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
99match
Sophie Wilson
The ambulance crew and paramedic were unaware of the deceased's multi-agency 'familiar faces plan', which held crucial information, due to data limitations on their electronic devices. The coroner is concerned this vital information is not easily accessible to first responders in emergency situations.
Matched on
terms: agency, information, multi
PFD report
85match
Michael Brennan
The coroner noted that a patient transfer backup plan relied on a bed that was unavailable, raising concerns that clinicians lacked real-time bed status information across the Trust's multiple sites when devising the plan.
Matched on
terms: 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
Andrew Bowles
The mental health liaison nurse lacked direct access to hospital records, leading to an assessment without critical information about a patient's command hallucinations and self-harm thoughts. This gap in record sharing between services may affect future patient safety.
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
Daniel Maher
The coroner identified challenges in information sharing between mental health services in West Sussex and Surrey. Professionals cannot easily access patient data across county lines, and clinical records from s.136 assessments are not routinely shared.
Matched on
terms: information, patient
PFD report
73match
Felicity Clough
The coroner identified challenges with information sharing due to a lack of interoperability between patient record systems across NHS trusts. Additionally, police forces lack automatic mechanisms to share welfare and health information about individuals.
Matched on
terms: information, patient
PFD report
73match
Stephen Cassidy
Clinical staff at SMH lack routine access to patients' Summary Care Records, which are not integrated with the hospital's electronic patient record system. This absence of critical patient information means doctors may be unaware of important details, such as allergies.
Matched on
terms: information, patient
PFD report
73match
Evie Davies
The coroner noted a lack of real-time information sharing between the cafe71 service and the mental health team, meaning cafe71 staff lack access to patient background and risk factors, and mental health teams are not notified of contacts.
Matched on
terms: information, patient
PFD report
73match
Liam McCarlie
Mental health professionals in the Emergency Operations Centres lack access to patient mental health records held on SystmOne, despite EMAS having access to GP records on the same system. This information could be crucial for triage and dispatch of ambulance resources, particularly for patients with a history of suicidal ideation.
Matched on
terms: information, patient
PFD report
73match
Lee Armstrong
The NHS Pathways system does not prompt for existing conditions, and information from 111 online is not shared with NWAS. Call handlers also lack access to patient medical records, which may lead to crucial medical history not being known during emergency calls.
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
John Matthews
The report notes that the triage nurse did not see the ambulance patient report form and a locum doctor lacked access to complete computerised patient information. There were also concerns that necessary neurological observations were not instituted and an unnecessary CT scan was performed.
Matched on
terms: information, patient
PFD report
69match
Derek Larkin
The coroner identified a lack of interoperability between Dorset Council Adult Social Care's Mosaic system and NHS SystemOne, limiting Adult Social Care's access to crucial patient medication information and review dates.
Matched on
terms: information, patient
PFD report
69match
Akhona Moyo
Hospital doctors at Northampton General Hospital lack electronic access to detailed primary care medical notes, including GP and community mental health records. This absence of crucial information hinders their ability to provide comprehensive patient treatment and care, particularly for vulnerable patients.
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
CQC action
69match
Clatterbridge Hospital
The services should review the format and language availability of patient information offered.
Matched on
terms: information, patient
PFD report
65match
Audrey Kelly
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.
Matched on
terms: patient
PFD report
65match
Jean Groves
The coroner expressed concern that emergency responders lack access details for vulnerable patients when assisting the ambulance service via the NHS "Access to the Stack" initiative, which could lead to future deaths.
Matched on
terms: patient
CQC action
65match
Chorley and South Ribble Hospital
The trust should ensure that all patients with protected characteristics are supported such as availability of information in formats that patients understand.
Matched on
terms: information, patient
Inquiry recommendation
62match
165 - Reporter to obtain police information
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 being immediately required for purposes of criminal proceedings (18.53).
Matched on
terms: information
PFD report
61match
Rita Paton
The coroner raises concerns about the lack of a system to ensure requested blood tests are reported to GPs, and insufficient processes for patients lacking capacity to attend appointments. There is also a noted lack of readily available past medical and medication history for emergency crews.
Matched on
terms: patient
PFD report
61match
John Griffiths
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.
Matched on
terms: patient
PFD report
61match
Lee Thrumble
The coroner noted that not all clinical staff in prisons can access the NOMIS system, which holds critical prisoner information, because training for it is not compulsory for them. This lack of access to information puts prisoners at risk.
Matched on
terms: information
PFD report
61match
John Charles Spencer
The coroner noted that GP medical history summaries are not always accessible to out-of-hours GP surgeries due to incompatible computer systems, even with patient consent, hindering appropriate medical examinations.
Matched on
terms: patient
PFD report
61match
Chloe Ellis
The West Yorkshire Integrated Care Board has not commissioned the accessibility of NHS 111 online assessment outcomes for Emergency Department clinicians at Mid Yorkshire Teaching NHS Trust. This means crucial patient history, such as suspicion of pulmonary embolism, is not readily available to clinicians.
Matched on
terms: patient
CQC action
60match
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.
Matched on
terms: information, patient
CQC action
60match
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.
Matched on
terms: information, patient
PFD report
57match
Robert Brown
Information about prisoners was not consistently available across different prison systems and to all relevant staff, leading the coroner to seek an update on the national development of a unified information system and its implementation timeline.
Matched on
terms: information
PFD report
57match
Ketheeswaren Kunarathnam
The coroner noted a disparity in information and advice for detained prisoners awaiting deportation, with limited access to support and ineffective communication between the prison and Home Office regarding their cases.
Matched on
terms: information
PFD report
57match
Daniel Ludlam
The NHS Pathways triage system does not adequately account for patients with learning disabilities, lacking specific procedures to ensure accurate symptom communication and appropriate triage. This gap risks delays in care, particularly for callers without a carer to assist.
Matched on
terms: patient
PFD report
57match
Amy Pugh
Clinical staff at Avondale Unit were unable to access important mental health records from partner NHS institutions, which compromised the patient's assessment and subsequent management.
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
CQC action
57match
St Benedict's Hospice
The service must comply with Accessible Information Standards by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability/sensory loss.
Matched on
terms: information
CQC action
57match
Durham Diagnostics and Treatment Centre
The service must comply with Accessible Information Standards by identifying, recording, flagging, sharing and meeting the information and communication needs of people with a disability/sensory loss.
Matched on
terms: information
CQC action
56match
Newark Hospital
The provider should review patient information to ensure is clearly displayed and readily available in wards areas in languages other than English.
Matched on
terms: information, patient
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
The coroner identified that seasonal agricultural workers often lack awareness of how to access UK GP services, emergency numbers, and their entitlement to free care, leading some to obtain prescription medicines from their home countries.
Matched on
classifier match
PFD report
53match
Kwabena Amoateng
A critical Paediatric Respiratory Action Plan was mislabelled and misfiled in online records, making healthcare professionals unaware of its existence. This reflects a lack of coordinated process for producing and storing such important documents consistently in clinical records.
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
CQC action
53match
367 Thornaby Road
We recommend the provider consider current guidance on accessible information and take action to update their practice accordingly.
Matched on
terms: information
Scottish FAI
53match
Michael Towell
The Sheriff Principal, having considered the information presented at the inquiry, in terms of 26(1)(b) of the Act, recommends: R1. That the BBBC should, as soon as reasonably practicable, obtain from each boxer presently licensed by them details of their current GP and of any other medical professional from whom they have received treatment in the past 12...
Matched on
terms: information
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
The report identifies a lack of a digital system for doctors and staff in the Emergency Department.
Matched on
classifier match