Inconsistent Healthcare Data Infrastructure
Lack of a consistent and mature data infrastructure across NHS providers, hindering technological adoption and data sharing.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
80match
#26 - NHS still lacks consistent data infrastructure and technological maturity, delaying productivity gains.
We asked what was being done to improve productivity through the use of new technologies. NHSE told us the NHS currently lacks a consistent data infrastructure and that NHS providers varied in terms of their levels of technological maturity.50 NHSE said that it was putting modern technology into some of its providers that “have lived on paper”. While...
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terms: infrastructure
Committee recommendation
71match
#7 - Publish plans to reduce NHS paper reliance and set deadline to end fax machines.
Despite ambitions to improve productivity through the introduction of new technologies, the switch to digital in parts of the NHS has been glacially slow. Digital and technological improvements could have a transformative effect on the NHS. However, NHSE’s investment in technology over the period 2022–23 to 2024–25 stalled because funding was redirected to mitigate ICBs’ spending deficits. For...
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terms: infrastructure
HSSIB recommendation
69match
Access to critical patient information at the bedside
It may be beneficial for healthcare organisations to assess their information technology infrastructure needs, such as equipment availability and network coverage, to enable staff to consistently access critical patient information.
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terms: healthcare, infrastructure
Committee recommendation
66match
#9 - Department struggles monitoring sector engagement with inaccessible digital systems and inconsistent records
We asked the Department about its ability to monitor its engagement with economic sectors, given that officials do not consistently record their interactions with companies, and its digital system — DataHub — is not accessible across the whole of Whitehall.17 The Department noted the challenges of different digital platforms operating in different government departments, and that a single...
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terms: inconsistent
Committee recommendation
66match
#45 - Publish regular, transparent data on prison healthcare access and outcomes for accountability
NHS England, or its successor, should publish regular, transparent data on healthcare access and outcomes across the prison estate. This data should be used to monitor progress against the principle of equivalence and to hold both NHS England or its successor and HMPPS accountable for delivering effective, joined-up care. (Recommendation, Paragraph 204)
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terms: healthcare
HSSIB recommendation
66match
Workforce and patient safety: temporary staff - integration into healthcare providers — HSSIB
How do you ensure that temporary workers can access electronic systems and physical environments that are vital to providing safe care?
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terms: healthcare
PFD report
65match
Shayla Walmsley
The coroner identifies concerns regarding delays in Medtronic providing safety data, the inconsistent distribution of Field Safety Notices to NHS Trusts, and the insufficient analysis of medical devices during post-mortem examinations, which could hinder investigations.
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terms: inconsistent
PFD report
65match
Masoud Ghaderi
The coroner noted inconsistent record-keeping of service user engagement and a lack of a designated staff member with overall responsibility for reviewing risk assessments to identify trends. Concerns were also raised about ward rounds relying on brief summaries rather than the full care record.
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terms: inconsistent
PFD report
65match
Michael Giles
The coroner identified inconsistent handover processes across different hospital wards and a lack of routine senior doctor review for complex patients admitted over weekends. Concerns also included insufficient leadership during a patient's crisis period and inadequate medical record-keeping.
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terms: inconsistent
PFD report
65match
Robert Wrinch
The coroner identified a lack of pathology sample tracking systems, inconsistent tracking of outstanding reports across hospital departments, and clinician reliance on slower paper reporting methods. Concerns were also raised about incompatible IT systems between trusts and national pathology backlogs causing delays.
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terms: inconsistent
NCEPOD recommendation
62match
Transition From Child Into Adult Healthcare
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terms: healthcare
PFD report
61match
Ronald Perry
The coroner noted inconsistent criteria for requesting CT scans depending on the time of day or weekend, creating varying levels of care for patients "out of hours" and posing risks of future deaths.
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terms: inconsistent
PFD report
61match
Richard Jones
The coroner raises concerns about the inconsistent recording of information from patients presenting with mental health issues, specifically regarding the perceived level of risk and urgency for assessment. There were also conflicting accounts about the division of responsibilities and the urgency of care between different mental health services.
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terms: inconsistent
Inquiry recommendation
61match
F262 - Enhancing the use analysis and dissemination of healthcare information
All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against patient safety and minimum quality standards; Effective real-time information of the performance of each of their consultants and specialist teams in relation to mortality, morbidity, outcome and patient...
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terms: healthcare
HSSIB recommendation
61match
Healthcare provision in prisons
HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing...
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terms: healthcare
Committee recommendation
61match
#2 - Recommend a trial of a centralised Secure Data Environment and simplify ethical governance
Should our successor Committee wish to explore the reform of the UK health data strategy, we recommend it considers: • Investigating the replication of the academic model of open and competitive funding to solve problems and develop Privacy Enhancing technologies (PETs) and other critical pieces of data infrastructure as an alternative to internal or contracted software development work;...
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terms: infrastructure
HSSIB recommendation
61match
Healthcare provision in prisons: data sharing and IT
HSSIB recommends that NHS England/Department of Health and Social Care includes within its healthcare IT procurement system specification the need to support interoperability between the operational prison IT systems and any future prison healthcare IT system. This will ensure that information which does not impinge on the confidentiality requirements of either system, relevant to the safety and wellbeing...
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terms: healthcare
PFD report
57match
Peter Hinchliffe
The coroner raised concerns regarding delays in private sector investigations requiring NHS transfer, inconsistencies in advice for young athletes with syncope, and the lack of a consistent national approach to managing such cases.
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Inquiry recommendation
57match
F267 - Enhancing the use analysis and dissemination of healthcare information
All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.
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terms: healthcare
GIRFT recommendation
56match
Respiratory Medicine
Review aspects of respiratory care integration and supporting infrastructure at system level to reduce variation in service provision, enable better care delivery and facilitate information flow between providers. a) Review service provision across the STP to ensure services are uniform and equitable for respiratory patients, regardless of where they live. b) Consider how respiratory departments interface with diagnostic...
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terms: infrastructure
GIRFT recommendation
56match
Paediatric Critical Care
Improve the accuracy and completeness of PCC data capture and flow. a All providers should implement a full electronic patient report (EPR). This should include automated data capture from ventilators, monitoring and infusion devices, and electronic prescribing. Ensure digital connectivity standards are specified to allow capture and automated upload of PCC activity. b Ensure that every paediatric provider...
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terms: healthcare
PFD report
53match
Lexie Harrison
Sheffield Children's and Leeds Teaching Hospitals NHS Trusts lack specific policies for paediatric oesophageal varix banding, and there are no national guidelines for this procedure, leading to varied practices among consultants.
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PFD report
53match
Edward Gascoigne
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.
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PFD report
53match
Amy Cooper
The coroner noted concerns about the lack of a required specification for digital record keeping and scans in regional maternity services, leading to reliance on paper notes for continuity of care between providers. This inefficiency could impact patient referrals and safe admissions to maternity units.
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PFD report
53match
David Hamilton
The coroner identified a lack of documentation for therapy selection, unclear triggers for referrals, and limited information sharing among health professionals. There was also no formal process for escalating health professional concerns.
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PFD report
53match
Susan Longden
The NHS Pathways algorithm lacks a question regarding recent surgical procedures for patients reporting severe abdominal pain. There is also insufficient emphasis on speaking directly with the patient when a non-patient makes the NHS 111 call.
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PFD report
53match
Alexander Davidson
The NHS 111 service used medical terminology unclear to young patients and rigid scripts. Concerns were also raised about delays in GP uploading of triage notes and the lack of routine lipase/amylase testing for young people with abdominal symptoms.
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Committee recommendation
53match
#44 - Disconnected health data systems and lack of central repository hinder effective antimicrobial stewardship.
Lord O’Neill told us there is an underlying data problem in the health sphere, with many data systems not connecting properly.111 Better data in health would make it easier for clinicians making decisions on infection management and prescribing antimicrobials. The ability to link the results of diagnostic tests to prescription information could result in better antimicrobial stewardship, but...
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Committee recommendation
53match
#4 - Require NHSE and Department to set out plans for elective care digital transformation and IT connectivity.
We are not confident that the Department is being realistic about the immense effort needed to reduce NHS elective care waiting times, and see a significant risk that digital solutions are being treated as a ‘cure- all’ as the 10 Year Plan is being implemented. While NHS England and the Department for Health and Social Care have outlined...
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GIRFT recommendation
53match
Ophthalmology
Improve the quality, depth and accuracy of data collected nationally about ophthalmology services and clinical outcomes, without adding to provider workloads. Actions: a) Providers, including independent sector providers, to increase case ascertainment for cataract surgery in the NOD to at least 85% of cases. b) GIRFT to work with RCOphth and NHS England to consider the introduction of,...
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Inquiry recommendation
53match
BRIS-154 - Invest in world-class IT systems for efficient healthcare data collection and feedback
The need to invest in world-class IT systems must be recognised so that the fundamental principles of data collection, validation and management can be observed: that data be collected only once; that the data be part and parcel of systems used to support healthcare professionals in their care of patients; and that trusts and teams of healthcare professionals...
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terms: healthcare
Inquiry recommendation
53match
F266 - Enhancing the use analysis and dissemination of healthcare information
In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard to the views of patient groups and the public about the information needed by them.
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terms: healthcare
Inquiry recommendation
53match
F265 - Enhancing the use analysis and dissemination of healthcare information
The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on the efficacy of treatment in that specialty, for publication and use in performance oversight, revalidation, and the promotion of patient knowledge and choice.
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terms: healthcare
Inquiry recommendation
52match
1 - Single consultant data repository
We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data, for example, how many times a consultant has performed a particular procedure and how recently. This should be accessible and understandable to the public. It should be mandated for use...
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terms: healthcare
HSSIB recommendation
52match
Management of chronic health conditions in prisons
It is recommended that the National Prison Healthcare Board for England oversees work to implement interoperability between SystmOne and the Prison-National Offender Management Information System, enabling sharing of essential information across the prison service which does not impinge on the confidentiality requirements of either system.
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terms: healthcare
HSSIB recommendation
52match
Intrapartum stillbirth: learning from maternity safety investigations that occurred during the COVID-19 pandemic 1 April to 30 June...
HSIB recommends that NHSX develops specifications for electronic patient record (EPR) systems that require adherence to national interconnectivity standards for the exchange of core maternity healthcare information. The specifications should include functionality to enable both women and pregnant people and professionals to add to the record, and also support alerting functionality.
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terms: healthcare
GIRFT recommendation
52match
Renal Medicine
Ensure that data on hospitalisation of RRT patients are available and adopted as a routine element of the quality assurance process in renal care. a) Linked data in prevalent patients with ESKD in the UKRR annual report to be used to report patterns of hospitalisation. b) Monthly quality assurance review and regular access to healthcare professional support for...
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terms: healthcare
IMB recommendation
52match
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...
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terms: healthcare
IMB annual report
51match
Hewell Grange (2020)
This report covers the final six months of HMP Hewell Grange as it underwent a planned closure, ceasing to hold prisoners by 31 March 2020. The Board found the prison generally safe and praised staff for their humane management of the closure, despite unacceptable living conditions. Healthcare provision was inconsistent, and purposeful activity was curtailed due to the...
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terms: healthcare, inconsistent
PFD report
49match
Georgina Swindells
The coroner identified concerns regarding an unexplained delay in image transfer, the absence of a robust backup system, and insufficient data to investigate the issue. There was also a lack of clarity on the cause of an apparently erroneous scan report.
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PFD report
49match
Suzanne Cammell
The coroner noted concerns regarding a lack of communication between Thames Valley Police and Gloucestershire Constabulary, and within Gloucestershire Control, meaning high-risk information about a prior incident was not available to officers conducting a welfare check. This prevented them from initiating a Mental Health Act assessment.
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PFD report
49match
Evelyn Smith
The coroner noted difficulties with accurate and consistent recording of vital signs and integrating the Paediatric Early Warning Scoring system into GP medical records. Additionally, the GP computer system does not alert clinicians to complete relevant clinical parameters, such as a croup severity score, after a diagnostic code is entered.
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PFD report
49match
Simon Costin
The coroner noted inconsistencies in patient assessment approaches among clinicians and suggested that nationally agreed standard forms would improve communication when patients are transferred between different mental health care providers.
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PFD report
49match
Jayne Jowett
The coroner noted insufficient training for PIC staff in interpreting National Early Warning Scores and understanding clinical signs, impacting patient assessment. There is also no clear service level agreement or guidance for information sharing between PIC and local GPs.
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PFD report
49match
Elizabeth Godwin
The coroner identified concerns regarding the process for gathering information for mental health assessments, assessing their urgency, and sharing this information with other agencies. Further concerns relate to establishing responsibility for patient care and ensuring clear communication during transfers between agencies.
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PFD report
49match
Anna Masson
The coroner raised concerns regarding the robustness of the mental health screening pathway, noting that junior staff conduct initial screenings. There was also an identified need for consistent practice of this pathway across all equivalent teams within the Trust.
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PFD report
49match
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.
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PFD report
49match
Patrick Clifford
The coroner noted unclear policy on patient supervision in toilets and issues with inter-hospital transfer of radiology images. Concerns were also raised regarding Royal Blackburn Hospital's refusal to perform specific X-rays, causing treatment delays.
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PFD report
49match
Angela Byrne
The coroner noted inadequate application of staff training at W-CDAS, resulting in poor risk assessment for vulnerable patients. Additionally, improved communication between inpatient and community services and a consistent set of clinical records were identified as necessary.
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PFD report
49match
Janice Davies
The coroner noted an absence of documented observations and an updated pain score before discharge. Concerns were raised regarding a lack of formal guidance for clinicians on prescribing oramorph to discharging patients, which led to inconsistencies in dosage and supply.
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