Inaccessible multi-agency patient information
Critical patient information (e.g., 'familiar faces plans') being inaccessible to emergency services due to technology limitations.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
97match
Michael Brennan
A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.
Matched on
terms: information, multi, patient
PFD report
89match
Sophie Wilson
Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies for vulnerable individuals.
Matched on
terms: agency, information, multi, patient
Committee recommendation
81match
#20 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
NHS health and publicly funded social care services are legally required, by the Accessible Information Standard, published under section 250 of the Health and Social Care Act 2012, to provide health and care information to patients and service users in a way they can understand. The aim is to ensure a consistent approach to identifying and meeting the...
Matched on
terms: inaccessible, information, patient
HSSIB recommendation
78match
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.
Matched on
terms: information, patient
PFD report
77match
Daniel Maher
Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.
Matched on
terms: information, patient
HSSIB recommendation
74match
Surgical care of NHS patients in independent hospitals
HSIB recommends that NHSX expands its work programme addressing the challenges associated with interoperability of information systems used in healthcare to include transfer of information between the NHS and independent sector in support of safe care delivery.
Matched on
terms: information, patient
PFD report
73match
Stephen Cassidy
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Matched on
terms: information, patient
PFD report
73match
Andrew Bowles
A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Matched on
terms: information, patient
Inquiry recommendation
73match
BRIS-29 - Require trusts to provide clear patient access to information and explanation
NHS trusts and primary care trusts must have systems which ensure that patients know where and to whom to go when they need further information or explanation.
Matched on
terms: information, patient
HSSIB recommendation
73match
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?
Matched on
terms: information, patient
PFD report
69match
Felicity Clough
Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.
Matched on
terms: information, patient
PFD report
69match
Derek Larkin
Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.
Matched on
terms: information, patient
PFD report
69match
Evie Davies
A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.
Matched on
terms: information, patient
PFD report
69match
John Charles Spencer
Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Matched on
terms: information, patient
HSSIB recommendation
69match
Provision of care for children and young people when accessing specialist gender dysphoria services
It may be beneficial if further work considered the ability to allow for shared record systems and ways to appropriately share information between NHS and non-NHS services involved in the care of patients with gender identity concerns.
Matched on
terms: information, patient
PFD report
65match
Jean Groves
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Matched on
terms: patient
PFD report
61match
Audrey Kelly
The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic notes, describing this as a serious lapse in procedures that could lead to future loss of life.
Matched on
terms: patient
PFD report
61match
John Matthews
Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Matched on
terms: patient
PFD report
61match
John Griffiths
The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.
Matched on
terms: patient
PFD report
61match
Lee Thrumble
Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
Matched on
terms: information
PFD report
61match
Liam McCarlie
Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Matched on
terms: patient
PFD report
61match
Lee Armstrong
Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Matched on
terms: patient
PFD report
61match
Chloe Ellis
Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.
Matched on
terms: information
PFD report
57match
Rita Paton
There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.
Matched on
terms: patient
PFD report
57match
Robert Brown
Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Matched on
terms: information
PFD report
57match
Ketheeswaren Kunarathnam
Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Matched on
terms: information
PFD report
57match
Daniel Ludlam
The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
Matched on
terms: patient
PFD report
57match
Paul Gander
A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.
Matched on
terms: patient
PFD report
57match
Kwabena Amoateng
A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.
Matched on
classifier match
PFD report
57match
Amy Pugh
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
Matched on
terms: patient
PFD report
57match
Akhona Moyo
Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.
Matched on
terms: patient
HSSIB recommendation
57match
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.
Matched on
terms: information
Scottish FAI
56match
Xi Biao Huang
(i) All medical assessments, and particularly clinical examinations should be carried out with the use of a professional interpreter where the detainee does not speak fluent English. Whilst the nature of the establishment may mean that it would not be possible or practicable to use professional interpretation services for every interaction with a detainee, the use of fellow...
Matched on
terms: patient
IOPC learning recommendation
55match
Recommendation - Hampshire Constabulary, September 2024
The IOPC recommends that Hampshire Constabulary creates and implements a memorandum of understanding (MOU) regarding sharing patient information with University Hospital Southampton NHS Foundation Trust. This follows an investigation in which a man was found by police in a hospital gown and wheelchair in central Southampton. The man was arrested for an outstanding warrant, but the police were...
Matched on
terms: information, patient
PFD report
53match
Dimitar Shtarbov
Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their home countries.
Matched on
classifier match
Committee recommendation
53match
#10 - Third Report: Flying Home: The FCO’s consular response to the COVID-19 pandemic
The move to using social media for mass communications was partially successful. However, accessing online information was particularly difficult for elderly people and those with certain disabilities. The FCO placed too much reliance on this generic advice and this approach disadvantaged those with medical conditions and those stuck in remote areas, as they were unable to access advice...
Matched on
terms: information
Committee recommendation
53match
#15 - Second Report - Disability employment gap
We heard that more needs to be done to improve the way a disabled person’s communication preferences are recorded by Jobcentre Plus. DWP should take inspiration from the Accessible Information Standard model used in the NHS and create an automated process which can record a disabled person’s preferred communication method and provide the correct support accordingly.
Matched on
terms: information
HSSIB recommendation
53match
Investigation report: Clinical investigation booking systems failures - written communications in community languages
It may be beneficial if NHS trusts identify mechanisms to appreciate the language needs of their patient demographic and adjust the written communications accordingly.
Matched on
terms: patient
Inquiry recommendation
53match
F35 - Need to share information between regulators
Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work should be done on a template of the sort of information each organisation would find helpful.
Matched on
terms: information
Committee recommendation
52match
#14 - Second Report - Disability employment gap
It is unacceptable that some disabled people still face barriers when trying to access services through Jobcentre Plus. It is particularly shocking that services provided by the Department for Work and Pensions, whose ministerial team includes the Minister for Disabled People and which is responsible for a significant proportion of the Government’s work on disability, remain inaccessible to...
Matched on
terms: inaccessible
PFD report
49match
Vera Williams
Emergency Department doctors and staff lack a digital system to support their work.
Matched on
classifier match
IMB recommendation
48match
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...
Matched on
terms: information
Committee recommendation
47match
#10 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
The widespread adoption of continuous facemask wearing in health and social care settings has made effective communication impossible for patients and healthcare professionals who lip-read, and much more difficult for Deaf people who use British Sign Language and people with disabilities which mean they are more reliant on facial expressions for communication. We therefore strongly welcome the development...
Matched on
terms: patient
PFD report
45match
Caroline and Bernard Cleall
Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities to revise safety packages.
Matched on
classifier match
Inquiry recommendation
45match
R93 - Regional service map with vacancies
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 services and vacancies, searchable by both families and care managers.
Matched on
classifier match
HSSIB recommendation
45match
Potential under-recognised risk of harm from the use of propranolol
Paramedics would benefit from the ability to access TOXBASE when responding to emergency calls.
Matched on
classifier match
CQC action
45match
Birmingham Children's Hospital
The trust should ensure that records are accessible to both emergency department staff and the mental health team.
Matched on
classifier match
CQC action
44match
Doncaster Royal Infirmary
The trust should ensure it continues to complete the work needed to meet the requirements for the Accessible Information Standards.
Matched on
terms: information
IOPC learning recommendation
44match
Care and attention for man whilst detained in custody – Thames Valley Police, June 2021
The IOPC recommends that Thames Valley Police ensures arrangements are in place for all custody officers, staff and HCPs to receive information about detainees when their shift starts. This follows an investigation into the death of a man at a Thames Valley Police police station. One of the detention officers involved in the observation of the detainee began...
Matched on
terms: information
Inquiry recommendation
43match
LAMI-32 - Ensure single, compatible electronic database for all children and families services
Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or at least compatible with it, so as to facilitate the sharing of information, as appropriate.
Matched on
terms: information