oct 2021
P-002894 — Northern Care Alliance NHS Foundation Trust
Mr H complained his urgent GP referral was wrongly downgraded to routine without consultation, and a consultant couldn't view his scan, causing prolonged worry and pain.
NHS in England
Aug 2024
P-003049 — Leeds Teaching Hospitals NHS Trust
Ms D complained the Trust failed to perform requested endocrinology blood tests for her daughter, R, between 2018 and 2020, and lacked inter-departmental coordination, leaving her thyroid undertreated.
NHS in England
Upheld
Oct 2024
P-003420 — Mid Yorkshire Teaching NHS Trust
Care for Miss Y's father was allegedly poor, including lack of observation, delayed treatment, and inadequate communication of his deteriorating condition, which Miss Y believes contributed to his death.
NHS in England
Upheld
Mar 2025
P-003398 — North West Anglia NHS Foundation Trust
Mrs E complained the Trust inappropriately moved her husband, delayed treatment, failed to perform an MRI, transferred him without consent, and provided inadequate communication during his critical illness.
NHS in England
Upheld
Mar 2025
P-001250 — Gloucestershire Hospitals NHS Foundation Trust
Mr A complained GPs failed to recognise his son's pneumonia deterioration and about lost blood tests and inadequate care by an MS Specialist Nurse. He also complained about medication changes not being discussed and inappropriate staff behaviour.
NHS in England
Sep 2021
P-001970 — Wrightington, Wigan and Leigh NHS Foundation Trust
Ms S complained the Trust failed to support her complaint against another hospital by not requesting records or giving an opinion, causing her medical negligence claim to lapse.
NHS in England
Apr 2023
P-002664 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs J complained about a lack of diagnosis, unnecessary epilepsy medication, delayed/missed follow-up appointments, and slow communication of medication changes to her GP.
NHS in England
Partly Upheld
Jun 2024
P-003018 — A practice in the Hertfordshire area
Miss A complained the Practice failed to give her ANA test results in February 2024, causing stress and anxiety, and potentially delaying diagnosis and contributing to subsequent health issues.
NHS in England
Oct 2024
LGO / SPSO decisions(23)
NIPSO-19933 — Belfast Health and Social Care Trust
The Belfast Health & Social Care Trust is setting up a process to tell GPs when it has downgraded their referrals after we asked it to apologise to a patient who had complained about a delay in treatment.
NIPSO (NI Public Service…
Health & Social Care
Mar 2021
PSOW-202106438 — A GP Practice in the area of Aneurin …
A complainant complained about the delay in an agreed complaint meeting taking place, and the fact that the Medical Centre did not retain telephone recordings, which the complainant considered would provide evidence in support of their complaint. The complainant also complained that the Medical Centre made reference to highly sensitive …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202106097 — Swansea Bay University Health Board
Mr X complained that an Out of Hours GP employed by the Health Board provided him with incorrect advice and said he should have been referred to hospital. He also complained that the Out of Hours GP was dismissive in his attitude and his concerns were not addressed. The investigation …
PSOW (Public Services Om…
Health
Upheld
Dec 2022
PSOW-202303749 — Aneurin Bevan University Health Board
Mrs B complained about the advice her husband Mr B received from an Advanced Nurse Practitioner (ANP) employed by the Out of Hours GP service, shortly before he was admitted to hospital and sadly died of neutropenic sepsis. Mrs B said that a home visit she requested should have been …
PSOW (Public Services Om…
Health
Upheld
Mar 2024
PSOW-202402126 — Cwm Taf Morgannwg University Health Board
Miss T complained that Cwm Taf Morgannwg University Health Board has not provided the necessary treatment to deal with her chronic pain. The Ombudsman found that whilst the Health Board had responded to Miss T’s concerns informally, it failed to correctly escalate her complaint in accordance with its complaints process …
PSOW (Public Services Om…
Health
Sep 2024
PSOW-202409193 — Cardiff and Vale University Health Board
Ms A complained that Cardiff and Vale University Health Board cancelled her thyroidectomy surgery on the day of the procedure because she was a smoker. Ms A was removed from the waiting list and referred for smoking cessation. Ms A said that the Health Board had not previously advised her …
PSOW (Public Services Om…
Health
May 2025
PSOW-202500244 — Aneurin Bevan University Health Board
Mr X complained that Aneurin Bevan University Health Board had failed to respond to his complaint. The Ombudsman decided that there had been a significant delay by the Health Board to respond to Mr Xs complaint. She said this caused inconvenience and frustration for Mr X. The Ombudsman decided to …
PSOW (Public Services Om…
Health
May 2025
NIPSO-202000972 — Belfast Health and Social Care Trust
Nursing staff in the Belfast Trust provided appropriate care to a patient before he underwent elective vascular surgery. However, we found it of significant concern that the Trust failed to keep records of a discussion it had with him about the surgery’s risks.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Jul 2024
PSOW-202203921 — A GP Practice in the area of Aneurin …
Mrs D complained about the care and treatment provided to her husband, Mr D, by Aneurin Bevan University Health Board (“the Health Board”) and his GP Practice. Mrs D’s complaint that the GP Practice missed opportunities to carry out assessments, investigations and/or referrals that would have led to the earlier …
PSOW (Public Services Om…
Health
Upheld
Sep 2023
PSOW-202200785 — A GP Practice in the area of Betsi …
Mrs P complained on behalf of her late husband, Mr P, about Betsi Cadwaladr University Health Board (“the Health Board”) and a GP Practice (“the Practice”) in the same health board area. Mrs P complained about the Health Board’s handling of her complaint about the service provided by the Practice. …
PSOW (Public Services Om…
Health
Upheld
Sep 2023
PSOW-202405171 — A GP Practice in the area of Hywel …
Mr A complained about how the Practice dealt with his complaint, how he was de-listed from the Practice, and the clinical treatment he received from the Practice. After assessment, the Ombudsman found that the Practice had not responded to Mr A’s complaints under the Putting Things Right process. The Ombudsman …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407040 — Betsi Cadwaladr University Health Board
Ms C complained that she was unable to make an appointment with a GP Practice in the area of Betsi Cadwaladr University Health Board, which resulted in delays in reviewing her medication and issuing prescriptions The Ombudsman decided that the Practice had failed to recognise that the patient had made …
PSOW (Public Services Om…
Health
Feb 2025
21-018-340a — East Lancashire Hospitals NHS Trust (21 018 340a)
Summary: We uphold Mr X’s complaint about the care and treatment provided to his mother, Mrs Z. We found fault with the way the Trust and the Council handled Mrs Z’s discharge from hospital and how staff communicated with her during her physiotherapy assessments. We also found fault with the …
LGO (Local Government & …
Health
Upheld
Dec 2022
22-011-572 — Sandwell Metropolitan Borough Council
Summary: We will not investigate this complaint about Mrs X’s request for her late father’s social care records. The Information Commissioner’s Office is best placed to consider requests for information made under the Freedom of Information Act 2000.
LGO (Local Government & …
Other Categories
Dec 2022
24-017-682d — Gants Hill Medical Centre (24 017 682d)
Summary: Mr X complained about end-of-life care for his mother, Mrs Y, from Jewish Care, Gants Hill Medical Practice, Partnership Of East London Co-Operative, NHS North East London Integrated Care Board and London Ambulance Service NHS Trust. We would likely find fault with the Practice, PELC and ICB if we …
LGO (Local Government & …
Health
Jun 2025
24-017-682c — Partnership Of East London Co-Operatives (24 017 682c)
Summary: Mr X complained about end-of-life care for his mother, Mrs Y, from Jewish Care, Gants Hill Medical Practice, Partnership Of East London Co-Operative, NHS North East London Integrated Care Board and London Ambulance Service NHS Trust. We would likely find fault with the Practice, PELC and ICB if we …
LGO (Local Government & …
Health
Jun 2025
25-004-266a — Maywood Healthcare Centre (25 004 266a)
Summary: Mrs X complained West Sussex County Council failed to provide her late husband, Mr X, with alternative domiciliary care after a care agency ended its contract. She said this meant he had to go into residential care in one of Saffronland Homes’ nursing homes. Mrs X says he received …
LGO (Local Government & …
Health
Nov 2025
PSOW-202305872 — A GP Practice in the area of Betsi …
Mrs X complained that a GP Practice in the area of Betsi Cadwaladr University Health Board had failed to respond to the complaint she had made to it in July 2023. The Ombudsman found that the Practice had verbally updated Mrs X, but had not offered her a written apology, …
PSOW (Public Services Om…
Health
Nov 2023
21-000-200b — Worthing Medical Group (21 000 200b)
Summary: We found fault by a care home acting on behalf of the Council regarding the care it provided to Mr X, an elderly man with complex care needs. We found the care home failed to support Mr X and his wife, Mrs X, to make an informed choice about …
LGO (Local Government & …
Health
Upheld
Mar 2022
201701848 — A Medical Practice in the Fife NHS Board …
Miss C complained on behalf of her late mother (Mrs A) that the practice unreasonably admitted Mrs A to hospital when it was her wish to remain at home. Mrs A had terminal cancer and was being cared for at home. A GP from the practice visited her at home …
SPSO (Scottish Public Se…
Health
Upheld
Jun 2018
201607293 — Lothian NHS Board - Acute Division
Mrs C complained on behalf of her child (Child A) about the care and treatment they received at the Royal Edinburgh Hospital. Child A was admitted to hospital and diagnosed with a severe depressive episode and suicidal thoughts. Child A remained in hospital some months, and mental health staff consulted …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jul 2018
PSOW-202302562 — Aneurin Bevan University Health Board
Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms …
PSOW (Public Services Om…
Health
Not Upheld
Jun 2024
PSOW-202304622 — A GP Practice in the area of Aneurin …
Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms …
PSOW (Public Services Om…
Health
Upheld
Jun 2024