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 20 independent accountability sources, so the source mix matters as much as the headline total.
79 inquiry recs
157 PFD reports
125 committee recs
103 HSSIB recs
92 CQC actions
3 HMICFRS recs
9 PPO recs
48 IMB recs
22 Scottish FAIs
6 Article 2 learning points
1 detention investigation rec
1147 DHR recs
16 PHSO decisions
23 LGO/SPSO decisions
2 CJINI reports
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(79)— showing 50 strongest matches
57 — Intimate Order to police and Reporter
Recommendation: A Child Protection Order together with the form of application and any supporting documentation should be intimated both to the police and to the Reporter (16.30).
Unknown
12 — Agencies share information in joint approach
Recommendation: In a joint approach while investigation of a case is properly a matter for the police each agency should share fully with each other the whole information relevant to their particular responsibilities (15.30-31).
Unknown
78 — Guide on disclosure by healthcare staff
Recommendation: The Prison Service should prepare a readable guide, which explains the circumstances in which personal information about a prisoner should be disclosed by healthcare staff to officers on the wing. The guide should contain practical examples of situations where disclosure …
Unknown
59 — OASys assessor access to prior behaviour
Recommendation: OASys assessors should have access to information relating to prisoners’ behaviour while serving previous sentences and to information held in security files.
Unknown
42 — Security information before NOMIS covers it
Recommendation: Since security information is not to be included in the first phase of NOMIS, there remains a need for a national database for security information. Establishments should have the 4x4 system converted to the 5x5 system if that has not …
Unknown
40 — Written notice to wings of prisoner arrival
Recommendation: All establishments should have a procedure for notifying wings in writing that a prisoner is currently charged with, or has been convicted of, an offence under the Protection from Harassment Act 1997.
Unknown
38 — Wing files required for admission to wing
Recommendation: Prisoners should not be admitted to a wing without their current wing file, save with the permission of a governor or the approval of the night orderly officer. Important entries in it should be made in red.
Unknown
37 — Checklist for files on transfer
Recommendation: To ensure that all files accompany prisoners on their transfer to another establishment, they should be ticked off at the reception of the sending establishment against a checklist. Prisoners should not be allowed to leave unless all their files have …
Unknown
36 — Telling receiving prison reason for transfer
Recommendation: Whenever a prisoner is transferred to another establishment, the receiving establishment should be told what the reason for the transfer is. If the transferring prisoner is a particularly problematic one, the receiving establishment should be warned beforehand.
Unknown
35 — Police National Computer link to prisons
Recommendation: The Police National Computer should be linked to the whole of the prison estate. In the meantime, any intelligence the police may have about prisoners which could affect their management in prison should be sent to the police liaison officers …
Unknown
33 — Policy on disclosing medical reports to prisons
Recommendation: In the light of such legal advice as the Courts Service receives, it should publish a policy on the disclosure to the prison of medical or psychiatric reports on a prisoner submitted to the court.
Unknown
5 — Operating systems (interoperability)
Recommendation: NHS England must provide, by 31 March 2027, a clear and timed route to ensuring that computer systems are harmonised across the NHS by December 2028. Work on the development of a mandatory information standard with requirements for interoperability between …
Gov response: The report also makes recommendations for the regulators, including CQC, which we will ensure are taken seriously, and on technology. We have implemented the maternity outcome signal system, which provides near real-time safety alerts, but …
Response Unclear
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 …
Gov response: The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the …
Accepted in part
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 …
No response yet
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.
No response yet
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.
No response yet
165 — Reporter to obtain police information
Recommendation: An express statutory provision should be made enabling the Reporter to obtain from the police any information or articles held by them so that they may be available for the conduct of a proof under Section 42, subject to their …
Unknown
13 — University audit trail to clinical record
Recommendation: University records shall provide a confidential audit trail back to the clinical record.
Unknown
12 — Review and update medical records
Recommendation: The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death …
Unknown
115 — Consistent background information for interviewers
Recommendation: Each interviewer should wherever possible have consistent and relevant background information about the child and in particular about his or her emotional, physical and mental development (17.54), and an assessment of the child’s wider family (17.55).
Unknown
18 — School information on children in writing
Recommendation: Any information about children which is to be used for the purposes of their compulsory care and which is provided by their school-teacher should be provided in writing (15.38).
Unknown
58 — OASys use in all establishments
Recommendation: OASys should be used by all establishments to identify the risks posed by prisoners to staff and other inmates, and the risks which are identified should be fed back to the wings.
Unknown
50 — Prisoner escort record handbook and completion
Recommendation: The handbook giving guidance on how to complete the prisoner escort record should be revised to make it clear that it is not merely of use while a prisoner is in transit, but it is also intended to inform the …
Unknown
46 — Completing discharge reports
Recommendation: The discharge report which used to be prepared on prisoners on their discharge should be completed as a matter of course, and a copy included in their main prison file. It should be accessible on NOMIS when NOMIS becomes operational.
Unknown
41 — Vetting security files
Recommendation: Each Security Department should establish a proper system for vetting security files to ensure that they are read by the end of the working day following their arrival, that any relevant information is relayed in writing to the wings, and …
Unknown
39 — Missing cell-sharing risk assessment form on arrival
Recommendation: If prisoners arrive on a wing without a copy of the cell-sharing risk assessment form, they should be placed in a single cell until the form is found or a new one completed.
Unknown
32 — Transcripts of judges' remarks to prison
Recommendation: When a judge asks for any remarks which they make to be brought to the attention of the Prison Service, the court should assume responsibility for commissioning a transcript of what has been said and sending a copy to the …
Unknown
31 — Court responsibility for warrant and conviction documents
Recommendation: There should be someone in court whose responsibility it is to ensure that the dock officer gets copies of the warrant authorising the prisoner’s detention, the list of their convictions, and the indictment or charge sheet.
Unknown
30 — Reports accompanying prisoners from court
Recommendation: To avoid prisoners leaving court without being accompanied by bail information reports or pre-sentence reports, the probation officer should ensure that a copy of the report is available for the escort contractor, and there should be someone in court whose …
Unknown
26 — Security Departments entering shareable information on NOMIS
Recommendation: Although there are no plans for security information to be entered onto NOMIS in its first phase, Security Departments should enter any information which can be shared with the majority of staff when the first phase of NOMIS becomes operational.
Unknown
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.
No response yet
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.
No response yet
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).
No response yet
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 government response published. The Northern Ireland Executive had not published a response to the Module 4 report of 16 April 2026 when the Executive Office's publications list was checked on 25 September 2026.
Accepted in part
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
11 — Review records and develop audit trail
Recommendation: Records should be reviewed and updated and an audit trail should be developed and put in place.
Unknown
161 — Local guidelines on information to Reporter
Recommendation: It should be clearly stated in all local guidelines in what form if any information requires to be given to the Reporter (18.48-49).
Unknown
78 — Mutual understanding between authorities
Recommendation: Where a child is placed outside the area of the child’s own local authority the Social Work Departments of the two areas should have a clear mutual understanding of the roles and responsibilities of those involved in the care of …
Unknown
76 — Constable to intimate removal likewise
Recommendation: Correspondingly any constable or other person removing a child should give a like intimation to the Social Work Department (17.6).
Unknown
75 — Intimate removal to Social Work Department
Recommendation: Any Order authorising the removal of a child should require the person so authorised to intimate the removal and the whereabouts of the child to the appropriate Social Work Department (17.5).
Unknown
64 — Written background on the child
Recommendation: Where practicable written information should be available about the background of the child for the use of the social worker or police officer removing the child (16.37).
Unknown
43 — Obtaining security files of returning prisoners
Recommendation: Where prisoners have served a sentence before, the Security Department should always obtain their security files from the establishment from which they were discharged.
Unknown
34 — Facts of offences in conviction lists
Recommendation: The list of a prisoner’s convictions sent to the prison should include a short statement of the facts of each offence and the charges the prisoner is facing.
Unknown
27 — NOMIS alert for sensitive security information
Recommendation: NOMIS should include a facility for an alert to appear if information is held by the Security Department on prisoners which could affect their management but which is too sensitive for wider dissemination. An officer at the grade of senior …
Unknown
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).
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
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: The government agrees with the Inquiry that data systems need to be improved to identify individuals at high risk during a pandemic. The government’s 10 Year Health Plan and existing data policy work provide a …
Accepted
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: If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Gov response: Accept in principle The government agrees that, where patient safety is at risk, information should be shared with other providers. However, there must be an element of judgement by providers as they will be taking …
Accepted in part
Prevention of Future Deaths reports(157)— showing 50 strongest matches
Felix Cembrowicz
Concerns: The electronic Rio record system did not migrate historical patient records, including relapse management plans for discharged patients, leaving staff unaware of important patient histories and delaying assessments.
Response (Avon and Wiltshire NHS Trust): • A new requirement has been included in the initial assessment/admission process for re-referred patients to establish if historic relapse management plans exist and to search historic electronic and paper … (AI summary)
Responded
Joanne Manning
Concerns: The coroner raised concerns about the lack of established communication procedures between general practitioners and secondary care prescribers of methadone, which led to a psychiatrist not receiving crucial patient medical information from the GP practice.
Overdue
Keith Fleming
Concerns: The coroner noted a lack of recorded vital signs and impressionistic assessment of physical symptoms, which meant healthcare staff were unaware of a dehisced bowel anastomosis and internal abscess leading to a catastrophic infection.
Overdue
Chloe Grace Flavell
Concerns: The coroner noted concerns regarding the management of the reception area before triage, which could lead to significant delays in providing immediate care, particularly for children. A more appropriate and efficient system is needed to minimise these delays.
Overdue
Daniel Williams
Concerns: The coroner noted deficiencies in staff training regarding record keeping and communication, and the absence of clear guidance for checking patients and rooms for potential self-harm items. Concerns were also raised about the lack of a single summary sheet in patient notes and the balance between holistic care and patient safety.
Response: • All Inpatient staff received training packs and completed e-learning on 'Personalised Care Planning 2013 Record keeping and communication' in November. • The Trust developed and distributed guidance for checking … (AI summary)
Responded
James Withers
Concerns: The coroner identified delays in cardiologist review, missing medical notes, and poor communication among staff and with the family. Concerns included the Do Not Attempt Resuscitation (DNAR) process lacking family discussion, and a doctor incorrectly assuming the status.
Overdue
Andrew John Fallon
Concerns: Insufficient staffing levels in the Emergency Department led to doctors being overwhelmed and significant treatment delays, particularly for patients with severe health issues, exacerbated by the volume of minor complaints.
Overdue
Grace Mary Bates
Concerns: The coroner identified the lack of availability of a specialist diabetic nurse at the hospital over the weekend.
Response: • A business case for the appointment of a minimum of one specialist diabetic nurse was submitted and approved. • The appointment of a specialist diabetic nurse is awaited. (AI summary)
Response: • The NHS Services Seven Days a Week Forum developed ten clinical standards for urgent and emergency care, intended to reduce risks from weekend admissions, including for diabetes. • NHS … (AI summary)
Responded
Simon McAndrew
Concerns: The coroner raised concerns about poor communication between different NHS Trusts, noting that important information regarding Mr McAndrew's psychiatric care was not effectively shared or accessed, leading to an inappropriate referral.
Overdue
Matthew Simmonds
Concerns: The coroner noted that a local action plan for complex care pathways, particularly for ventilated patients discharged to the community, has not been shared with other Clinical Commissioning Groups, limiting its potential to prevent similar deaths nationally.
Overdue
Audrey Kelly
Concerns: The coroner raises concerns that Out of Hours Service doctors and hospital Emergency Departments lack direct access to patients' electronic GP notes, noting this could lead to adverse patient outcomes.
Response (Department of Health2): • Mastercall confirmed that all relevant staff members now possess an NHS Smartcard. • Stockport CCG stated it would seek formal assurance from Mastercall regarding processes for new starters and … (AI summary)
Response (Department of Health): • The Department of Health described the national Summary Care Record (SCR) system and the local Stockport Health Record (SHR) system, which provide urgent and emergency care staff with access … (AI summary)
Responded
Janet Blackman
Concerns: The coroner noted psychiatric units struggle to provide physical health care and that deep vein thrombosis (DVT) prophylaxis policies were not consistently applied to patients in these units. The report suggests developing a system for integrated physical and mental health care delivery.
Overdue
Stephen Widman
Concerns: The coroner identified a need for an accelerated pathway for neutropenic sepsis patients to prevent prolonged A&E waits, and noted frequent catheterisation without urologist management. The report also suggested considering a vulnerable patient card to expedite emergency care.
Overdue
Mary Wanya
Concerns: The coroner identified significant delays in urgent psychiatric assessments, particularly out-of-hours, and an insufficient system for mentally ill patients on the Medical Admissions Unit. Concerns were also raised about the Level 3 Investigation Report omitting critical medical issues.
Overdue
Peter Franklin
Concerns: The coroner noted confusion in terminology and insufficient information exchange between hospital staff and the CRISIS team during out-of-hours calls. Additionally, significant delays prevented hospital and mental health documentation from reaching the GP.
Response (Kent Medway NHS Trust): • The Trust developed a Joint Action Plan, which is being updated and monitored by Patient Safety Groups in both Trusts. • A SMART tool for use between Accident & … (AI summary)
Response (Tunbridge Wells Hospital): • The Trust stated that a SMART Tool for terminology was discussed and agreed, and its implementation is underway, with incorporation into the Junior Doctor Handbook planned. • The Trust … (AI summary)
Responded
Denise Parramore
Concerns: The coroner noted insufficient communication between psychiatric services and the general practitioner regarding a patient's Tramadol prescription. There is a need for open, two-way information sharing and access to documentation between primary and secondary care.
Overdue
Graeme Kidd
Concerns: Concerns included locum doctors lacking access to electronic records and awareness of mental health support teams. Additionally, GPs faced delays in referring patients to mental health services due to mandatory physical checks, and medication advice was unavailable.
Overdue
Anne Whitworth
Concerns: Incompatible computer systems prevented out-of-hours doctors from accessing the patient's full medical records, impacting treatment decisions and leading to a missed opportunity for escalation of care.
Overdue
John Shelley
Concerns: The coroner noted that some staff in caring roles at the residential unit had not received basic life support training, or their training was out-of-date, highlighting a need for regular updates.
Response: • The Health Board confirmed that all staff in the residential units have been trained in Basic Life Support since the event. • The Health Board stated it is evaluating … (AI summary)
Responded
William Jackson
Concerns: The coroner noted a lack of formal systems at Freeman Hospital to record sudden medical interactions, meaning advice given by a specialist could not be traced or recalled. This advice appeared to have been given without reviewing the CT scan, which the coroner indicated could place patients at risk.
Response (Newcastle upon Tyne Hospital NHS Trust): • An electronic system has been implemented within Cardiothoracic to record details of advice given when medical opinion is sought by healthcare professionals in other hospitals. • The importance of … (AI summary)
Responded
Shannon Gee
Concerns: The coroner identified delays in resolving clinical disputes between organisations due to differing treatment thresholds, which created a gap in service provision. Difficulties with the transfer of medical notes and records were also noted.
Overdue
Brian Francis
Concerns: Concerns were raised about the reliability of a 'tick in the box' system for consultant attendance and the impact of unavailable community medical records at the time of hospital admission.
Response: • The hospital implemented an enhanced system requiring consultants to sign a new register after reviewing emergency medical patients in the ED and AMU. • The Health Board is piloting … (AI summary)
Overdue
Keith Gallimore
Concerns: The coroner notes that important patient information from the CANDI service is not readily accessible to other Trust services without a proactive request, and access methods for out-of-hours situations are unclear.
Response (Camden and Islington NHS Trust): • The Trust identified a gap in information sharing between its ICope and other services due to different electronic patient record systems. • It agreed to provide IAPTUS system training … (AI summary)
Responded
Olive Darbyshire
Concerns: Concerns were raised about a significant delay in Mrs. Darbyshire receiving an urgent CTPA procedure, attributed to the clinical team not chasing it up and the radiology department's incorrect patient categorisation. These issues were potentially exacerbated by reduced staffing during the Christmas period.
Response (Olive Darbyshire): • The Trust held meetings of key team leaders and staff to address weaknesses in diagnostic request status, identification, messaging, and follow-up. • A Standard Operating Procedure (SOP) was created … (AI summary)
Responded
John Lloyd
Concerns: The coroner identified frequent failures in UHW's system for notifying GPs of patient admissions, despite an electronic system being in place. Concerns were also raised about providing adequate management support to overhaul this notification process.
Overdue
Jean Hannon
Concerns: The diagnosis of autonomic dysreflexia was not sufficiently highlighted in the patient's medical record, which meant a consultant physician was unaware of it during a subsequent hospital admission.
Response (East Lancashire Hospitals NHS Trust): • The Trust implemented an electronic system to include GP case summaries in patient notes for urgent, emergency, and planned admissions. • The Trust is piloting the use of daily … (AI summary)
Responded
Edward Gascoigne
Concerns: Clinicians experienced difficulty accessing comprehensive patient information because relevant data was stored in disparate record 'silos'. The coroner noted a concern that the current approach to NHS record sharing does not adequately address these risks.
Response (Response ny Department of Health): • The Summary Care Record (SCR) system has been implemented, with over 96% of people in England having SCRs created and uploaded to the NHS National Spine. • NHS England's … (AI summary)
Responded
Thomas Collins
Concerns: The coroner noted that the attending paramedic lacked the confidence required to make a clinical decision.
Response (North West Ambulance Service NHS Trust): • NWAS Paramedics perform a clinical assessment of patients and apply a clinical algorithm called 'Paramedic Pathfinder'. • NWAS has agreements with thirty Commissioning Groups (CCGs) to refer patients identified … (AI summary)
Response (Haughton Thornley Medical Centres): • The practice will ensure findings are clearly recorded and more information is obtained regarding the circumstances of a fall, particularly whether it was witnessed or unwitnessed. • The practice … (AI summary)
Responded
Antony Briggs
Concerns: The coroner identified an incompatible IT system preventing urologists at Stepping Hill Hospital from viewing test results from Buxton. This led to a lacuna in follow-up care, as local GPs in Buxton either could not or did not act on crucial information, delaying diagnosis.
Response (A Briggs): • The Trust will strengthen communications between the secretarial teams at Stepping Hill and Buxton. • The Trust will jointly develop a standard operating procedure to ensure all Radiology reports … (AI summary)
Responded
Norma Holden
Concerns: The coroner noted incomplete history taking and a failure to report obvious symptoms like swollen tongue and facial swelling to treating doctors. Concerns were also raised that basic blood tests for infection/sepsis were not obtained, affecting patient management.
Overdue
Anthony Fraser
Concerns: There is no robust system to ensure that summary medical information from electronic records is conveyed to A&E departments when inmates are referred, which risks delaying diagnosis for other patients.
Response (Nottinghamshire Healthcare NHS Trust): • A collaborative meeting was held to develop a shared system for conveying summary medical information. • A procedure was co-authored, identifying roles and responsibilities for custodial and healthcare staff. … (AI summary)
Responded
Anielka Jennings
Concerns: The coroner noted a lack of an identified lead professional for individuals, particularly children transitioning to adult services, being cared for by numerous agencies, which can lead to communication breakdowns.
Overdue
Stephen McDermott
Concerns: The coroner noted that different electronic record systems across mental health teams resulted in incomplete patient information for assessments. There was also poor use of available records by liaison nurses and insufficient training regarding assessments and record keeping.
Overdue
Leah Ratheram
Concerns: The coroner identified uncoordinated mental health care for young adults (18-25) in crisis, with unclear responsibility and ineffective information sharing between two service providers. Concerns also noted insufficient early involvement of approved social workers in Mental Health Act assessments.
Overdue
Christiana Pelle
Concerns: The coroner noted a lack of clear guidance for community district nurses on GP involvement and insufficient systems for sharing information or escalating concerns among various partner agencies and care providers involved in community patient care.
Overdue
David Birtwistle
Concerns: The coroner identified the need for a national review of serious incidents in 'front door' services to inform future design. NHS 111 should immediately share information with Emergency Departments in a user-friendly format.
Overdue
Constance Connolly
Concerns: The coroner identified gaps in follow-up for a critical scan, insufficient communication with the general practitioner regarding ongoing investigations, and procedural issues that led to the cancellation of an essential outpatient appointment.
Response (The Royal College of Emergency Medicine): • The Royal College of Emergency Medicine recently issued two guidance documents to its Fellows and Members on ensuring test results are followed up. • The College is preparing a … (AI summary)
Response (King's College Hospital NHS Foundation Trust): • The Trust has taken steps to ensure that formal discharge notifications are always sent to a patient's GP, detailing all relevant tests, assessments, and follow-up arrangements, even if the … (AI summary)
Responded
Stephen Leven
Concerns: The coroner identified a lack of secondary care access to GP records, such as a patient's haemophilia diagnosis, which risks future deaths if critical medical information is unavailable.
Overdue
Sam Crick
Concerns: The coroner noted that neuroradiological reviews missed obvious signs of rising intracranial pressure on CT scans, and a critical report was not available for a key neurosurgeon consultation. There was also a lack of a Serious Incident Report for a preventable death.
Response (Barking Havering and Redbridge University Hospitals NHS Trust): • A Significant Incident (SI) notification was completed, and an SI was declared on 31 August 2017, with an investigation ongoing. • The Trust developed a 'Learning Deaths' policy and … (AI summary)
Response (CQC): • The CQC contacted Barking, Havering and Redbridge University Hospital NHS Trust (BHRUT) to request confirmation and evidence of actions taken and planned in response to the PFD report. • … (AI summary)
Response (NHS England): • NHS England stated it would work with the Society of British Neurological Surgeons and the Royal College of Emergency Medicine to produce and distribute national guidance on the use … (AI summary)
Responded
John Griffiths
Concerns: The emergency department lacked a system to check patients' recent presentations or admissions, which meant previous relevant records and investigation results were not routinely accessed.
Response (UHSM): • The Emergency Department system includes an alert on the patient's electronic record to identify previous attendances. • The Trust plans to enhance systems for identifying patient clinical history through … (AI summary)
Responded
Frances Greenhalgh
Concerns: The surgery lacked adequate systems for processing and recording notifications from external healthcare professionals, leading to a General Practitioner being unaware of a treatment plan and insufficient communication with the patient.
Overdue
Percy Jacks
Concerns: The coroner identified inadequate communication between hospital, GP, and care home, including misdirection of scan results. Concerns also noted the GP surgery's poor system for reviewing prescribed medication dosage and duration.
Response (Welsh Government): • Healthcare Inspectorate Wales (HIW) is undertaking a review of discharge arrangements, focusing on communication and documentation. • The Regulation 28 report has been shared with the lead for the … (AI summary)
Response (Rhayader Group Practic): • The practice implemented new procedures for administrative staff to record and follow up on suspected DVT referrals and to inform patients with positive DVT diagnoses about their prescriptions. • … (AI summary)
Response: • A streamlined DVT patient management process and a definite pathway have been introduced. • An investigation was undertaken into the incorrect addressing of the deceased's discharge summary. • The … (AI summary)
Response (CQC): • The CQC revised and improved the wording of its Key Lines of Enquiry for inspections, to be used from November 2017, to clarify how providers meet information transfer requirements … (AI summary)
Responded
Timothy Smedley
Concerns: The coroner identified fragmented care from out-of-hours services due to a lack of joint NHS record access. Concerns also included difficulties for patients with alcohol addiction accessing timely mental health services and insufficient awareness of their complex needs.
Response (Department of Health): • The Department of Health stated it is working to ensure the Summary Care Record is available in more settings and in use in all urgent and emergency care by … (AI summary)
Responded
Paul Mullen
Concerns: The coroner raises concerns about the 'red flag system' for reporting uncollected methadone prescriptions, noting that reports were routed indirectly through GMMH instead of directly to the patient's Key Worker at Addaction, causing delays. This system did not allow for earlier reporting for diligent patients who missed a single dose.
Overdue
Peter Stojilkovic
Concerns: The coroner noted inadequate pre-discharge communication between the hospital and GP regarding melatonin prescription, leading to the patient's unawareness and a risk of sourcing from unlicensed online sources. Inconsistent CCG prescribing guidelines also created uncertainty for GPs.
Response (NHS England): • The Medical Director will review the case with the practice to identify further learning. • The organisation will discuss with Pennine Care the finding regarding advice to access medication … (AI summary)
Overdue
Adrian Jennings
Concerns: The coroner noted issues with multiple IT systems hindering information sharing and patient data capture across the Mental Health Trust and a hospital. Additionally, a necessary mental health support service could not be delivered due to commissioning limitations.
Response (Tameside Glossop CCG): • The Tameside and Glossop Strategic Commissioning Board is investing in additional mental health support services. • The CCG stated it does not recognise a gap in provision for individuals … (AI summary)
Response (NHS England): • The Emergency Department module of the Lorenzo national IT system has been updated to include mandatory data collection fields for 'mode of arrival' and 'Attendance Source', including options for … (AI summary)
Response (Department of Health): • The Department of Health highlighted the 2015 revision of the Mental Health Act 1983 Code of Practice, which includes principles for involving patients' carers and families and multi-disciplinary teams … (AI summary)
Responded
Greg Hutchins
Concerns: The coroner noted a lack of clear purpose and documentation for telephone triage, including no notes, system updates, or staff recollection. There was also no national system for rapid information sharing for patients from outside the local area.
Overdue
Grahame Searby
Concerns: The coroner noted that the mental health team lacked access to the EMIS database for referencing GP data, which affected the information gathering process. The report recommends reviewing operational systems to facilitate such access.
Overdue
Robert Power
Concerns: The coroner identified a risk that patients treated as outpatients could be lost to follow-up care, noting that one patient was not followed up for eight years without explanation.
Response (North Bristol NHS Trust): • The Trust confirmed it operates under different systems compared to 2008. • The Trust stated that processes have been introduced to arrange follow-up appointments. • The Trust stated that … (AI summary)
Responded
Jacob Sulaiman
Concerns: The coroner identified issues with insufficient information sharing and accessibility between care services regarding a patient's recent contacts, leading to an incomplete picture for response officers and potentially affecting assessment and management.
Response (London Borough of Camden): • Camden Council decided to bring the call handling function in-house, ending the contract with Welbeing. • A new IT platform is being implemented to support records management and mobile … (AI summary)
Responded
Select committee recommendations(125)— showing 50 strongest matches
#195 —
Recommendation: The Environment Agency and Natural England work with several organisations, including specific development industry groups, to communicate changes and strengthen the capability of the sector. 249 Nonetheless we heard that there is not a single source of information on issues …
Response attribution not verified
#194 —
Recommendation: Interrelated legislation and guidance, developed in isolation, has made it difficult for developers to understand what they must deliver and when. 248
Response attribution not verified
#39 —
Recommendation: Local planning authorities should work with local partners and, where relevant, upper- tier authorities to share expertise and drive economies of scale. The approach taken by Warwickshire County Council should be considered a best practice example and delivered through two-tier …
Response attribution not verified
#25 —
Recommendation: More urgency is required in developing Electronic Prescription Systems for homecare providers to use. These must be developed in collaboration between homecare providers and NHS trusts. (Paragraph 103) Who is responsible?
Response attribution not verified
#24 —
Recommendation: A single homecare portal should be created and provided by NHS England. If possible this should be linked with existing online services such as the NHS App.
Response attribution not verified
#183 —
Recommendation: Rebecca Robson told us that probation staff are based in her organisation âone or two days a weekâ, and thanks to this âinformation sharing works really well, including about the ongoing riskâ. 349 She explained that âin Cumbria, it is …
Response attribution not verified
#182 —
Recommendation: Voluntary sector organisations ârepeatedlyâ told HM Inspector of Probation that they would like direct access to probation case management systems. 345 âAccess to the authority systems OASys and nDelius would put us in a better position for keeping abreast of …
Response attribution not verified
#181 —
Recommendation: Carrie Peters told us that her company carries out their own âin-depth assessmentâ and that if they realise that persons on probation âneed to be on different pathways or they have a higher level of complexityâ of needs, then they …
Response attribution not verified
#179 —
Recommendation: Damian Hinds MP confirmed that âCommissioned Rehabilitative Service (CRS) providers do not have access to nDelius â¦, OASys â¦, NOMIS (the Prison Serviceâs case management system) or an equivalent system in place in privately contracted prisonsâ. He explained that âthese …
Response attribution not verified
#178 —
Recommendation: Previously, âvoluntary sector providers had direct access to probation case management systemsâ: the case management tool nDelius and the risk assessment tool OASys (see Box 8). 336 They were able to receive and share updates on people on probation, but …
Response attribution not verified
#177 —
Recommendation: Lack of clarity around data protection regulation, some of which came into effect after the IT systems were designed, was put forward as a potential cause of communication problems. Rebecca Robson told us about âprobation practitioners who worry about sharing …
Response attribution not verified
#176 —
Recommendation: Rudimentary facts are often missing. Niki Scordi told us that âbasic information like accurate contact detailsâ is often missing in initial referrals. 332 Carrie Peters added that âpractical changes like someone having moved address or having a different officerâ are …
Response attribution not verified
#175 —
Recommendation: Communication issues persist after initial referrals. Carrie Peters told us that ârisk and need are dynamicâ, meaning that the risk presented by an offender, as well as their rehabilitative needs, may evolve while they are on probation. She explained that …
Response attribution not verified
#174 —
Recommendation: Communication issues arise at referral stage. Damian Hinds MP told us that âProbation practitioners are required to share information with CRS [Commissioned Rehabilitative Services] providers to enable them to engage with people on their caseloads appropriately and be responsive to …
Response attribution not verified
#173 —
Recommendation: Besides the commissioning process, we also sought evidence on the operation of existing contracts. Witnesses told us about communication issues between the Probation Service and its partners, focusing specifically on referral mechanisms, updates on needs and risk assessments, and the …
Response attribution not verified
#163 —
Recommendation: The Probation Service is aware of these challenges. Chris Jennings told us that âthere are still definitely areas where sharing information across the system is complicatedâ. For instance, he told us that âgetting information on child safeguarding is not straightforwardâ …
Response attribution not verified
#159 —
Recommendation: In terms of best practice in information sharing, the APPC pointed to the example of âsharing discussionsâ which arise from âMulti-Agency Public Protection Arrangements (MAPPA)â. These are âstatutory arrangements bringing together the police, probation and prison services to assess and …
Response attribution not verified
#43 —
Recommendation: HMPPS should continue investing in its IT systems, such that Probation staff can dedicate more time to people on probation (see also section starting at paragraph 166 on âmaking the most out of partnershipsâ on the partners of the Probation …
Response attribution not verified
#35 —
Recommendation: The Probation Service should improve communications with its partners. This could include guidance on what can, or cannot, be shared under data protection legislation . It should consider granting them direct access to its databases , as used to be …
Response attribution not verified
#32 —
Recommendation: The Probation Service, however, is not making the most out of these partnerships. Referrals do not always contain sufficient information, risk assessments are not always produced and shared in a timely manner, and commissioned partners find it difficult to feed …
Response attribution not verified
#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 …
Response attribution not verified
#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 status not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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.
Response attribution not verified
#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 …
Response attribution not verified
#197 —
Recommendation: The Probation Service should improve communications with its partners. This could include guidance on what can, or cannot, be shared under data protection legislation. It should consider granting them direct access to its databases, as used to be the case …
Response attribution not verified
#194 —
Recommendation: The Probation Service, however, is not making the most out of these partnerships. Referrals do not always contain sufficient information, risk assessments are not always produced and shared in a timely manner, and commissioned partners find it difficult to feed …
Response attribution not verified
#164 —
Recommendation: Community sentences are more effective when the Probation Service is a fully engaged member of local partnerships, be it through the co-location of services or through cooperation forums, allowing information to circulate. This benefits offenders and there is also a …
Response attribution not verified
#161 —
Recommendation: While we heard about best practices in the local delivery of probation services, we were also told that communication may be difficult among the various local agencies involved in the delivery of community sentences. Justin Russell, for instance, told us …
Response attribution not verified
#28 —
Recommendation: Community sentences are more effective when the Probation Service is a fully engaged member of local partnerships, be it through the co-location of services or through cooperation forums, allowing information to circulate. This benefits offenders and there is also a …
Response attribution not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 status not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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, …
Response attribution not verified
#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 …
Response attribution not verified
#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 …
Response attribution not verified
#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.
Response status not verified
#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.
Response attribution not verified
#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.
Response attribution not verified
#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.
Response attribution not verified
#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.
Response attribution not verified
#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, …
Response attribution not verified
HSSIB safety recommendations(103)— showing 50 strongest matches
Electronic patient record systems – electronic referrals for ongoing care
Organisations can improve patient safety by ensuring the mandated requirements for digital clinical risk management (under DCB0160) for the deployment of the electronic referral service (e-RS) are achieved. For general practices and integrated care boards this includes agreeing responsibilities for …
Safety Observation
Electronic patient record systems – electronic referrals for ongoing care
HSSIB recommends that NHS England/Department of Health and Social Care, in collaboration with relevant Royal Colleges: commissions the development of advice and guidance request and response templates for specialties where these do not exist, including general practice supports effective implementation …
Safety Recommendation
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
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
NCEPOD recommendations(57)— showing 50 strongest matches
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Just Say Sepsis!
Wording not shown. See the report on NCEPOD's website.
Just Say Sepsis!
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Treat as One
Wording not shown. See the report on NCEPOD's website.
Treat as One
Inspiring Change
Wording not shown. See the report on NCEPOD's website.
Inspiring Change
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
Acute Heart Failure
Wording not shown. See the report on NCEPOD's website.
Acute Heart Failure
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Mental Healthcare in Young People and Young Adults
Wording not shown. See the report on NCEPOD's website.
Mental Healthcare in Young People and Young Adults
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
In Hospital Care of Out-of-Hospital Cardiac Arrests
Wording not shown. See the report on NCEPOD's website.
In Hospital Care of Out-of-Hospital Cardiac Arrests
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
End of Life Care
Wording not shown. See the report on NCEPOD's website.
End of Life Care
Rehabilitation following critical illness
Wording not shown. See the report on NCEPOD's website.
Rehabilitation following critical illness
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
Acute illness in people with a learning disability
Wording not shown. See the report on NCEPOD's website.
Acute illness in people with a learning disability
Each and Every Need
Wording not shown. See the report on NCEPOD's website.
Each and Every Need
On The Right Course?
Wording not shown. See the report on NCEPOD's website.
On The Right Course?
Highs And Lows
Wording not shown. See the report on NCEPOD's website.
Highs And Lows
Dysphagia in Parkinson’s Disease
Wording not shown. See the report on NCEPOD's website.
Dysphagia in Parkinson’s Disease
Physical Healthcare in Mental Health Inpatient Settings
Wording not shown. See the report on NCEPOD's website.
Physical Healthcare in Mental Health Inpatient Settings
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Prison Healthcare
Wording not shown. See the report on NCEPOD's website.
Prison Healthcare
Blood sodium
Wording not shown. See the report on NCEPOD's website.
Blood sodium
CQC inspection actions(92)— showing 50 strongest matches
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
Westmorland General Hospital
The service should implement effective use of the whiteboard communications system on the birth centre.
Should Do
Westmorland General Hospital
The service should act to improve the quality of safety information shared in situation, background, assessment and recommendation (SBAR) handover.
Should Do
Westmorland General Hospital
The trust should consider ensuring that there is a doctor or consultant at all safety huddles so that clinical information is not omitted from being shared with nursing staff.
Should 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
Salford Royal Hospital
The trust should consider the use of Situation, Background, Assessment, Recommendation (SBAR) for handover processes.
Should Do
Salford Royal Hospital
The trust must ensure that records are completed contemporaneously and all are accessible to staff providing care.
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
Rochdale Infirmary
The trust should consider the use of Situation, Background, Assessment, Recommendation (SBAR) for handover processes.
Should Do
Pilgrim Hospital
The service must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must Do
Pilgrim Hospital
The trust must ensure systems and processes to check nationally approved child protection information sharing systems are fully embedded and compliance is monitored.
Must Do
North Manchester General Hospital
The trust should ensure they review the trauma pathway so that all information relating to the patient is conveyed to staff on the day surgery ward, so that they can assess the patient’s suitability for admission.
Should Do
Mount Vernon Cancer Centre
The trust must ensure that all necessary staff have access to records and information systems to enable them to review patient details. This includes investigation results from other providers.
Must Do
Mount Vernon Cancer Centre
The trust must ensure that all medical staff have access to electronic patient systems to enable them to review patient details.
Must Do
Lister Hospital
The trust should consider ways to enable visiting psychiatrists to use ED prescribing systems.
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
Kidderminster Hospital and Treatment Centre
Monitor turnaround times for clinic letters to be issued to GPs to ensure national standards are met.
Should Do
Kidderminster Hospital and Treatment Centre
The serviceshould consider implementing an electronic notes system.
Should Do
Kidderminster Hospital and Treatment Centre
Develop systems for more joined up working across divisions to monitor and share referral to treatment time information and manage service capacity and demand.
Should Do
Kidderminster Hospital and Treatment Centre
The trust should ensure systems support the tracking of and response to specialist referrals across the sites.
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
Hemel Hempstead General Hospital
The trust should ensure that records are always clear, up-to-date or easily available to all staff providing care.
Should 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
Clatterbridge Hospital
The service must comply with the national information sharing standard designed to safeguard children who were looked after or in protection.
Must Do
Clatterbridge Hospital
The service must ensure that staff share key information, in line with trust policy, when handing over the care of patients who are medical outliers or moved into escalation areas. It must ensure these patients receive regular senior medical reviews.
Must Do
Castle Hill Hospital
The service should consider reviewing and revising the electronic system to ensure all staff have access and the system allows personalisation of care plans
Should Do
The Walton Centre
The service should consider how to minimise the impact of patient records being in different formats, to ensure all staff can access information in a timely manner.
Should Do
St Benedict's Hospice
The trust should continue to explore ways to improve access to electronic systems with the local mental health trust.
Should Do
St Benedict's Hospice
The service should work to ensure that a situation, background, assessment, recommendation (SBAR) handover is used in all areas in the maternity service, including theatres, in line with trust policy.
Should Do
Fairfield General Hospital
The trust should consider the use of Situation, Background, Assessment, Recommendation (SBAR) for handover processes.
Should Do
Fairfield General Hospital
The trust should ensure they review the trauma pathway so that all information relating to the patient is conveyed to staff on the day surgery ward, so that they can assess the patient’s suitability for admission.
Should Do
Warrington Hospital
The serviceshouldensurethatelectronicpatientrecordsareintegratedasfarasispossibletoavoidtheriskofmissed information.
Should Do
Victoria Infirmary
The service should continue to identify actions to enhance access to and use of electronic records in community locations and special schools.
Should Do
Victoria Infirmary
The trust should continue to prioritise the introduction of electronic patient records.
Should Do
Tower Hamlets Out of Hours GP Service
Review how two separate databases are used to record patient information, and to store policies and procedures.
Should Do
The Royal Orthopaedic Hospital
The trust should continue to develop solutions to overcome its fragmented information systems
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
Royal Sussex County Hospital
The trust should develop a system that ensures that patient diaries stay with the patient when they leave critical care.
Should Do
Royal Bolton Hospital
The trust must ensure that records relating to care and treatment of each person using the service are accessible to authorised people as necessary to deliver people’s care through improved IT connectivity.
Must Do
Rochdale Infirmary
The trust should ensure they review the trauma pathway so that all information relating to the patient is conveyed to staff on the day surgery ward, so that they can assess the patient’s suitability for admission.
Should Do
Family Nurse Partnership & Health Visiting
The service should ensure consistent approaches to frequency of meetings and sharing risk information with other agencies, for example with local GP practices.
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
Durham Diagnostics and Treatment Centre
The trust should continue to explore ways to improve access to electronic systems with the local mental health trust.
Should Do
Clifton Hospital
The trust should ensure the trust improves and monitors the use of patient passports in all surgical areas.
Should Do
Chesterfield Royal Hospital
The service should consider implementing a structured approach to all handovers between clinical staff.
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
Addenbrooke's and the Rosie Hospitals
The service should ensure the electronic records management system had the ability to transfer electronic patient record from multiple systems and community and could be reorganised easily to meet the needs of patients.
Should 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
Health investigations(1186)
Independent investigation: Alan Riddock, Bristol (2008) — Rec 8
The Avon and Wiltshire Mental Health Partnership NHS Trust should ensure that it has in place robust mechanisms for the handing over of clinical information and responsibilities when a clinician retires or moves from a clinical team. The Trust should put in place appropriate mechanisms to ensure that these protocols …
south_west
Independent investigation: Alan Clarke, Salisbury (2008) — Rec 8
• The Trust should agree a protocol with the Local Authority, which provides the out of hours emergency duty system, to ensure that assessments undertaken out of hours are forwarded in a timely manner to Mental Health teams who will ensure that these assessments are uploaded on to the Trust’s …
south_west
Independent investigation: Alan Clarke, Salisbury (2008) — Rec 4
If clinicians are to conduct robust and reliable assessments of risk and need it is essential that they have access to all relevant historical information. Given that the Trust does not provide CAMH services it cannot, on its own, put in place a protocol or mechanism to ensure that information …
south_west
*Mental health homicide investigation legacy report into the care and … — Rec L4
The trust should continue to develop relationships with partnership agencies. This should include reviewing the protocols with partnership agencies to ensure effective communication and information sharing for the safety of patients and the general public e.g. information to service providers such as housing associations and hostels. This should take place …
south_east
Independent investigation: Stelios Economou, Hatch End Station,Pinner (1999) — Rec (xv)
The Trust should make arrangements for a system of record keeping which enables clinicians and all other mental health staff with responsibility for monitoring a service user to have access to the entirety of the case notes.
london
Independent investigation: Rosalind McManus, Birch Hill H, Rochdale, Lancs (2007) — Rec 6
The Trust should ensure the implementation of the electronic care record supports and enhances MDT working.
north_west
Independent investigation: Katie Kazmi, Reading (1999) — Rec 16
In order that adequate care can be maintained the trusts and social services should ensure that hand-over procedures are developed to enable all staff to be fully acquainted with the patient’s history and care plans. Hand-overs should not be merely oral.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 14
The trusts’ risk management policy should require consideration of whether: • the individual is a driver with access to a car; • driving for that individual would give rise to a significant risk; • the risk is such that advice is given not to drive • carers and significant others …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 11
Tertiary services should follow local CMHT models for the integration of records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 7
The trusts should take urgent action to review clinical files and establish a universal system highlighting, and regularly reviewing: a basic chronology; a risk management plan including relapse profile; a care plan and clinical reviews.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 6
Trusts and social services should review the standard of recording, and consider adopting a system of unified records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 14
In order that adequate care can be maintained the trusts and social services should ensure that hand-over procedures are developed to enable all staff to be fully acquainted with the patient’s history and care plans. Hand-overs should not be merely oral.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 6
Tertiary services should follow local CMHT models for the integration of records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
Social services and trusts and should review the standard of recording, and consider adopting a system of unified records.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 13
The Home Office and the DofH should prepare a model information leaflet for the use of professionals (including housing), family and carers who are involved with conditionally discharged patients. The leaflet should explain the patient’s legal status and contain the names and contact information for both supervisors and those others …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 12
The Home Office should ensure that the chief constable’s letter contains a summary of the index offence (c.f. the social supervisor’s) and a précis of other convictions, and direct that: the information is copied to both the police national computer and local force intelligence; such information should only be inputted …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 9
The Home Office should require that supervisors’ reports contain information on: the frequency and venue of meetings; home and work circumstances; the views of the care team other than the supervisors.
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
The trusts’ risk management policy should require consideration of whether: • the individual is a driver with access to a car; • driving for that individual would give rise to a significant risk; • the risk is such that advice is given not to drive; • carers and significant others …
south_east
Independent investigation: Katie Kazmi, Reading (1999) — Rec 2
The DofH and The Home Office should prepare a model information leaflet for the use of professionals (including housing), family and carers who are involved with conditionally discharged patients. The leaflet should explain the patient’s legal status and contain the names and contact information for both supervisors and those others …
south_east
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 11
Given that new protocols have now been put in place the local Housing Associations, the Trust and the commissioners of mental health services should institute a monitoring system to ensure that: the proper roles and responsibilities of these organisation are adhered to; the protocol for sharing information is adhered to; …
north_east_yorkshire
Independent investigation: Eddie Thorpe, Dewsbury (2008) — Rec 10
The PCT should put in place a system to ensure that there is timely communication between primary care and secondary care services. This should include: a mechanism to ensure that Secondary Services are informed, in a timely manner, who has clinical responsibility in Primary Care, for a service user where …
north_east_yorkshire
Independent investigation: Bridget MaclennanElizabeth Valad, Camden — Rec 1
While it remains important to all concerned that voluntary sector resources are independent of the local mental health service, all CMHT’s should meet with their local voluntary sector resources to develop protocols for regularly recording and sharing information about individuals in contact with them, especially that relevant to risks to …
london
Independent investigation report into the care and treatment of Yusuf — Rec 3
Parents and relatives raised repeated concerns over time and across providers that his presentation was not his usual self. They took videos and pictures to document his presentation in an attempt to demonstrate their concerns. The history of concerns over the preceding week prior to admission was not clearly apparent …
York Road Surgery; The Rotherham NHS Foundation Trust; Sheffield Children’s NHS Foundation Trust; Yorkshire Ambulance Service NHS Trust
north_east_yorkshire
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 3
Westminster City Council Social Services Department should review its arrangements for liaison with the criminal justice system to ensure that relevant information is exchanged in a timely and effective manner, particularly in relation to bail decisions and the provision of appropriate adult services. This review should include consideration of dedicated …
london
Independent investigation: WPC Nina Mackay, Stratford, London (1997) — Rec 1
NHS Trusts and Health Authorities should ensure that there is a clear procedure for the transfer of the statutory after-care duty on mental health services when an individual moves away from an area, together with a standard format for passing on pertinent information on risk management. This should include a …
london
Independent investigation: Stuart Robertson, Glasgow (2004) — Rec 11.1.2
The Health Board must ensure that written risk assessments and management plans are shared between all members of the clinical team and are easily available in the patient’s case notes. For restricted patients, it should consider sharing them with general practitioners and other primary care staff who may come into …
scotland
Independent investigation: Simon Breed, Wood Green (2004) — Rec R11
Until a fully integrated electronic information system is available protocols should be developed to provide guidance as to the documentation that should be reviewed in all CPA cases at the time of allocation, review, transfer and closure.
london
Independent investigation: Simon Breed, Wood Green (2004) — Rec R3
The trust should establish a database (or modify existing databases) of all patients who are entitled to section 117 MHA aftercare. The database should contain or link with details of CPA aftercare plans as well as risk assessment and risk management information. One of the purposes of such a database …
london
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The Government should consider establishing an independent committee to review the subject of the supply and dissemination of information within the services dealing with people in need of treatment, care and control.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec 4
The Case Worker Guide should be updated to require information not just from the RMO but from others who will bear responsibility for the after-care of the patient.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Four general measures in respect of restricted patients should be considered by the Home Office: 1. C3 Division of the Home Office should act as a repository of information about the patient's index offence(s); 2. The procedures and practices of C3 Division could usefully be compared with Home Office practice …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
The medical member of the tribunal should expect the hospital to provide a set of summary documents with reports from the professionals involved in the multi-disciplinary teams responsible for the patient's care and treatment.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
In any case where the criminal event involving a mentally disordered person is serious or dangerous, it should be the responsibility of the Crown Prosecution Service to prepare a full account of the criminal event before criminal proceedings have been finalised. The CPS should also ensure that this account is …
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Social Services Departments which transfer case responsibility for restricted patients should also transfer the case records.
east_of_england
Independent investigation: Robert MitchellArthur WilsonShirley Wilson, Bramford, Suffolk (1994) — Rec B
Significant contributions to clinical assessments by professional staff in disciplines other than psychiatry and nursing should be captured systematically, e.g. in the compilation of reports for case conferences, other reviews and hospital transfers.
east_of_england
Independent investigation: Richard Marden, Towcester (1999) — Rec 9
That work on extending electronic links between primary and some aspects of secondary care in the NHS be extended as soon as possible to key communications between primary and secondary mental health services.(Para 12.5)
midlands
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.3.c
Probation service Communication between the probation and mental health services should be clarified, in relation to a person on either standard or enhanced CPA and subject to a probation order.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.3.b
Inpatient teams, the CMHT, and vice versa. We noted difficulties in communicating information from inpatient to community teams on a patient’s admission and discharge. For example a patient taking their own discharge against medical advice could result in a delay in the transfer of relevant information. Likewise, we were told …
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.3.a
Primary health care We were told that it was sometimes difficult for a GP to obtain feedback if his /her patient had been in contact with either community or inpatient psychiatric services.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.3
We list below some of the communication issues that have been raised in this report. We recommend that the Mental Health Trust consider gathering data and identifying solutions to the following problems:
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.2.g
Procedures and information systems Mental health services should develop clear policies and procedures relating to their interface with MAPPA. Mental health services may consider developing systems to ensure that without breaching confidentiality, patients known to both mental health and probation services can be identified and so managed safely.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.2.f
Guidelines The Trust should develop guidance relating to the duty to cooperate and the circumstances in which information can be shared. Staff should be provided with training relevant to their roles and responsibilities in this area.
london
Independent investigation: Richard Loudwell, Broadmoor (2004) — Rec 20.1.d
Inpatients The use of the phrase ‘the transfer of relevant information’ from hospital team to community-based staff should be re-evaluated. Consideration should be given to itemising information to be made available where a patient is being discharged from an inpatient setting.
london
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.18.5
The issue of the disclosure of case notes and other information is one of the principal causes of delay. There should be a tight timescale for the disclosure of documents and information required by the panel.
south_west
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.12
NHS Trusts, the Probation Service, and the Court Service should review the protocols concerning the sharing of information and in particular pre-sentence reports and psychiatric reports in the case of patients who are receiving treatment at a time when they are before the court, and/or under supervision on licence.
south_west
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.11
On receipt of referrals from prison or probation service the receiving member of the team should request a full history of the patient’s offence record from the referrer, and a member of the team should be allocated to the patient to liaise with the prison or probation service about the …
south_west
Independent investigation: Philip Hendy, Bristol (2007) — Rec 11.8
There should be a unified case record for every patient that is filed logically, is capable of being viewed and searched in its entirety, and is accessible to all who might reasonably require to refer to it. The current set of records should include all key documents. There should be …
south_west
Independent investigation: Philip Ellison, Preston (2008) — Rec 11
The Trust should ensure that there is full information exchange between care coordinators when case responsibility is transferred. There should be a system in place to ensure continuity of care when service users are seen by junior doctors under the supervision of a Consultant Psychiatrist .
north_west
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 12
Patient records should be maintained electronically with one core record to which all team members should have access and onto which entries by all mental health workers (including medical staff) relating to the patient must be added.
north_east_yorkshire
Independent investigation: Peter PurcellJoyce PurcellKeith PurcellGlen Purcell, Benwell, Newcastle (2006) — Rec 11
A system must be devised and introduced to ensure that if there is more than one patient at any particular address that fact is recognised and brought to the attention of all secondary mental health workers involved.
north_east_yorkshire
Scottish Fatal Accident Inquiries(22)
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
Stephen Masson
The sheriff having considered the information presented at the Inquiry, in terms of section 26(1)(b) of the Act, in having regard to matters mentioned in section 26(4) of the Act recommends that: (1) A note of all ongoing prescriptions currently prescribed to a patient should be registered with the NHS regardless of the prescriber to allow healthcare professionals immediate access …
Mar 2023
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.
Nov 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 …
Dec 2015
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 …
Nov 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
1 rec
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
11 recs
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)
Independent reviews(50)
Owens Review — Rec 18
That this strategy considers the effectiveness of the current separate Courts, HMPPS and Justice Digital transformation programmes, which may be creating unnecessary and counter-productive system divide. The Ministry of Justice's Permanent Secretary, with system leaders, should examine whether structural changes could aid the ambition to have a joined-up technology approach …
Justice & Legal
Owens Review — Rec 17
A plan for developing a clear cross agency strategy for the criminal justice system is agreed and driven by Government. This must include a complementary technology and data strategy with specific actions to make substantial and connected changes to the technology provision directly and determinedly creating systems that interact with …
Justice & Legal
Owens Review — Rec 15
The Ministry of Justice with HMPPS & HMCTS develop a shared target operating model for working together, including on communicating sentences and sharing critical information, without which I am almost certain it will be impossible to bring the number of releases in error down. This should consider: Information shared about …
Justice & Legal
Caldicott Review 2013 — Rec 22
The information governance advisory board to the Informatics Services Commissioning Group should ensure that the health and social care system adopts a single set of terms and definitions relating to information governance that both staff and the public can understand. These terms and definitions should begin with those set out …
Health & Social Care
Caldicott Review 2013 — Rec 20
The Department of Health should lead the development and implementation of a standard template that all health and social care organisations can use when creating data controller to data controller data sharing agreements. The template should ensure that agreements meet legal requirements and require minimum resources to implement.
Health & Social Care
Caldicott Review 2013 — Rec 18
The Department of Health and the Department for Education should jointly commission a task and finish group to develop and implement a single approach to recording information about 'the unborn' to enable integrated, safe and effective care through the optimum appropriate data sharing between health and social care professionals.
Health & Social Care
Caldicott Review 2013 — Rec 4
Direct care is provided by health and social care staff working in multi-disciplinary 'care teams'. The Review Panel recommends that registered and regulated social workers be considered a part of the care team. Relevant information should be shared with members of the care team, when they have a legitimate relationship …
Health & Social Care
Caldicott Review 2013 — Rec 2
For the purposes of direct care, relevant personal confidential data should be shared among the registered and regulated health and social care professionals who have a legitimate relationship with the individual. Health and social care providers should audit their services against NICE Clinical Guideline 138, specifically against those quality statements …
Health & Social Care
Wachter NHS IT Review — Rec 9
Ensure Interoperability as a Core Characteristic of the NHS Digital Ecosystem – to Promote Clinical Care, Innovation, and Research. The new effort to digitise the NHS should guarantee widespread interoperability. The goals of interoperability are to enable seamless care delivery across traditional organisational boundaries, and to ensure that patients can …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 21
Until such a system is developed, a National Breast and Cosmetic Implant Registry should be established and operational within 12 months. All cosmetic surgery providers need to keep a minimum data set that should be defined by the RCS Interspecialty Group. This should include details of the implant, the surgeon, …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 20
A system should be developed by the MHRA to link the Unique Device Identifier for all implants to the patient's electronic record, enabling routine collection through Hospital Episode Statistic (HES) data. This information would enable assessment of implant performance, and the tracking and tracing of patients in case of a …
Health & Social Care
Keogh Cosmetic Interventions Review — Rec 12
All providers must keep full patient records, including clear operative records and precise details of any implant or device used. Providers should also be able to access data of implant cohorts readily and this should be available to regulatory authorities. Details of the surgery and implant used must be sent …
Health & Social Care
Mental Health Taskforce 2016 — Rec 45
The Department of Health and HSCIC should advocate the adoption of data-rich Summary Care Records that include vital mental health information, where individuals consent for information to be shared, by 2016/17.
Health & Social Care
Mental Health Taskforce 2016 — Rec 44
By 2020/21, NHS England and NHS Improvement should work with the HSCIC and with Government to ensure rapid using and sharing of data with other agencies. The Department of Health should hold the HSCIC to account for its performance, and consult to set minimum service expectations for turning around new …
Health & Social Care
Goldacre Review — Rec IG 22
Ensure DHSC can access data when appropriate The management and delivery of NHS care is complex, changeable, and spread across a wide range of organisations. However, we have not encountered any convincing argument why analysts in the Department of Health and Social Care should not be entitled to a legal …
Health & Social Care
Goldacre Review — Rec IG 20
Address the “multiple permissions” problem NHS patient data is a vital and powerful resource for improving the quality, safety, and efficiency of healthcare. This requires that data is accessible. The current requirement to obtain permission separately from each organisation for each act of data sharing is a substantial practical barrier …
Health & Social Care
Goldacre Review — Rec IG 4
Create an arbitrator for disagreements over specific access requests Disagreements over access should reduce when data controllership has been streamlined across the NHS, and where strong TREs reduce privacy risks. However, issues may still arise, especially when trying to link to datasets outside of NHS control. In these circumstances, an …
Health & Social Care
Goldacre Review — Rec IG 2
Streamline the number of approvals meetings Researchers regularly have applications rejected because of the need for clarification of another aspect of their permissions from another approval body. As with the single form above, where possible, whenever one project requires multiple permissions from multiple bodies, this should be addressed at a …
Health & Social Care
Goldacre Review — Rec IG 1
Create a single form for all ethics, IG, and other data access permissions Researchers are regularly required to describe the same aspects of the same project in multiple different ways for multiple different organisations to approve multiple different aspects of their permissions separately. Researchers should be able to fill in …
Health & Social Care
Goldacre Review — Rec TRE 41
Academic TREs should use standard NHS TRE Service Wrapper and governance There is a very diverse array of governance and access arrangements across a very wide range of DAEs and TREs delivered or funded through the academic community, including a large number of new projects created only very recently. This …
Health & Social Care
Goldacre Review — Rec TRE 8
Expand the National TRE in time to accept bespoke datasets The Minimum Viable Product for the National TRE must be to support the core national datasets. However, there are many external datasets - such as the cohorts, registries and audits - that rely on ingesting large volumes of national EHR …
Health & Social Care
Goldacre Review — Rec TRE 7
Include GP data and certain commonly used national datasets from the start The first iteration of a national TRE should contain the key, commonly used national datasets including GP data, HES/SUS, and prescribing data. GP data is by far the most challenging dataset to support; the others represent a marginal …
Health & Social Care
Goldacre Review — Rec Open 42
All Trusted Research Environments for NHS data must facilitate and require code sharing All national TREs should be designed such that researchers are able to use services such as GitHub and Gitlab; and ideally require such that code is shared by default. This must be a core part of the …
Health & Social Care
Goldacre Review — Rec Open 8
Amend the Code of Practice for the Research Powers of the Digital Economy Act The Department of Health and Social Care and the UK Health Security Agency should work with the Department of Digital, Culture, Media and Sport to make a minor amendment to the Code of Practice for the …
Health & Social Care
Goldacre Review — Rec Open 7
Data Controllers should require RAP and open code sharing from data users Data controllers and especially the NHS should require all those accessing patients’ data to share all analysis code, or openly argue for exceptions in single cases. Where the system is in a period of transition, this should be …
Health & Social Care
Goldacre Review — Rec NHSA 22
Improve the provision of data analysis environments In the sections on Trusted Research Environments and Information Governance there are a range of detailed recommendations to ensure that local service analysts have access to data in environments that support modern, open approaches to computational data science, and to ensure that data …
Health & Social Care
Goldacre Review — Rec S25
Address the problem of 160 Trusts and 6,500 GPs all acting as separate data controllers: either through one national organisation acting as Data Controller for a copy of all NHS patients’ records in a TRE; or an “approvals pool” where Trusts and GPs can nominate a single entity to review …
Health & Social Care
Goldacre Review — Rec S22
Rationalise approvals: create one map of all approval processes; require all relevant organisations to amend it until all agree it is accurate; de-duplicate work by creating a single common application form (or standard components) for all ethics, information governance, and other access permissions; coordinate shared meetings when approval requires multiple …
Health & Social Care
Harris Review: Deaths in Custody — Rec 85
The Secretary of State for Justice should introduce legislation to create a statutory duty of cooperation for the sharing of information with the Prison Service to be placed upon those organisations that have direct engagement with the Prison Service (including health, mental health services, police, etc.). Primary Recommendations
Justice & Legal
Harris Review: Deaths in Custody — Rec 82
Guidance from health organisations should be considered to reflect the duties of the State to protect life in custodial settings, with appropriate guidance given as to the disclosure and sharing of health information in such settings (including in those instances where consent is not provided).
Justice & Legal
Harris Review: Deaths in Custody — Rec 79
Department of Health, Home Office and the Ministry of Justice need to issue joint guidance to the effect that when consent to sharing medical information has been given by a person in custody, then the assumption is that that consent remains valid (unless withdrawn) throughout the criminal justice journey of …
Justice & Legal
Harris Review: Deaths in Custody — Rec 78
Any health assessment (both physical and mental) produced at the police station by the liaison and diversion practitioner and others at the start of a prisoner’s journey through the criminal justice system should be shared amongst specified CJS organisations (e.g. CPS, legal team, NOMS, HMPS) in order to assist them …
Justice & Legal
Harris Review: Deaths in Custody — Rec 77
A record of any time a prisoner has spent on an ACCT/or the crisis plan of a SAVRAS must be recorded on System 1(or replacement) so that it is available for prison healthcare staff.
Justice & Legal
Harris Review: Deaths in Custody — Rec 74
When the transfer is between the youth estate and an adult institution, the YJB will be accountable for the transfer of all relevant information from the YOT, including health, mental health and care leaver status.
Justice & Legal
Harris Review: Deaths in Custody — Rec 68
There should be a consistent approach throughout the criminal justice system to requesting consent to share medical information, which should happen at the first point of contact with the health services in a CJS setting, whether that be at a police station or at a prison, and that that consent …
Justice & Legal
Sayce Review — Rec 2k
Government should, longer term, radically simplify assessment, thereby saving time, money and bureaucracy. There should be an aspiration to a single, portable assessment covering employment, health and social support needs as well as benefit entitlement.
Other
Laming Review (Baby P) — Rec 23
Every Children's Trust should assure themselves that partners consistently apply the Information Sharing Guidance published by the Department for Children, Schools and Families and Department for Communities and Local Government to protect children.
Other
Laming Review (Baby P) — Rec 18
Whether or not a national system is introduced, the Department for Children, Schools and Families should take steps to improve the utility of the Integrated Children's System, in consultation with social workers and their managers, to be effective in supporting them in their role and their contact with children and …
Other
Laming Review (Baby P) — Rec 17
The Department for Children, Schools and Families should undertake a feasibility study with a view to rolling out a single national Integrated Children's System better able to address the concerns identified in this report, or find alternative ways to assert stronger leadership over the local systems and their providers. This …
Other
Laming Review (Baby P) — Rec 12
The Department of Health and the Department for Children, Schools and Families must strengthen current guidance and put in place the systems and training so that staff in Accident and Emergency departments are able to tell if a child has recently presented at any Accident and Emergency department and if …
Other
Black Review on Health and Work — Rec 6
The paper-based sick note should be replaced with an electronic fit note, switching the focus to what people can do and improving communication between employers, employees and GPs.
Health & Social Care
Tickell Review of the EYFS — Rec 14
I recommend that an insert is added to the early childhood health record, known as the Red Book, to encourage parents and carers, or their nominee, to enter information arising from this early years summary and from children's interaction with other professionals, for example speech and language therapists.
Education
Selous Review — Rec 99
The Ministry of Defence and the Armed Forces to address improvements in communication with families as a key priority by: • exploring and implementing changes to the JPA DPA questions to encourage Service personnel to give permission for their spouses/partners to receive direct communications • supporting the development and availability …
Other
Selous Review — Rec 95
The Ministry of Defence to establish a dedicated Serving Families Gateway, separate from the Veterans’ Gateway, to collate information and advice about the support available, and ensure greater coordination of the range of interventions and how to access them.
Other
MacAlister Review — Rec 19
Government should set a target to achieve frictionless sharing of information between local authority and partner systems and between different local authorities by 2027. To enable this they must take an imminent decision on whether to adopt the NHS number as a consistent identifier alongside work by the National Data …
Education
Wessely Review — Rec 149
Work should be carried out to streamline activity undertaken between NHSE, NHSD, NHSI, CQC, Tribunals and providers, to include improved digitisation of notifications such as early discharge to avoid late cancellation of tribunal hearings.
Health & Social Care
Accepted
Wessely Review — Rec 146
A national MHA data hub should be established to pull together and routinely analyse MHA data across NHS services, exploring possibilities for developing linkages across the various datasets, local authorities and policing.
Health & Social Care
Accepted
Wessely Review — Rec 141
The Department of Health and Social Care and the Ministry of Justice should work together to remove the gap in provision of information to victims of crimes committed by unrestricted patients, and to make sure victims are aware of their ability to make impact statements to the Tribunal in appropriate …
Health & Social Care
Accepted
Angiolini Review — Rec 31
Forensic Medical Examiners and other medical services within police stations should be brought within NHS commissioning, in order to introduce minimum standards of medical care in police custody and so that medical records of the individual are quickly available to the doctor.
Policing & Security
Accepted
Stevenson/Farmer Review — Rec 33
We recommend that Government and the NHS work to improve patient access to their personal health record, empowering employees to share their data and information with their employer when they wish to do so, where it can be done safely and securely, to support people to thrive in work.
Employment & Work
Accepted
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
Domestic Homicide Reviews(1147)— showing 50 strongest matches
Bury — recommendation 2
Review MASH information sharing Pathway within PCFT.
Pennine Care NHS Foundation Trust
Pennine Care NHS Foundation …
Portsmouth — recommendation 1
All referrals made by 111 and the emergency operations centre to be referred electronically.
Southcoast Ambulance Service (SCAS)
Lincoln — recommendation Recommendation 6
The Safer Lincolnshire Partnership and Lincolnshire Safeguarding Children Partnership should seek assurance from partners that their information sharing systems, ensure that in cases of domestic abuse, information is being shared in a timely and appropriate manner and that the voluntary sector are included as an integral part of information sharing …
Safer Lincolnshire Partnership | Lincolnshire Safeguarding …
Lincoln — recommendation iii)
The Trust’s Head of Safeguarding to meet with the Trust Named Doctors for Safeguarding and the Trust Medical Director to review the process of how a safeguarding concern disclosed within an outpatient’s appointment is cross referenced with the record and the care coordinator to ensure it has already been identified …
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation i)
The Trust to review how known risks and risk management plans identified within the Police custody environment translate from the CJL&D ‘Assessment of Needs and Outcomes’ into the ‘Clinical Risk Framework’ (where other LPFT services are involved or later become involved) to ensure the Clinical Risk Framework is a complete …
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
Lincoln — recommendation iii)
Internal Children Services review of MOSAIC recording and reporting of CIN meetings and attendance of partner agencies.
Lincolnshire County Council Children Services
Doncaster — recommendation 1
Improving MARAC communication to primary care
Doncaster Clinical Commissioning Group
West Lancashire — recommendation 25
WLCSP to seek assurances that the process to ensure timely escalation of safeguarding concerns from other agencies, via letters are shared with GP leads via Practice administration staff regarding safeguarding risks/ vulnerability and DA
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
West Lancashire — recommendation 20
WLCSP to seek assurances that prompt contact is made between with Wrightington Wigan and Leigh Hospital and the Safeguarding Team
Wrightington, Wigan and Leigh NHS Trust …
Wrightington, Wigan and Leigh …
West Lancashire — recommendation 19
WLCSP to seek assurance from MARAC that the Lancashire Safeguarding team are aware of all MARAC meetings and are provided with the details of all those to be discussed at each meeting
Lancashire County Council Safeguarding Adults | …
Lancashire Constabulary
West Lancashire — recommendation 14
WLCSP to seek assurance from General Practice and the MARAC, that the template currently used to share MARAC information with General Practice, is effective and efficient; If areas of improvement are identified, to construct a means to deliver these changes.
NHS Lancashire and South Cumbria Integrated …
NHS Lancashire and South …
Sheffield — recommendation 10
All Agencies should recognise the importance of multi-agency working and follow agreed protocols around information sharing in order to assess risk.
All Agencies
Doncaster — recommendation 2
Withdrawal of consent to support by clients, should be communicated to the referring agencies.
Doncaster Domestic Abuse Caseworker service
Doncaster — recommendation 1
Domestic Abuse Case closure information should be shared with referring agencies, with consent from the client.
Doncaster Domestic Abuse Caseworker service
Norfolk — recommendation 3
That the Ministry of Justice and HM Prison Service establish that all commissioned Prison Health Services are required to provide a timely written discharge report with a transfer of notes to community services and primary care prior to or on release from custody. There should also be a requirement that …
Ministry of Justice | HM Prison …
Ministry of Justice
Norfolk — recommendation Q
To improve communication and process between the criminal justice system and the general medical services in Norfolk at the point of release from prison including registration at a new practice, timely transfer of medical records and communication regarding ongoing physical and psychological needs as well as repeat medication.
Norwich GP
Norfolk — recommendation C
Review of safeguarding hand over in Primary Care specifically for post-prison registrations with a GP including history of violent offending, mental health and substance misuse.
Hackney ICB for General Practitioner (GP)
Gloucester — recommendation 3
Gloucestershire CCG to encourage primary care that patient records should be flagged with social care history, substance misuse as well as the children of the index patient.
Gloucestershire Clinical Commissioning Group
Gloucestershire Clinical Commissioning Group
Gloucester — recommendation 4
Probation services to ensure that all Offender Managers are pro-active in their approach to partnership work, both together and share information, particularly where there are safety concerns.
BGSW CRC
Gloucester — recommendation 4
NHS England to develop capability for prison healthcare to access Summary Care Records for prisoners so that prisoners’ healthcare needs are addressed immediately.
NHS England
NHS England
Gloucester — recommendation 3
NHS England to ensure that community GPs promptly provide comprehensive details of a patient’s health records when asked by a prison healthcare team for this information. This should include details of the prisoner’s history of both physical and mental health problems.
NHS England
NHS England
Gloucester — recommendation 2
NHS England to ensure that, at regional and national level, patients with severe mental health issues (such as schizophrenia) requiring regular antipsychotic medication have clear and specific care plans that identify their regular medication needs. This information must be contemporaneous and should be visible across all healthcare systems, including prison, …
NHS England
NHS England
Wokingham — recommendation R6
Berkshire Cancer Centre (BCC) will improve assessment documentation and interagency sharing of documentation.
Royal Berkshire NHS Foundation Trust
Royal Berkshire NHS Foundation …
Enfield — recommendation 3
The multi-agency risk assessment conference (MARAC) meeting should consider how to share any pertinent information with the relevant GPs
multi-agency risk assessment conference (MARAC)
Cheshire West and Chester — recommendation 2
Statutory partners to provide reassurance to the CSP that Professionals seek to triangulate information which may help them to inform a more holistic assessment of a patient/client which is inclusive of information available from family and partner agencies.
Cheshire West and Chester Community Safety …
Kent — recommendation 11
When adult offenders have been previously subject to youth offending supervision, liaison must take place with the previous allocated YOT worker/s in order to gather information to inform risk assessment and risk management.
NPS | YOS
National Probation Service
Kent — recommendation 10
In considering the appropriateness of accommodation for persons leaving prison or detention centres, agencies involved should use their own risk assessment processes to determine the suitability of the premises in respect of the vulnerability of existing occupants. Information from risk assessments should be shared with other agencies.
Social Services | NPS | YOS …
National Probation Service
Kent — recommendation 5
To facilitate information exchange, East Kent Housing to attend formal and minuted Tasking and Coordinating Meetings held by the Thanet Community Safety Unit.
East Kent Housing | Thanet District …
Thanet District Council
Swindon — recommendation 6
To ensure that the Swindon Intensive Team update RiO with any outcomes of multi-agency processes.
Avon and Wiltshire Mental Health Partnership …
Avon and Wiltshire NHS …
Swindon — recommendation 1
In this DHR professionals from different organisations made conflicting decisions on whether to share with the police information relating to the victim, without her consent when they believed she was a risk of serious harm or death. Some (including Mental Health Services, and Hospital) ,following the ICO Codes of Practice …
Home Office | Dept of Health …
Home Office
Milton Keynes — recommendation 18
Procedures to share information legally and appropriately between housing officers and neighbourhood officers should be reviewed to ensure that risk to tenants can be assessed and protective measures taken where appropriate
Milton Keynes Council, Housing and Regeneration
Milton Keynes — recommendation 16
The pathway of sharing intelligence and information between Thames Valley Police and the Probation Service staff needs to have concise lines of provenance and governance
Thames Valley Police | Probation Service
Thames Valley Police
Milton Keynes — recommendation 14
All agencies represented on the panel should ensure that there are suitable Information Sharing Agreements within all domestic abuse policies and strategies.
Milton Keynes Community Safety Partnership
Plymouth — recommendation 20
Children’s Social Care to review their information exchange policy with GP’s in line with multi-agency safeguarding procedures.
Children’s Social Care
Plymouth — recommendation 14
Education to undertake a review to establish the feasibility and implementation of live chronologies across the school’s network in Plymouth.
Education
Warrington — recommendation 19.8
Warrington Community Safety Partnership and Warrington Safeguarding Adult Board should consider the feasibility of developing a coordinated case management/information sharing approach to the care of high intensity service users, who for whatever reason engage in risky behaviours that are not captured by other safeguarding processes. The two boards are best …
Warrington Community Safety Partnership | Warrington …
Warrington — recommendation 19.6
Warrington Community Safety Partnership should seek assurance from its constituent partners that there are no inappropriate barriers to sharing information with the third sector partners.
Warrington Community Safety Partnership
Warrington — recommendation 19.5
Warrington Community Safety Partnership should seek written assurance from HMP Altcourse that the failure in internal communications which led to the perpetrator’s restraining order not being recorded and his subsequent ability to communicate with the victim in breach of the restraining order has been effectively resolved.
Warrington Community Safety Partnership
Lincoln — recommendation 2
The LSAB should assure itself that multi-agency safeguarding arrangements are effective and in particular that: • Information is shared appropriately and in a timely manner between agencies to inform decision-making in accordance with LSAB Safeguarding Adults Policy, Procedure and Process 2017; • LSAB Policies and Procedures are reviewed to provide …
LSAB | partner agencies
Kent — recommendation 11
There needs to be more effective information sharing and challenge of partner agencies. The establishment of a MASH type functionality should close this gap. The CRC will need to prioritise finite resources to support this initiative if they are to extract the clear benefits such an information sharing structure has …
KSS Community Rehabilitation Company and Kent …
Kent — recommendation 9
There needs to be more effective information sharing and challenge of partner agencies. The establishment of a MASH type and functionality and structure should close this gap. Social Services will need to prioritise finite resources to support this initiative if they are to extract the clear benefits that such an …
Kent Social Services and Kent Police
Kent — recommendation 4
To examine how specialist patient information can be made available to Out of Hours Services.
NHS Clinical Commissioning Group
Kent — recommendation 4
That the process of Mental Health Tribunal Review hearing applications for Absolute Discharge be reviewed to ensure that current arrangements are adequate to provide the panel with the appropriate breadth of information needed to reach their decision. Such changes should also consider how best to receive intelligence/information from the family.
SoS
Kent — recommendation 1
Secure Units and other similar establishments should ensure that there is a process of effective communication between them, the Police and other appropriate agencies regarding reporting assaults in their establishments. This must include the local authority where assaults occur in hospitals between patients.
NHS England
NHS England
Pembrokeshire — recommendation 10
Implementation of a force wide policy relating to the sharing of information for the purpose of DHRs to ensure a consistency of approach across the four Local Authority areas
Dyfed Powys Police
Dyfed-Powys Police
Pembrokeshire — recommendation 4
Clinical leads for Acute, Community, Primary Care and Mental Health services, supported by the Lead VAWDASV and Safeguarding Practitioner to communicate expectations in relation to the importance and means of recording whether patients attend alone or are accompanied during presentations/consultations
Hywel Dda University Health Board
Hywel Dda University Health …
Hillingdon — recommendation 4.6.4a
Hillingdon Hospital to improve the arrangements for sharing safeguarding concerns between Accident and Emergency, liaison psychiatry, and all other departments within the hospital, including outpatients. Success measures should be identified and audited.
Hillingdon Hospital NHS Foundation Trust
South Tyneside — recommendation AP13
Dissemination of learning from the IMR to improve inter-agency working, engagement with families and professional challenge.
South Tyneside Council – Early Years’ …
South Tyneside — recommendation 18.2.3
Dissemination of learning from the IMR across the Early Help Partnership with a view to: a) Strengthening communication between all professionals with the Early Help Plan; b) Ensuring the engagement with families as a whole unit (as appropriate) in the work being undertaken; and c) Providing effective challenge where family …
South Tyneside Council: Early Years Service
Lancaster — recommendation 1.
Update Post Natal Care planning standards [SOP] to include transfer of care information and requirement to document family/household members and social support and who is present at visits.
Bolton NHS Foundation Trust
Bolton NHS Trust
CJINI inspection reports(2)
Connecting Criminal Justice: A Follow-Up Review of the exchange of information by criminal justice organisations through the Causeway IT programme
Transforming Justice, The Criminal Justice System
Oct 2007
Connecting Criminal Justice: A review of the exchange of information by criminal justice organisations through the Causeway programme
Transforming Justice, The Criminal Justice System
Jul 2006