Inconsistent Healthcare Data Infrastructure
Lack of a consistent and mature data infrastructure across NHS providers, hindering technological adoption and data sharing.
Source spread
Where this theme appears
This theme appears across 19 independent accountability sources, so the source mix matters as much as the headline total.
40 inquiry recs
117 PFD reports
169 committee recs
29 HSSIB recs
64 CQC actions
3 HMICFRS recs
1 ICIBI rec
1 IOPC rec
12 NAO recs
11 IMB recs
2 IMB reports
2 detention investigation recs
21 DHR recs
1 PHSO decision
7 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(40)
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
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: DBT rejects this recommendation as we believe it comes into conflict with the principle of “full and fair” redress set out as we accepted Recommendation 2. DBT’s view is that it would not be fair …
Not accepted
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
7 — Data reporting
Recommendation: i. All hospitals with a neonatal unit should name a ‘lead reporter’ with responsibility for inputting data regularly (at least weekly) and reviewing real-time data viewers on neonatal and maternity units in the MBRRACE system. Whilst the lead reporter does …
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
FR-1 — Single Core Data Set
Recommendation: The Inquiry recommends that the UK government and the Welsh Government improve data collected by children's social care and criminal justice agencies concerning child sexual abuse and child sexual exploitation by the introduction of one single core data set covering …
Gov response: We accept that robust data collection on the scale and nature of child sexual abuse is critical to underpin and drive a more effective response to child sexual abuse. We have made a number of …
Accepted in part
1 — Single consultant data repository
Recommendation: We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data, for example, how many times a consultant has performed a particular procedure …
Gov response: Accept in principle Significant progress has been made on the collection of consultant performance data in the independent sector and the NHS. In 2018, ADAPt was launched to move towards a common set of standards …
Accepted in part
IHRD-91 — Synchronise Patient Safety Systems
Recommendation: The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F272 — Improving and assuring accuracy
Recommendation: There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and Social Care Act 2012, it should be used as soon …
Gov response: Accepted. The Health and Social Care Act 2012 established powers for the Health and Social Care Information Centre to establish an accreditation scheme for information service providers. The Act allows the Health and Social Care …
Accepted
F271 — Improving and assuring accuracy
Recommendation: To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should work towards establishing such status for them or any successor …
Gov response: Accepted. The Summary Hospital-level Mortality Indicator which reports mortality data at trust level across the NHS in England, has been produced and published by the Health and Social Care Information Centre as an experimental Official …
Accepted
F270 — Improving and assuring accuracy
Recommendation: There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other outcome indicators. In particular, there could be benefit from consideration …
Gov response: Accepted. The UK Statistics Authority is undertaking an independent review of patient outcome statistics recognised as official statistics. The review, among other things, is considering how to make such statistics more readily useable by the …
Accepted
F269 — Improving and assuring accuracy
Recommendation: The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.
Gov response: Accepted. It is the role of local providers to ensure that the accuracy of the data it generates and submits into the system. As such, existing requirements for local audit of clinical records and the …
Accepted
F262 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: 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 …
Gov response: Accepted. Timely, accurate and robust data should be used by every provider to determine the quality of the services that they provide and identify whether there are any risks to patient safety. Wherever possible, such …
Accepted
F260 — Information standards
Recommendation: The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied …
Gov response: Accepted in principle. Where appropriate to do so, information standards should be applied to the reporting of serious incidents and that such information should be made as transparent and accessible as possible. The Government also …
Accepted in part
IBI-7f(iii) — Blood Tracking Systems Funding
Recommendation: Establishing the outcome of every transfusion: That funding for the provision of enhanced electronic clinical systems in relation to blood transfusion be regarded as a priority across the UK.
Gov response: Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that minimises complexity, …
Accepted in part
IBI-7f(ii) — NHSBT Transfusion Outcome Funding
Recommendation: Establishing the outcome of every transfusion: To the extent that the funding for digital transformation does not already cover the setting up and operation of this framework, bespoke funding should be provided.
Gov response: Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that minimises complexity, …
Accepted in part
IBI-7f(i) — Transfusion Outcome Framework
Recommendation: Establishing the outcome of every transfusion: That a framework be established for recording outcomes for recipients of blood components. That those records be used by NHS bodies to improve transfusion practice (including by providing such information to haemovigilance bodies). Success …
Gov response: Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that minimises complexity, …
Accepted in part
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
BRIS-154 — Invest in world-class IT systems for efficient healthcare data collection and feedback
Recommendation: 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 …
Unknown
BRIS-152 — Review incentives for data quality; include trust performance in validation process
Recommendation: The system of incentives and penalties to encourage trusts to provide complete and validated data of a high quality to the national database should be reviewed. Any new system must include reports of each trust’s performance in terms of the …
Unknown
BRIS-151 — Improve status, training, and qualifications of clinical coding staff for data accuracy
Recommendation: Systems for clinical audit and for monitoring performance rely on accurate and complete data. Competent staff, trained in clinical coding, and supported in their work are required: the status, training and professional qualifications of clinical coding staff should be improved.
Unknown
BRIS-150 — Support Hospital Episode Statistics as a reliable national resource for monitoring outcomes
Recommendation: The Hospital Episode Statistics database should be supported as a major national resource which can be used reliably, with care, to undertake the monitoring of a range of healthcare outcomes.
Unknown
BRIS-149 — Improve clinician confidence in Patient Administration Systems data through collaboration
Recommendation: Steps should be taken nationally and locally to build the confidence of clinicians in the data recorded in the Patient Administration Systems in trusts (which is subsequently aggregated nationally to form the Hospital Episode Statistics). Such steps should include the …
Unknown
BRIS-148 — Implement a single, trusted system for collecting clinical and administrative data
Recommendation: The current ‘dual’ system of collecting data in the NHS in separate administrative and multiple clinical systems is wasteful and anachronistic. A single approach to collecting data should be adopted, which clinicians can trust and use and from which information …
Unknown
BRIS-109 — Create single, unified system for reporting and analysing sentinel events
Recommendation: There should a single, unified, accessible system for reporting and analysing sentinel events, with clear protocols indicating the categories of information which must be reported to a national database.
Unknown
IHRD-27 — Electronic Patient Information Systems
Recommendation: Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
F267 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.
Gov response: Accepted. The data referred to in recommendation 264 is made available through NHS Choices website so that it can be used to meet a wide range of purposes. Providers are expected to link to this …
Accepted
F266 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: 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 …
Gov response: Accepted. There is a clear role for the users of services in the development of appropriate information and statistics. The UK Statistics Authority’s Code of Practice for Official Statistics139 (January 2009) outlines a protocol on …
Accepted
F265 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: 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 …
Gov response: Accepted. On behalf of NHS England, the Healthcare Quality Improvement Partnership has worked with specialist associations to develop the data referred to in recommendation 264 from selected national clinical and medical audits for consultants practising …
Accepted
F261 — Information standards
Recommendation: The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.
Gov response: Accepted. The Health and Social Care Information Centre collects and publishes national data and statistical information in health and social care as required by the The Health and Social Care Act 2012. In doing so, …
Accepted
F258 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.
Gov response: Accepted. The Health and Social Care Information Centre publishes, and keeps under regular review, the methodologies used for the calculation of national indicators and statistics. To support this function the Health and Social Care Information …
Accepted
F36 — Use of information for effective regulation
Recommendation: A coordinated collection of accurate information about the performance of organisations must be available to providers, commissioners, regulators and the public, in as near real time as possible, and should be capable of use by regulators in assessing the risk …
Gov response: Accepted. The Health and Social Care Act 2012, requires the Health and Social Care Information Centre to establish and operate a system for the collection or analysis of information in connection with the provision of …
Accepted
COVID-M4.4 — Proportionate Access to Linked Healthcare Records
Recommendation: The UK government and devolved administrations should work together, with their respective health delivery services, to facilitate and coordinate regulatory bodies' access to healthcare records in order to make the post-authorisation safety monitoring of new vaccines and therapeutics more efficient. …
Gov response: No formal 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
IBI-7b — Transfusion 2024 Review Progress
Recommendation: Review of progress towards the Transfusion 2024 recommendations: Progress in implementation of the Transfusion 2024 recommendations be reviewed, and next steps be determined and promulgated; and that in Scotland the 5 year plan is reviewed in or before 2027 with …
Gov response: These recommendations are accepted in principle by the UK Government, the Scottish Government, the Welsh Government, and the Northern Ireland Executive. Recommendation 7b) is accepted in full by the Scottish Government. Parts of these recommendations …
Accepted in part
IBI-7a(iii) — Transfusion Performance Benchmarking
Recommendation: Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management
Gov response: In relation to the recommendation on standardising and benchmarking, a review of current benchmarking practices and associated data collection and ongoing intelligence and analysis requirements, including model health dashboard and national clinical audit, has been …
Accepted
WATE-(70) — Strengthen national statistics services in Wales for management information system
Recommendation: The national statistics services in Wales should be strengthened to provide a comprehensive management information system.
Unknown
F268 — Resources
Recommendation: Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.
Gov response: Accepted. In order to ensure that good quality data is collected locally and made available to central repositories such as the Health and Social Care Information Centre, resources need to be available to providers of …
Accepted
F264 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.
Gov response: Accepted. The Mandate (Department of Health, November 2013) NHS England states that, ‘The NHS should measure and publish outcome data for all major services by 2015, broken down by local clinical commissioning groups where patient …
Accepted
F263 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.
Gov response: Accepted. The Government stated in Patients First and Foremost (Department of Health, 2013) that, ‘From 2015, [NHS England] will ensure that data on services at specialty level is increasingly available. To do this they will …
Accepted
IBI-9f — National Haemophilia Database Support
Recommendation: That the National Haemophilia Database, run by the UKHCDO, merits the support of additional central funding.
Gov response: Recommendation 9f: NHS England currently provides ‘central’ funding of approximately 40% of the total annual cost for running the National Haemophilia Database. A task and finish group relating to the database has been established, reporting …
Accepted in part
P2-25 — Postgraduate training governance clarity
Recommendation: Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue …
Gov response: For the remaining 21 recommendations, these remain under consideration.
Response Unclear
Prevention of Future Deaths reports(117)— showing 50 strongest matches
John Morgan
Concerns: The coroner noted inconsistencies in whiteboard use across Wales, raising concerns about potential over-reliance on whiteboards instead of patient notes, the risk of human error leading to incorrect information, and the possible continued use of a "DNR red star" system in some health board areas.
Response (Welsh Government): • The incident was reported to the Welsh Government under the Serious Patient Safety Incident reporting process. • The Chief Nursing Officer for Wales issued a request to all Nurse … (AI summary)
Responded
Jude Augustus Gordon
Concerns: The coroner noted failure to escalate care despite a marked increase in the Early Warning Score (SHEWS) and miscalculations. Concerns included the absence of a national, standardised Early Warning Score system and automatic alerts for deteriorating patients.
Response (Department of Health): • The Royal College of Physicians published a report in July 2012 advocating a National Early Warning Score (NEWS) to standardise acute illness assessment. • Clinical observation charts and e-learning … (AI summary)
Responded
Georgina Swindells
Concerns: 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.
Overdue
Katie Davies
Concerns: The coroner identified concerns about previously unknown 'blind spots' in hospital bleeper systems that could delay emergency responses, and the absence of a policy for prompt transfer of Cerebral Venous Sinus Thrombosis patients to regional neuroscience centres for specialised treatment.
Response (Department of Health): • A safety alert will be sent to all Trusts in England regarding potential blind spots in bleeper systems. • The National Clinical Director for Stroke at NHS England will … (AI summary)
Responded
Samuel Openshaw
Concerns: The coroner raised concerns about the slow electronic transfer of echocardiograph studies to tertiary centres and the workload pressures experienced by specialist paediatric retrieval teams.
Overdue
Ralph Goslin
Concerns: A junior doctor did not recognise a sub-therapeutic sodium valproate level due to an unclear reference range, which delayed the recognition that the patient was not taking their anti-epilepsy medication.
Response: • The Trust issued two Patient Safety Alerts concerning epilepsy care plan reviews and bathroom/shower room protocols. • The Trust commissioned specialist epilepsy training for all inpatient and residential services … (AI summary)
Responded
Peter Hinchliffe
Concerns: 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.
Overdue
Ronald Perry
Concerns: 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.
Response: • The Health Board confirmed that an emergency on-call CT service is provided for life-threatening conditions, with consistent criteria for scans performed at any time. • The Health Board stated … (AI summary)
Responded
Shayla Walmsley
Concerns: 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.
Overdue
Suzanne Cammell
Concerns: 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.
Response (Thames Valley Police): • Measures were put in place to address concerns regarding information sharing between the Professional Standards Department and the officer who prepared the report for the Coroner. • An appointment … (AI summary)
Overdue
Evelyn Smith
Concerns: 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.
Overdue
Alan Jones
Concerns: The coroner noted concerns regarding inadequate training for GPs on electronic patient systems, leading to difficulty accessing important clinical information. The software also failed to alert users to significant diagnosed conditions when patient records were opened.
Response (Department of Health): • The Department of Health in England stated that GP practices have the freedom to choose and implement their own IT systems through the GP Systems of Choice (GPSoC) scheme. … (AI summary)
Overdue
Lexie Harrison
Concerns: 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.
Response (Cardiff and Vale University Health Board): • The respondent stated they were unable to directly address the concerns regarding policies for paediatric oesophageal varix banding or national guidelines. • The respondent suggested directing the concerns to … (AI summary)
Response (The Leeds Teaching Hospitals NHS Trust): • The Trust confirmed it had local guidelines for the management of bleeding oesophageal varices and for post-operative care, which it had shared with referring Trusts. • The Trust stated … (AI summary)
Overdue
Richard Jones
Concerns: 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.
Response (Ministry of Defence): • The Ministry of Defence stated it is updating its medical policy document (JSP 950, leaflet 2-7-2) to include new guidance on transfer principles and clarification of primary responsibility for … (AI summary)
Response (Avon and Wiltshire NHS Trust): • The Critical Incident Review Group considered the report. • The Trust stated it would conduct a joint root cause analysis investigation with Salisbury District Hospital and the Armed Forces. … (AI summary)
Response (Department of Health2): • Discussions are underway between the Department of Health, Ministry of Defence, and NHS England regarding the transfer of medical notes between services. • These discussions are intended to address … (AI summary)
Response (Salisbury NHS Trust): • The Trust implemented a new mental health risk assessment tool and amended its Standard Operating Procedure in collaboration with Avon & Wiltshire Mental Health Partnership (AWP). • A 'Mental … (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency (PHE) outlined its existing role in supporting public health parity for mental health, including the National Mental Health Dementia and Neurology Intelligence Network. • … (AI summary)
Responded
Simon Costin
Concerns: 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.
Response (NHS England): • The Leicestershire Partnership Trust addressed the issue of standardised mental health assessments. • The Trust identified specific learning points from the incident, including the use of translators, liaison with … (AI summary)
Responded
Paige Bell
Concerns: The coroner identified fragmented patient case notes and queried plans for immediate electronic access, alongside the need for a national policy for engagement and observation. Concerns were also raised regarding updated guidance for the treatment and management of Borderline Personality Disorder.
Response (Northumberland Tyne Wear NHS Trust): • The Trust developed a new Engagement and Observation Policy, which emphasizes clinical assessments and patient engagement. • Staff received reiteration and training on the importance and correct completion of … (AI summary)
Response (Department of Health): • The Summary Care Record (SCR) system is in place to provide healthcare staff with electronic access to essential patient information. • NHS England is planning to update its Suicide … (AI summary)
Responded
Hilda Harris
Concerns: The coroner identified an unreliable booking system for community INR testing, which led to appointments not being transferred, and an unreliable notification system for such omissions.
Response: • A corrective Action Plan for Improvement was developed. • Actions have been implemented by the Primary Community & Localities Directorate. (AI summary)
Overdue
Jayne Jowett
Concerns: 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.
Response (Partnership in Care): • All qualified nursing staff were retrained on National Early Warning Scores (NEWS) following the inquest, with this training now part of induction and scheduled for annual refresh. • The … (AI summary)
Overdue
George Richardson
Concerns: Catheterisation was performed by multiple individuals without a consolidated record, leading to staff being unaware of previous challenges and delaying timely involvement of a Urologist.
Response (Department of Health): • The Department of Health forwarded the report to the British Association of Urological Surgeons (BAUS) and the British Association of Urological Nurses (BAUN). • BAUS and BAUN were asked … (AI summary)
Responded
Elizabeth Godwin
Concerns: 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.
Response (Royal United Hospitals Bath NHS Trust): • The Royal United Hospitals Bath NHS Trust has implemented an allocated space on the self-harm proforma for next of kin information. • The Trust, in collaboration with Avon and … (AI summary)
Response (Avon and Wiltshire NHS Trust): • The Trust developed a Standard Operating Procedure for Primary Care Liaison Services and a triage tool to establish urgency of response. • The Trust's policies outline requirements for urgent … (AI summary)
Responded
Masoud Ghaderi
Concerns: 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.
Response (Avon and Wiltshire NHS Trust): • The Trust rolled out local training on its Engagement and Observation Policy and conducted targeted training in inpatient suicide prevention. • Monthly spot audits of caseload supervision records will … (AI summary)
Overdue
Michael Quinn
Concerns: The coroner notes confusion regarding appropriate pre-operative blood glucose levels for surgical patients, as the hospital's policy differed from national guidelines and published research. The Trust is asked to review its recommended levels.
Overdue
Harry Pryal
Concerns: The coroner noted the absence of documented medical advice provided by WWL to the Lakeside Unit, which impacts continuity of treatment. There were also differing interpretations of the Service Agreement between SBP and WWL, and no scheduled liaison meetings had taken place as required by the agreement.
Response (Department of Health): • The Academy of Medical Royal Colleges (AoMRC) has produced Standards for the clinical structure and content of patient records. • The Health and Social Care Information Centre (HSCIC) is … (AI summary)
Response (Wigan Borough CCG): • The CCG wrote to SBP stating that SBP should have a service agreement for the provision of physiotherapy and occupational therapy. • SBP confirmed that all requests for physiotherapy … (AI summary)
Response (5 Borough Partnership NHS Trust): • The Trust developed a standardised proforma for use during transfers between trusts and issued a directive requiring clinicians to fully record clinical advice, including the name, grade, and contact … (AI summary)
Response (Wrightington Wigan and Leigh NHS Trust): • The Trust updated its Standing Financial Instructions (SFIs) to include a new sign-off process for Service Agreements, which was approved at Trust Board level. • Discussions were held, and … (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
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
Amy Cooper
Concerns: 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.
Overdue
Anna Masson
Concerns: 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.
Response (Southern Health NHS Foundation Trust): • The Trust identified variations in screening processes across Adult Community Mental Health Teams and has been reviewing its Standard Operating Procedure to ensure a consistent process. • The Trust … (AI summary)
Responded
Leslie Carswell
Concerns: Technical difficulties transmitting CT scans between hospitals led to delays in treatment planning. The coroner noted these issues are ongoing, risking delays in lifesaving treatment for patients with urgent conditions.
Response (Sandwell and West Birmingham Hospitals): • The Image Exchange Portal (IEP) Standard Operating Procedure was updated to clarify image transmission, including contingencies for out-of-hours and technical faults. • Work is in progress to configure all … (AI summary)
Overdue
Captain James Bedforth
Concerns: The coroner identified concerns about DVT scanning practice, specifically the absence of lower leg scans and insufficient supervision after negative results. The report also noted poor safety-netting, delays in medical assessment and medication on re-admission, and issues with anticoagulation management.
Response (Department of Health): • The Department of Health advised the Coroner to invite NICE to respond directly regarding lower leg scanning guidelines. • Officials provided the Coroner with contact details for NICE. • … (AI summary)
Overdue
Natalie Thornton
Concerns: The coroner noted inadequate monitoring and trend analysis of blood sugar levels from an insulin pump, and the absence of a formal Pump Agreement. Concerns were also raised regarding variable national support for insulin pump users.
Response (Department of Health): • Department of Health officials sought advice from NHS England, NHS Improvement, and NICE regarding national support for insulin pump users. • NHS England is discussing a possible extension of … (AI summary)
Overdue
Daniel Maher
Concerns: 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.
Overdue
David Hamilton
Concerns: 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.
Response (Pennine Care NHS Trust): • A process will be initiated to clearly state in patient clinical records that a patient has completed a treatment options session, identifying the selected treatment and allocated pathway. • … (AI summary)
Response (Grosvenor Medical Centre): • The practice circulated the report to all colleagues and raised concerns about mental health support with the Clinical Commissioning Group. • The practice escalated concerns regarding the psychiatrist referral … (AI summary)
Responded
Patrick Clifford
Concerns: 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.
Overdue
Michael Giles
Concerns: 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.
Response: • The Trust confirmed existing standardised SBAR handover processes and daily nursing "board rounds" with senior clinicians. • It stated that working practices for consultants have been reorganised to facilitate … (AI summary)
Responded
Gwendoline Halfpenny
Concerns: Insufficient surgical cover at County Hospital was noted, with remote advice not a substitute for a physical presence. Concerns were also raised about inconsistencies in duty policies and equipment between County Hospital and RSUH within the same Trust.
Response (University Hospitals of North Midlands NHS Trust): • The Trust remedied the MEWS systems that previously operated differently between County Hospital and Royal Stoke University Hospital. • The Trust introduced a Standard Operating Procedure for surgical referrals … (AI summary)
Responded
Mildred Griffiths
Concerns: The care home's Braden Score for pressure sore risk may underestimate risk by not accounting for existing lesions and causes confusion due to its inverse calculation compared to the nationally recognised Walsall score.
Response (Avery Health Group): • The organisation conducted a root cause analysis in the specific case. • The organisation stated it would continue to use the Braden pressure ulcer risk tool. • The organisation … (AI summary)
Responded
Edwin Hooper
Concerns: The coroner raised concerns regarding measures to ensure patients with head injuries, especially those on anti-coagulant medication, undergo CT scanning in accordance with NICE guidelines, particularly where there are service issues with on-site CT scanners.
Response (Manchester University NHS Trust): • The Trust implemented a robust escalation and dissemination plan for CT scanner downtime. • Senior managers on call and out-of-hours teams were reminded of the CT scanner downtime protocol, … (AI summary)
Responded
Gail Bannister
Concerns: The care coordinator, central to the patient's new treatment strategy, did not see her, undermining the approach. Concerns were also raised about the difficulty contacting the care team during a crisis due to a single, inadequate phone line.
Response (Response Worcestershire Health and Care NHS Trust): • The Trust implemented interim measures, including providing a mobile telephone for staff to contact the on-duty worker. • An initial review of the current telephone system has taken place, … (AI summary)
Responded
Angela Byrne
Concerns: 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.
Overdue
Alfie Scambler-Holt
Concerns: The coroner noted the absence of a national Paediatric Early Warning Score (PEWS) system, which results in different systems across trusts and creates challenges for staff when children move between institutions.
Overdue
Robert Wrinch
Concerns: 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.
Overdue
Janice Davies
Concerns: 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.
Response: • A Standard Operating Procedure for the appropriate use of oral opioid medication in acute pain has been implemented. • The case was discussed in the Rapid Response to Acute … (AI summary)
Responded
Edward Hearn
Concerns: The coroner identified insufficient follow-up of a high globulin finding in A&E, indicative of a fatal disease, due to issues with laboratory reporting and clinician alerts. Concerns were also raised regarding the clarity of cardiac monitoring instructions in drug prescribing information.
Response (King's College Hospital NHS Foundation Trust): • The Trust is using this case to highlight to Emergency Department medical staff the importance of noting abnormal blood test results and ensuring appropriate follow-up. • A 'Safety Net' … (AI summary)
Response (AMGEN): • Amgen stated that cardiac monitoring guidance is definitively outlined in the current prescribing information for Kyprolis. • Amgen indicated that no further revisions to the Summary of Product Characteristics … (AI summary)
Response (Medicines and Healthcare Products Regulatory Agency): • The Medicines and Healthcare products Regulatory Agency (MHRA) added the case report to its Yellow Card database of adverse drug reactions. • The MHRA sought advice from the Pharmacovigilance … (AI summary)
Responded
Susan Longden
Concerns: 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.
Response (NHS England): • NHS Pathways is reviewing its abdominal pain algorithms, including the severe pain section, to consider the inclusion of a question about recent surgical procedures. • This review is scheduled … (AI summary)
Responded
Deborah Hopkinson
Concerns: Multiple equipment failures, including CT scanners and computer systems, affected treatment and caused delays. Additionally, there was insufficient specialist expertise in Cushing's disease, leading to delays in seeking advice from specialist centres.
Response (Northern Care Alliance NHS Trust): • The Trust replaced IT equipment, reconfigured software, and installed filtering equipment to address system failures. • Cortisol analysis was added to the test repertoire at Fairfield General and North … (AI summary)
Responded
Tarek Chowdhury
Concerns: Concerns included inadequate information sharing about prisoners becoming detainees between HMPPS, the Home Office, and IRCs. Issues were also raised regarding SystmOne's operation at IRCs, specifically its technology, nurse access to records, and staff training.
Overdue
Kevin McDonald
Concerns: The discharge documentation from the clinical decision-making unit was not standardised, leading to a lack of clarity and record of follow-up advice given to patients.
Overdue
Alexander Davidson
Concerns: 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.
Response (NHS England): • NHS Pathways confirmed call handlers receive communication skills training, including adapting questioning styles and avoiding jargon, supported by monthly call audits. • NHS Pathways reviewed the question regarding 'dark … (AI summary)
Response (National Institute for Health and Care Excellence): • The National Institute for Health and Care Excellence stated it would reconsider the scope of its pancreatitis guideline (NG104) when it is next reviewed. (AI summary)
Overdue
Maia Strachan
Concerns: The coroner identified gaps in the ability to store sequential scan data with alerts and the lack of clinician access to patient records in joint obstetric and diabetic care. Clear policies are needed for joint decision-making and foetal scalp electrode use.
Response (Maia Strachan): • Training on documentation standards has been reviewed and is provided to all relevant staff. • An ongoing monthly audit of specific notes has been agreed upon, with quarterly reports … (AI summary)
Overdue
Mark Jarvis
Concerns: The SystmOne computer system used for medication prescription and review at HMP Warren Hill was described as unclear and difficult, hindering GPs from verifying current prescriptions, tracking medication adherence, and managing prisoner medications effectively.
Overdue
Select committee recommendations(169)— showing 50 strongest matches
#28 —
Recommendation: NHS England should designate a senior, named person with responsibility for the homecare system. That person should be given sufficient powers and resources to discharge that responsibility. Responsibilities should include: (a) Setting clear national KPIs for organisations commissioning and providing …
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
#13 —
Recommendation: The Chief Pharmaceutical Officer for England should ensure that the KPI data is published in a consistent, standardised form which is sufficiently specific and regular to ensure meaningful public scrutiny. (Paragraph 58) Purchasing
Response attribution not verified
#11 —
Recommendation: NHS England must develop and implement one consistent set of performance metrics.
Response attribution not verified
#10 —
Recommendation: Different sets of performance data are available to manufacturers and the NHS. This creates confusion and prevents effective monitoring.
Response attribution not verified
#189 —
Recommendation: The FOS and the FCA’s review of the redress system must result in clear actions setting out how they will ensure that there is a consistent interpretation of regulatory requirements associated with the Consumer Duty.
Response attribution not verified
#188 —
Recommendation: Should the FCA fail to address concerns about the Consumer Duty requirements there is a risk that the FOS may inadvertently fill this gap, potentially creating inconsistencies in interpretation of the Duty’s application.
Response attribution not verified
#184 —
Recommendation: There was also considerable concern expressed around the way in which the Consumer Duty might interact with the FOS’s rulings. The FCA and FOS’s Call for Input on the redress system acknowledged: “A mass redress event could be triggered by …
Response attribution not verified
#29 —
Recommendation: We agree that the FOS has become a quasi-regulator as its actions have regulatory impacts by creating precedents that the FCA requires firms to follow. The responsibility for issuing binding rules and guidance lies with the FCA. The lack of …
Response attribution not verified
#19 —
Recommendation: NHSE informed us that it was establishing a national frailty dashboard which will take into account the range of interventions that NHSE expects ICBs to have in place. It noted that it does not intend to publish what it considered …
Response attribution not verified
#11 —
Recommendation: NHSE also highlighted variation in terms of the range of community services across the country that are not specified or described clearly or consistently. It explained that these services are coded, measured and counted in different ways and often funded …
Response attribution not verified
#16 —
Recommendation: NHSE&I must streamline the data collection process to reduce the burden for trusts. The Department must ensure that insights collected by all bodies are collated in a coordinated manner and shared across organisations in a timely manner. As part of …
Response attribution not verified
#2 — Recommend a trial of a centralised Secure Data Environment and simplify ethical governance
Recommendation: 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 …
Response status not verified
#26 — NHS still lacks consistent data infrastructure and technological maturity, delaying productivity gains.
Recommendation: 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 …
Response attribution not verified
#7 — Publish plans to reduce NHS paper reliance and set deadline to end fax machines.
Recommendation: 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 …
Response attribution not verified
#31 — Accuracy of criminal and civil court data, including remand population, remains questionable
Recommendation: Despite these assurances, we concur with a request from the Law Society of England and Wales in its written submission to us for confirmation from MoJ that other data and statistics across the criminal and civil courts are not similarly …
Response attribution not verified
#30 — Crown Court caseload data previously unreliable due to Common Platform errors
Recommendation: MoJ confirmed that it had identified three factors that caused it to pause publication of its Crown Court caseload data from June to December 2024. It had found that case records in Common Platform (the new digital case management system …
Response attribution not verified
#7 — Assure accuracy of criminal justice datasets and set out scope for courts' digitisation.
Recommendation: Despite MoJ assuring us that it has rectified the processing errors that led to it publishing inaccurate Crown Court statistics, we remain concerned that other datasets within the criminal justice system may be affected by the same quality and accuracy …
Response attribution not verified
#44 — Disconnected health data systems and lack of central repository hinder effective antimicrobial stewardship.
Recommendation: 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 …
Response attribution not verified
#24 — Diagnostics require further investment and greater integration across the entire health system.
Recommendation: Lord O’Neill told us that although DHSC and its arm’s-length bodies have done a decent job in some key areas, they have not really progressed diagnostics. He is of the view that diagnostics should be embedded across the entire health …
Response attribution not verified
#23 — Lack of progress on diagnostics target due to data limitations; no new quantitative goal.
Recommendation: The 2019–24 NAP had a target to be able, by 2024, to report on the percentage of prescriptions supported by a diagnostic test or decision support tool. However, this was not achieved due to continuing limitations with data, including diagnostic …
Response attribution not verified
#22 — Inadequate diagnostic tests hinder clinicians from reducing inappropriate antimicrobial prescribing effectively.
Recommendation: Better use of diagnostic tools can reduce inappropriate prescribing.56 Diagnostic tools are those which can help diagnose what infection a patient has, thereby helping clinicians determine with accuracy whether a patient needs an antimicrobial treatment and, if so, which one.57 …
Response attribution not verified
#4 — Mandate health bodies to demonstrate progress in using diagnostic tools for AMR over two years.
Recommendation: DHSC has made slow progress in implementing diagnostic tools that could help reduce AMR. Inappropriate prescribing of antibiotics in primary care is estimated to be around 20% of antibiotic prescriptions, which is too high and could drive AMR. ‘Inappropriate’ includes …
Response attribution not verified
#9 — Department struggles monitoring sector engagement with inaccessible digital systems and inconsistent records
Recommendation: 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 …
Response attribution not verified
#5 — UK Government has not provided Wales-specific data on IHT reform impact.
Recommendation: We are concerned that the UK Government has been unable to provide any clarity on the specific impact of its proposed IHT reforms in Wales or supply any Wales-specific data. Only UK-wide figures for farming estates potentially liable to pay …
Response attribution not verified
#4 — Establish a shared geospatial and environmental data platform for cross-government use
Recommendation: Within 12 months of this report, the Government should establish a shared geospatial and environmental data platform, integrated with a case working system. This should be designed for use across government departments, arms-length bodies and local planning authorities to aid …
Response attribution not verified
#3 — Existing data platforms remain siloed, hindering cross-organisational sharing of environmental data
Recommendation: Improved data sharing is a fundamental enabler of efficient and effective cross-organisational work to deliver sustainable housing. While there is evidence of cross-departmental working between DEFRA and MHCLG on planning, nature and housebuilding, the evidence we have taken suggests that …
Response attribution not verified
#24 — Fully integrated multi-species livestock tracing system not expected until winter 2027 with uncertain funding
Recommendation: Between 2019 and March 2025, the Department has spent £181 million on the programme and some services have been developed including a new sheep, goat and deer tracing service.33 However, the Department does not expect to have a fully integrated …
Response attribution not verified
#23 — Multi-species livestock tracing system programme experienced significant resets due to technical issues
Recommendation: The Department first started work to create a digital, multi-species, UK-wide tracing system in 2013 and acknowledged that it has been working on this for a long time. It explained that the original concept of using an off- the-shelf solution …
Response attribution not verified
#22 — Current UK animal tracing systems are fragmented, old, and fragile
Recommendation: Livestock movements in England are significant. For example, there are around 20 million movements of sheep to or from different farms, livestock markets, collection centres, and to abattoirs each year. These movements increase the risk of spreading disease. Being able …
Response attribution not verified
#18 — APHA's outdated paper-based systems and processes cause significant inefficiency and delays.
Recommendation: APHA acknowledged that its systems and processes are outdated and require modernisation. For example, its vets in the field must complete paper-based forms, which are scanned and manually deciphered before being added to a database. APHA also cited the example …
Response attribution not verified
#17 — EU exit reduced timely access to detailed animal disease intelligence for the UK.
Recommendation: The Department explained that following EU exit, the UK lost access to the EU’s Animal Diseases Information System which provided almost real-time intelligence on EU animal diseases. While the UK has access to an international intelligence system provided by the …
Response attribution not verified
#6 — Ensure progress and devolved alignment of the multi-species livestock tracing system
Recommendation: The Department’s progress delivering a multi-species livestock tracing system has been extremely slow and may not provide an integrated system for the UK. Tracing animal movements quickly—to understand where disease may have spread—is key in responding effectively to contain an …
Response attribution not verified
#22 — FCDO lacks crucial data on capital project delivery track record and performance.
Recommendation: FCDO completed or started work on 200 capital projects between April 2018 and November 2024, with a total value of £850 million. FCDO does not hold data on its track record in delivering its projects, but several high-profile projects have …
Response attribution not verified
#20 — FCDO acknowledges inadequate digital estate management, planning a comprehensive workplace system by 2028.
Recommendation: We note that modern property IT portals which are tried and tested are readily available. FCDO accepted that it is an organisation whose digital management of its large estate portfolio is not up to scratch and that it needs to …
Response attribution not verified
#19 — FCDO's disparate and unintegrated IT systems hinder central collection and effective management of estate data.
Recommendation: Even if staff at posts start collecting estate data, FCDO faces a challenge collecting this data centrally so it can use it to manage its estate portfolio.50 FCDO uses a range of different IT systems to manage its estate. FCDO …
Response attribution not verified
#17 — FCDO's federated structure and inadequate post resources hinder comprehensive estate data collection.
Recommendation: FCDO told us that it is very challenging to collect the data it needs to manage its estate as it is a “federated organisation,” and its central estate function relies on staff at each of its 282 posts to provide …
Response attribution not verified
#4 — Report FCDO progress on embedding quality estates data collection and implementing an integrated management system.
Recommendation: FCDO does not have all the data it needs to manage its estate effectively. FCDO has developed its central IT systems separately and they are not integrated with each other, or with systems at overseas posts. Overseas posts are responsible …
Response attribution not verified
#4 — Require NHSE and Department to set out plans for elective care digital transformation and IT connectivity.
Recommendation: 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 …
Response attribution not verified
#9 — BBC's digital account data cannot directly support licence fee enforcement activities.
Recommendation: We queried why digital audience engagement through the accounts necessary to use iPlayer cannot support more digital licence fee enforcement activities. The BBC told us that its household-address based licensing system does not match individual based BBC account data, so …
Response attribution not verified
#8 — Department lacks up-to-date information on children's care provision, demand, and available places.
Recommendation: The Children’s Commissioner told us that there needs to be a much tighter grip on the amount and type of provision needed and where.13 The Department lacks up-to-date information on the support children need, the demand for places and places …
Response attribution not verified
#21 — Fragmented police HR and other systems lack a firm plan for national simplification.
Recommendation: We sought reassurances that the Home Office was considering simplifying police systems, such as those used in human resources. The Home Office recognised police forces use many different systems and it is a highly fragmented picture. It told us that …
Response attribution not verified
#7 — Fragmented police data hinders understanding of financial risks and impact on productivity.
Recommendation: We asked the Home Office whether it has the data it needs to understand the financial risks facing police forces and the impact that this has on police productivity.9 The Home Office said there are multiple datasets scattered across bodies …
Response attribution not verified
#3 — Establish a national system for sharing and analysing clinical negligence data to improve patient safety.
Recommendation: We are concerned there is far too little data on the factors behind clinical negligence, given its huge impact on people’s lives and NHS finances. Behind every clinical negligence claim is a tragic incident of patient harm. We were disappointed …
Response attribution not verified
#45 — Publish regular, transparent data on prison healthcare access and outcomes for accountability
Recommendation: 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 …
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
#18 — Publish annual official estimates of delayed discharge costs to the NHS, broken down by reason
Recommendation: We recommend that the Department provides an official estimate of how much delayed discharges are costing the NHS, broken down by the reason for the delay and including costs associated with the beds themselves, staff time and wider activity that …
Response attribution not verified
#3 — Develop robust methodology for measuring care's impact on people's lives, health, and the economy.
Recommendation: The Government must also develop a robust methodology for measuring the impact of care on people’s lives, the wider health system, and the economy. As well as supporting the case for reform, such methodology would help councils to deliver outcome-based …
Response attribution not verified
#2 — Publish annual assessment of unmet care needs for adults, including methodology and supporting data.
Recommendation: The Government should publish an annual assessment of the level of unmet care needs for both older adults and working age disabled adults, publishing its methodology and supporting data to ensure transparency and allow for scrutiny. (Recommendation, Paragraph 21)
Response attribution not verified
HSSIB safety recommendations(29)
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?
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
Recognition of the acutely ill infant
HSIB recommends that NHSX develops national standards describing the electronic deployment of the NHS System-wide Paediatric Observations Tracking (SPOT) e-PEWS (the digital version of the Paediatric Early Warning Score tool), in collaboration with the NHS England and NHS Improvement SPOT …
Safety Recommendation
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.
Safety Observation
Access to critical patient information at the bedside
HSIB recommends that the British Standards Institution, with support from relevant stakeholders, provides symbology to standardise how information relating to a patient’s resuscitation status can be displayed in digital systems.
Safety Recommendation
Investigation report: Clinical investigation booking systems failures - written communications in community languages
It may be beneficial if the ‘preferred written communication method’ field of the Personal Demographics Service system is completed for patients who require written communications in a language other than English.
Safety Observation
Nutrition management of acutely unwell patients in acute medical units
NHS trusts can improve patient safety in acute medical units by implementing, and if already implemented then appropriately using, digital systems to monitor and highlight nutritional screening requirements.
Learning Prompt
Sepsis: investigating under the Patient Safety Incident Response Framework (PSIRF)
Difficulty for nursing staff getting medicines prescribed by GPs on the electronic patient record system. Area of improvement 3
Area of Improvement
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
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
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
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 …
Safety Recommendation
Delayed recognition of acute aortic dissection
There is a lack of detailed and accurate data regarding the incidence and patient outcomes for acute aortic dissection in England, particularly for those patients who do not reach a specialist treatment centre alive. Such data would assist in understanding …
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 …
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
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
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
Mental health inpatient settings
HSSIB recommends that the Department of Health and Social Care working with NHS England, and other relevant stakeholders, develop a comprehensive, unified data set with agreed definitions for recording and reporting deaths in mental health services to include deaths that …
Safety Recommendation
Creating conditions for learning from deaths and near misses in inpatient and community mental health …
Organisations can improve patient safety by involving ‘digital experts’ in their electronic patient record system improvement projects. This will support any digital configuration and infrastructure changes required to record person-centred approaches to psychosocial assessments and safety planning.
Safety Observation
Sepsis: a patient with a urine infection
Difficulty for nursing staff getting medicines prescribed by GPs on the electronic patient record system.
Area of Improvement
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 …
Safety Recommendation
Implantation of wrong prostheses during joint replacement surgery
The National Joint Registry (NJR) changes the response when data is entered into the registry suggesting the wrong prosthesis has been implanted due to incompatible manufacturers, so that it is consistent with the response when data indicates the wrong size …
Safety Recommendation
The role of clinical pharmacy services in helping to identify and reduce high-risk prescribing errors …
Clinical pharmacy services should consider using validated tools to assist in prioritising pharmacy care and identifying high-risk medicines and high-risk situations for medication error. Where electronic medical record systems are used, such tools could be integrated into these systems to …
Safety Observation
Positive patient identification
HSSIB suggests that integrated care boards assure processes for the transfer of patient care between healthcare organisations in their geographical footprints to reduce variation in processes for patient identification.
Safety Action
Positive patient identification
Those purchasing and implementing electronic patient record systems in healthcare organisations can improve patient safety by ensuring those systems are compliant with relevant risk management standards (such as DCB0129, DCB0160 and DCB1077).
Safety Observation
Mental health inpatient settings: overarching report of investigations directed by the Secretary of State for …
National bodies can improve patient safety in mental health inpatient settings in England by supporting provider investment in equipment, digital systems and physical environments to enable conditions within which staff are able to provide, and patients can receive, safe and …
Safety Observation
Workforce and patient safety
HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care …
Safety Recommendation
Workforce and patient safety: electronic communications on patient discharge from acute hospitals
HSSIB recommends that the NHS England/Department of Health and Social Care, in collaboration with relevant national bodies including the Professional Record Standards Body, adopts user-centred design principles to develop and validate new discharge correspondence templates for primary and community care …
Safety Recommendation
NCEPOD recommendations(10)
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!
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
Know The Score
Wording not shown. See the report on NCEPOD's website.
Know The Score
Balancing the Pressures
Wording not shown. See the report on NCEPOD's website.
Balancing the Pressures
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Community-Acquired Pneumonia
Wording not shown. See the report on NCEPOD's website.
Community-Acquired Pneumonia
Treat the Cause
Wording not shown. See the report on NCEPOD's website.
Treat the Cause
CQC inspection actions(64)— showing 50 strongest matches
The Queen Elizabeth Hospital
The service should ensure maternity telephone triage monitoring allows for detailed data collection.
Should Do
St Albans City Hospital
The trust should ensure that IT systems are appropriate to service needs.(Regulation 15).
Should Do
Leicester Royal Infirmary
The service should consider further separation of its maternity data for all sites.
Should Do
Leicester General Hospital
The service should consider further separation of its maternity data for all sites.
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
Hemel Hempstead General Hospital
The trust should ensure that IT systems are appropriate to service needs.
Should Do
Hemel Hempstead General Hospital
The trust should ensure that IT systems are appropriate to service needs.
Should Do
Hemel Hempstead General Hospital
The trust should ensure that IT systems are appropriate to service needs.
Should Do
Fleetwood Hospital
The trust should consider how IT systems can be used so that performance within the emergency department can be visualised throughout the hospital.
Should Do
Diana Princess of Wales Hospital
The service must collect reliable data to understand performance, make decisions and improvements.
Must Do
Broomfield Hospital
The trust should ensure data collection is reliable and integrated.
Should Do
St Benedict's Hospice
The service should improve data quality and collection of clinical data.
Should Do
Withington Community Hospital
Consider having data available to staff on performance at a local level including local audit activity.
Should Do
Warrington Hospital
The serviceshouldensurethatelectronicpatientrecordsareintegratedasfarasispossibletoavoidtheriskofmissed information.
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
Royal Bournemouth Hospital
The interface between paper and electronic risk assessments should be reviewed to mitigate the risk of staff using concurrent recording systems.
Should Do
Frimley Park Hospital
The service should continue to ensure there is an accurate overview of risks faced, including how assurance is gained in the absence of a live maternity dashboard or ability to extract all suitable data from IT systems.
Should Do
Friarage Hospital
The service should consider separating data collection from the James Cook University Hospital and use this to drive improvements.
Should Do
Durham Diagnostics and Treatment Centre
The service should improve data quality and collection of clinical data.
Should Do
Clifton Hospital
The trust should consider how IT systems can be used so that performance within the emergency department can be visualised throughout the hospital.
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
St Albans City Hospital
The trust should ensure that IT systems are appropriate to service needs.(Regulation 15).
Should Do
St Albans City Hospital
The trust should ensure that IT systems are appropriate to service needs (Regulation 15).
Should Do
Royal Sussex County Hospital
The trust must ensure that workforce data for the trust can be separated to show individual site performance.
Must Do
Princess Royal Hospital
The trust must ensure that workforce data for the trust can be separated to show individual site performance.
Must Do
Princess Royal Hospital
The trust must ensure action is taking to improve their compliance with national waiting list targets. And that performance data for the trust can be separated to show site performance.
Must Do
Montagu Hospital, Mexborough
ThetrustshouldensurethatK2technologyisupdatedwithnationalupdatesassoonastheyarereleased.
Should Do
Leighton Hospital
The trust should ensure that plans to develop and implement a new maternity digital patient record are completed as a priority so that the service can monitor outcomes for women and birthing people.
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 consider collecting formal therapy outcome data or using specific rehabilitation measures to assess outcomes.
Should Do
Homerton University Hospital
The service should ensure that it implements the planned new maternity digital records as planned.
Should Do
Windsor Dialysis Unit
IssueswithITsystemsprovidingoutcomedataandthoserelatingtoremoteworkingshouldberesolved.
Should Do
West Berkshire Community Hospital
IssueswithITsystemsprovidingoutcomedataandthoserelatingtoremoteworkingshouldberesolved.
Should Do
West Berkshire Community Hospital
Improvethequalityofdataandinformationavailableforinternalandexternalusetoensureitprovidesassuranceofperformanceandcompliance.
Should Do
Victoria Infirmary
The trust should continue to prioritise the introduction of electronic patient records.
Should Do
University Hospital North Durham
The service should consider ways to strengthen data capture within the trust maternity dashboard.
Should Do
Poole Hospital
Provide improved assurance at board level on progress and problems with technology and digital information systems, including possible poor quality of data.
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
Durham Diagnostics and Treatment Centre
The service should consider collecting formal therapy outcome data or using specific rehabilitation measures to assess outcomes.
Should Do
Durham Diagnostics and Treatment Centre
The service should record and monitor referral to treatment times and national care of the dying audit data to ensure services are in line with provider targets.
Should Do
Durham Diagnostics and Treatment Centre
The service should consider revising and reviewing maternity and obstetric dashboards so that performance can be easily benchmarked against regional or peer-group averages, and national and trust targets (where applicable).
Should Do
Darlington Memorial Hospital
The service should consider ways to strengthen data capture within the trust maternity dashboard.
Should Do
Bridlington Hospital
The trust should continue its work to improve its reporting of performance information to enable easier oversight and governance and continue its work to improve its digital systems and processes.
Should Do
Bridgwater Community Hospital
The service should ensure clinical outcomes data in relation to the the Mary Stanley freestanding birth unit at Bridgwater Community Hospital is included in the maternity dashboard.
Should Do
Westhaven
The provider must ensure decision specific mental capacity assessments are completed for people who might lack the capacity to make decisions about their care.
Must Do
Cygnet Bury Hudson
The service should ensure that it continues to improve the electronic care records system to include Mental Health Act and Mental Capacity Act paperwork to avoid confusion and duplication.
Should Do
Wexham Park Hospital
The service should continue to ensure there is an accurate overview of risks faced, including how assurance is gained in the absence of a live maternity dashboard or ability to extract all suitable data from IT systems.
Should Do
Stroud Maternity Hospital
The service should consider separating data collection between locations and to use this to drive improvements.
Should Do
St Benedict's Hospice
The trust should continue to develop dashboards and data collection across all services to support effective analysis of staff and service performance.
Should Do
HMICFRS recommendations(3)
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, where required, chief constables should seek changes to their crime recording systems to enable staff and officers to document and search for crimes not recorded as the principal crime, with stalking and related offences fully searchable.
Recommendation
Report on the Suzy Lamplugh Trust's super-complaint: The police response to stalking
By 27 March 2025, the Home Office should work with the College of Policing, the NPCC lead for stalking and harassment and the National Stalking Consortium to update information on stalking, aligning crime recording rules with Stalking Protection Act guidance.
Recommendation
Police perpetrated domestic abuse: Report on the Centre for Women's Justice super-complaint
To improve the consistent recording and monitoring of PPDA cases, the Home Office should amend the Annual Data Requirement connected to misconduct cases and criminal investigations. Police forces should be required to report the number of misconduct cases and criminal …
Recommendation
ICIBI immigration recommendations(1)
NAO audit recommendations(12)
Protecting and supporting the clinically extremely vulnerable during lockdown
DHSC should set out the core data requirements it is likely to need in a future pandemic or civil emergency and how it can access these data in a timely manner;
Accepted
Protecting and supporting the clinically extremely vulnerable during lockdown
DHSC should ensure that healthcare data systems allow easy, but secure, access to healthcare data;
Accepted
Progress in preventing cardiovascular disease
DHSC and NHSE should assess the effectiveness of data flows between DHSC, local authorities and primary care to inform a data improvement programme. This should include an assessment of the feasibility of adding Health Check data to CVDPREVENT and of …
Accepted
NHS England’s modelling for the Long Term Workforce Plan
Recommendation 16: NHSE analysts should document and share their long-term assumptions, for each iteration of the LTWP, within NHSE and with HM Treasury and DHSC. NHSE analysts across the organisation should use common assumptions where possible.
Accepted
Active Travel in England
In establishing itself as a new executive agency, ATE should: e. develop a clear, consistent framework for standardised local data collection to provide baselines and inform scheme evaluations using comparative analysis. This plan should draw on digital technologies and ATE …
Accepted
Progress in improving mental health services in England
d) NHSE, working with ICBs, should develop and issue guidance in 2023 on how the system will gain more transparency over capacity, activity, performance and outcomes in community mental health services, including improvements required to implement the proposed new clinical …
Partially accepted
Improving family court services for children
MoJ, DfE, HMCTS and Cafcass, working through the FJB, should agree a data and evidence strategy to identify data gaps from a family justice whole system perspective and consider how it will address these. This should include examining data in …
Accepted
Improving family court services for children
MoJ, DfE, HMCTS and Cafcass, working through the FJB, should agree a data and evidence strategy to identify data gaps from a family justice whole system perspective and consider how it will address these. This should include examining data in …
Accepted
Improving family court services for children
MoJ, DfE, HMCTS and Cafcass, working through the FJB, should agree a data and evidence strategy to identify data gaps from a family justice whole system perspective and consider how it will address these. This should include examining data in …
Accepted
Reducing the backlog in criminal courts
• strengthening its work with the judiciary and regional offices to capture local intelligence systematically and consistently.
Accepted
Reducing the backlog in criminal courts
d) support improvements in data it needs for recovery by: • devising and implementing a plan to tackle the systemic barriers to collecting, using and sharing data effectively across the criminal justice system; and
Accepted
Challenges in using data across government
c) Develop cross-government rules, standards and common ways to collect, store, record and manage data. Where multiple standards are used, government should develop a consistent approach to balancing competing demands between standardisation and local requirements, including implications for future decision-making …
Accepted
IMB annual reports(2)
Erlestoke (2022)
The report covers HMP Erlestoke from April 2021 to March 2022, a period significantly impacted by Covid-19 restrictions that limited out-of-cell time. Despite challenges like staff shortages and high turnover, the Board found prisoners to be relatively safe, though violence increased and self-harm remained high. Key concerns include delays in transfers, inadequate mental health provision, and the slow pace of infrastructure improvements.
PRISON
Key concerns
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 closure, though efforts were made to minimise negative impacts on resettlement.
PRISON
Key concerns
IMB individual recommendations(11)
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 (2021)
Will steps be taken to enhance IT capabilities in this regard?
NHS / Healthcare Provider
In Progress
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
Guys Marsh (2021)
HMPPS should prioritize investing in more efficient IT systems to improve both staff efficiency and accurate, timely communication.
HMPPS
In Progress
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
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
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
Scotland and Northern Ireland Short-Term Holding Facilities (STHF) (2023)
We would recommend a review with consideration being given to standardisation of the translation devices across all of the facilities.
Home Office
Grendon (2023)
The Board looks forward to a monthly set of routinely collected/agreed healthcare data through which we can monitor the quality of healthcare.
Governor / Director
Foston Hall (2023)
The healthcare service does not collect equalities’ data and, therefore, cannot monitor for disproportionate outcomes. When will this be addressed?
Governor / Director
The Mount (2024)
A proper data recording and management system should be introduced to replace the current use of myriad internally constructed spreadsheets and PowerPoint documents that are isolated, inconsistent and require too much manual involvement when reports or information are called for (see §9).
HMPPS
Health investigations(49)
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: Maurice Hilton, Peterlee (2006) — Rec 6
Trusts should give serious and urgent consideration to implementing a unified computerised record keeping system on which all entries relating to the day to day working with a client are recorded, by all mental health professionals.
north_east_yorkshire
Independent investigation: Phyllis Deane, Shaldon/Torquay Devon (2007) — Rec 3
It is strongly recommended that when the RiO Electronic Record System is installed that the Trust identifies a well identified place within the RiO System where the latest care plan and risk assessment and management plan is kept together with a brief synopsis of the history, this should be updated …
south_west
Independent investigation: Maxine Penfold, Cullompton, Devon (2004) — Rec 1.2
Practitioners involved in the provision of care and treatment have access to, and make use of, a unified and integrated health and social care record-keeping system. This could be ePEX or any other system adopted in the future, which ensures that contemporaneous information on which to base sound clinical decisions …
south_west
Independent investigation: Jan Jensen, Hassocks (2012) — Rec R10
The trust should agree how and when a new integrated community and ward IT system will be introduced and should tell staff about it.
south_east
Independent investigation: Jan Jensen, Hassocks (2012) — Rec R9
Pending the introduction of a ward-based IT system, a temporary procedure should be introduced which ensures that community and ward notes are accessed as part of one process.
south_east
Independent investigation: Caroline WillsAshley Wills, Cramlington, North-umberland (2000) — Rec 9
Agencies should work towards establishing a workable and integral system of electronic patient records so that a central record is maintained to which the GP can have immediate access to get a fuller picture of the patient.
north_east_yorkshire
Independent investigation: Chloe Sutherland (8 mnths), Edinburgh (2015) — Rec 5
Review IT systems and consider the use of electronic referral systems, for example using the SCI gateway system14. Ensure that general practices review and consider improvements to their IT systems. This could include having two PC monitors to allow access to different electronic systems simultaneously. This would allow access to …
scotland
Independent investigation: Anita Bawtree, Southampton (2011) — Rec 11
A greater correlation between the data available in the form of easily identifiable read codes and the information contained in individual patient records. Increase performance management of Primary Care services to ensure practices are complying with this mandatory process in line with guidance using uniform read codes.
south_east
Independent investigation: Abdullah Jama, Blackheath (2009) — Rec 5
Trusts should ensure that proper policies, procedures and training are in place to allow the rapid transfer of key clinical data to other Trusts 24 hours a day in an easily accessible format to a known recipient using Safehaven principles. All relevant staff should be competent to use these systems …
north_east_yorkshire
An independent inquiry into the care and treatment of Mr … — Rec 9
When commissioning and re-commissioning services, local commissioners should ensure that contracts consider the potential impact of non-compatible IT systems, carry out a gap analysis and risk assessment and mitigate any risks identified. Assessment and mitigation of any risks arising from new contracts entered into by local commissioners which involve incompatible …
Southern Health NHS Foundation Trust
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: 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: Steven Hoskin, St. Austell (2006) — Rec R4
Cornwall Partnership NHS Trust should assure its commissioners that the use of separate notes and recording systems in mental health services (e.g. general, forensic and psychological services) is subject to regular review and scrutiny and continued only where a clear evidence-base can be provided. (We note that the trust‘s revisions …
south_west
Independent investigation: Simeon Claxton, Petersfield, Hampshire (2004) — Rec Recommendation 6
It is recommended where patients who are severely mentally ill and under the long term care of an NHS psychiatric team that some level of communication and co-operation should be sought. Even within the NHS, psychotherapy notes may be kept separately from the main clinical notes and communication may be …
south_east
Independent investigation: Sandra Bainbridge, Belper (2013) — Rec 1
The Trust is required to adopt a strategic response in relation to patient records, i.e. the unification of the paper and digital notes system into one system. The Independent Investigation Team is of the view that this should ideally be an electronic system capable of allowing a care professional to …
midlands
Independent investigation: Peter Hartley, Keighley (2001) — Rec 6.2.8
There should be the development of electronic records accessible 24 hours, in line with the National Programme for Information Technology being run by the NHS.
north_east_yorkshire
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 7
IT systems should alert primary care practitioners when a child is within the household of an adult with mental health issues and should highlight key patient issues.
midlands
Independent investigation: Marta Elena Vento, Bournemouth (2020) — Rec R17
NHS England’s Health and Justice Team should work with all healthcare provider agencies to ensure that SystmOne functionality is maximised to promote appropriately accessible sharing of important information between prisons and community services when a patient transfers in and out of secure and detained settings. It must be ensured that …
south_west
Independent investigation: John Hall, West Rainton (2013) — Rec 4.8.2
The clinicians should ensure they comply with the information sharing requirements of the trust Care coordination policy.
north_east_yorkshire
Independent investigation: Geraldine Sureda(Mrs S), Mitcham Park, Merton (2000) — Rec 4
Consideration should be given to the development of a nationally standardized proforma Risk Assessment
london
Independent investigation: Enrique Parada- Blanco, Kingsbury (2008) — Rec 8
JADE – Electronic Care Record System: The Trust to address the concerns raised by staff in relationtoenteringqualitativeanddetailedinformationonthesystem.
london
Independent investigation: Colin Ricketts, Laindon, Essex (2009) — Rec R4
The trust commissioners should review with the trust its progress in moving to a single electronic record system that allows all professionals to input entries and view the notes of other professionals working with a client.
east_of_england
Independent investigation: Casey Kearney, Doncaster (2012) — Rec 11
RDaSH will review the quality of record keeping in adult community mental health services and establish an improved system of routinely monitoring the quality of records. Adult mental health in-patient services will move to an electronic patient record that is routinely shared with community mental health services.
north_east_yorkshire
Independent investigation: Ben Cargill (Mr D), Chesham, Bucks (2004) — Rec ten
The inquiry panel understands that the Trust, together with its partner agencies, is reviewing and developing an electronic data system, which can be used by the multi-disciplinary team. It is further recommended that the Trust: • Reviews the implementation of integrated records to ensure that the transition to this new …
south_east
Independent review of mental health treatment and care provided in … — Rec 1
NHS England and NHS Digital to support delivery of information to be used within and across services to support information-sharing across geographical and service boundaries. It should be evidence-based and contain guidance for staff. The aim is to ensure that key elements of the care provided for a patient can …
south_west
An independent mental health homicide investigation into the care and … — Rec 11
Cygnet Health Care should consider the viability of introducing electronic continuous records in their inpatient units.
Avon and Wiltshire Mental Health Partnership NHS Trust
south_west
An independent inquiry into the care and treatment of Ms … — Rec 6
We recommend that the OHFT and Oxfordshire County Council Social & Community Services Directorate work together to put in place information technology systems that are accessible to the staff of both organisations.
south_east
*Independent investigation into the care and treatment of Patient E: … — Rec 27.
All clinical notes, including psychology, should be integrated within the patient’s records and be readily accessible to all professionals involved in the individual’s care.
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of P in … — Rec 9
The new EHR must facilitate the recording of other agencies involvement and contact details.
midlands
Accepted
An independent review into the independent sector provider One to … — Rec 8
A robust methodology for determining the stillbirth rate by provider needs to be developed that takes into account shared care arrangements between providers of maternity care.
north_west
An independent review into the independent sector provider One to … — Rec 10
Data quality audits should be a core requirement of service specifications and the Data Quality Improvement Plan under the contract used to support this area of work.
north_west
An independent investigation into the care and treatment provided to … — Rec Local 4
The Trust should develop interoperable systems and processes to enable sharing of necessary clinical and risk-related patient data across clinical care settings. This should include sharing and increasing the visibility of information across primary and secondary care (NHS & independent providers). The purpose of this is to enable shared decision …
midlands
An independent investigation into the care and treatment of SV — Rec 5
Approaches to MDT meetings and the documentation of discussions were not standardised across community mental health teams. This meant that key risk information was not readily available at outpatient clinics, and medical staff were not always given the opportunity to discuss patient care in MDT meetings. The Trust must implement …
midlands
An independent investigation into the care and treatment of MS: … — Rec 5
LYPFT is required to adopt a strategic response in relation to its consolidation of patient records, i.e. the migration of the paper and digital notes system into one system. The Independent Investigation Team is of the view that ideally, this should be the unification of records within an electronic system, …
north_east_yorkshire
An independent investigation into the care and treatment of Mr … — Rec 2
The current situation where a social worker’s access to NHS mental health records is terminated, either because they have not accessed these in a set number of days, or because they have forgotten to update their password (for which there is no reminder system), needs to be reviewed and remedied. …
north_west
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: Abdullah Jama, Blackheath (2009) — Rec 9
The Trust should audit the information systems and take appropriate steps to ensure that care co-ordinators have access to clinical information about their clients irrespective of location within the Trust.
north_east_yorkshire
Independent investigation: Abdullah Jama, Blackheath (2009) — Rec 4
When Trusts are communicating with each other about a client they should ensure that key clinical information is prioritised before financial and administrative issues.
north_east_yorkshire
*Independent investigation into the care and treatment of Mr J: … — Rec 2
The Trust should consider the options available to refine and develop its electronic record systems in order to ensure greater integration of safeguarding, care planning and care delivery systems.
Mr J . At the time of the incident (2010) Mr J had been receiving support from a community mental health team at South West Yorkshire Partnership NHS Foundation Trust
north_east_yorkshire
Assurance Review: Recommendations for commissioners, NHS England, advisors and regulators — Rec 55
A reporting template should be developed which brings together quality, activity and performance information at a specialty level. A programme of reporting at this level should be agreed with the Trust, with frequency of reporting for each specialty to reflect jointly agreed priorities. This should provide a single source of …
University Hospitals of Morecambe Bay NHS Foundation Trust
north_west
An independent inquiry into the care and treatment of Ms … — Rec 5
All professionally registered clinical staff need to be able to open a new case of RiO to enable them to make contemporaneous records. This is subject to any information governance restrictions.
south_east
An independent inquiry into the care and treatment of Ms … — Rec 3
CMHT safeguarding managers should be afforded better more reliable access to OCC systems for reporting and recording adult protection concerns and outcomes
south_east
Independent investigation into the care and treatment of Ms A — Rec 20
MAPPA should hold a central database for those patients on Level 1 MAPPA.
Ms A who committed a homicide in October 2011. Ms A was in receipt of services from Oxleas NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr X … — Rec Recommendation Three
The referral system has been improved since the transfer from paper to electronic records. Referrals are now highlighted and audited. The system is fully integrated at the present time Action: For the current arrangements to be audited within six months of the publication of this report.
london
*Independent investigation into the care and treatment of Mr L: … — Rec 4.4
The Trust should consider the options available to refine and develop its electronic record systems and thereby ensure greater integration of systems in regard to safeguarding, care planning and care delivery.
Mr. L. At the time of the incident (2011) Mr L had three brief episodes of care with South West Yorkshire Partnership NHS Foundation Trust
north_east_yorkshire
An Independent Patient Safety Investigation (IPSI) Report of Yusuf Mahmud … — Rec 7
Paper Record Use: Review the continued use of paper-based records in paediatric care, due to potential risks to continuity and safety.
north_east_yorkshire
An independent investigation into the care and treatment of patient … — Rec 5
There were inadequate systems in place to monitor the frequency and quality of risk assessments. Trust-level data was not sensitive enough to provide adequate intelligence about whether individual patients were being risk assessed at the appropriate frequency. The Trust must introduce more sensitive and effective controls that monitor and maintain …
north_east_yorkshire
An independent investigation into the care and treatment of Harry … — Rec 16
We recommend that LTHT and LYPT work together to ensure that there is clarity about where decisions regarding patients who are being treated by both Trusts are recorded. Furthermore, we recommend that both Trusts adjust their healthcare records policies accordingly.
Leeds and York Partnership NHS Foundation Trust
north_east_yorkshire
Detention investigations(2)
Review into the Welfare in Detention of Vulnerable Persons — Rec 51
I further recommend that an alternative to SystmOne be pursued for those detention facilities not in England.
Immigration Detention
Independent Investigation into Concerns about Brook House Immigration Removal Centre — Rec R41
Healthcare should agree with how cleaning must be improved and how these new standards are adopted and maintained. Healthcare facilities should be deep-cleaned at least twice yearly. (To be completed as a matter of urgency)
Immigration Detention
Independent reviews(50)
Carter NHS Productivity Review — Rec 13
NHS Improvement should, in partnership with NHS England by July 2016, develop an integrated performance framework to ensure there is one set of metrics and approach to reporting, so that the focus of the NHS is on improvement and the reporting burden is reduced to allow trusts to focus on …
Health & Social Care
Carter NHS Productivity Review — Rec 12
NHS Improvement should develop the Model Hospital and the underlying metrics, to identify what good looks like, so that there is one source of data, benchmarks and good practice.
Health & Social Care
Carter NHS Productivity Review — Rec 9
All trusts should have the key digital information systems in place, fully integrated and utilised by October 2018, and NHS Improvement should ensure this happens through the use of 'meaningful use' standards and incentives.
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
Mental Health Taskforce 2016 — Rec 50
The Department of Health and NHS England should require CCGs to publish data on levels of mental health spend in their Annual Report and Accounts, by condition and per capita, including for children and Adolescent Mental Health Services, from 2017/8 onwards. They should require CCGs to report on investment in …
Health & Social Care
Mental Health Taskforce 2016 — Rec 46
The Department of Health should commission regular prevalence surveys for children, young people and adults of all ages that are updated not less than every seven years. CHAPTER SIX: INCENTIVES, LEVERS AND PAYMENT 6.1 THE CURRENT APPROACH TO AN UNEVEN PLAYING FIELD Mental health services have been plagued by years …
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
Mental Health Taskforce 2016 — Rec 43
During 2016 NHS England and PHE should set a clear plan to develop and support the Mental Health Intelligence Network over the next five years, so that it supports data linkage across public agencies, effective commissioning and the implementation of new clinical pathways and standards as they come online.
Health & Social Care
Mental Health Taskforce 2016 — Rec 42
NHS England and the HSCIC should work to identify unnecessary data collection requirements, and then engage with NHS Improvement to prioritise persistent non-compliance in data collection and submission to the MHSDS, and take regulatory action where necessary.
Health & Social Care
Mental Health Taskforce 2016 — Rec 41
The Department of Health, HSCIC and MyNHS, working with NHS England, should improve transparency in data to promote choice, efficiency, access and quality in mental health care, ensuring that all NHS-commissioned mental health data are transparent (including where data quality is poor) to drive improvements in services. The CCG Performance …
Health & Social Care
Mental Health Taskforce 2016 — Rec 40
The Department of Health should develop national metrics to support improvements in children and young people’s mental health outcomes, drawing on data sources from across the whole system, including NHS, public health, local authority children’s services and education, to report with proposals by 2017.
Health & Social Care
Mental Health Taskforce 2016 — Rec 39
The Department of Health, NHS England, PHE and the HSCIC should develop a 5-year plan to address the need for substantially improved data on prevalence and incidence, access, quality, outcomes, prevention and spend across mental health services. They should also publish a summary progress report by the end of 2016 …
Health & Social Care
Mental Health Taskforce 2016 — Rec 28
The Department of Health, through the National Information Board, should ensure there is sufficient investment in the necessary digital infrastructure to realise the priorities identified in this strategy. Each ALB should optimise the use of digital channels to communicate key messages and make services more readily available online, where appropriate, …
Health & Social Care
Shape of Caring Review — Rec 33
HEE, working with HEIs, should support the development of a standardised student minimum data set, which would enable the calculation of attrition rates at HEI, local and national levels.
Health & Social Care
Cavendish Review — Rec 12
Regulators, employers and commissioners in health and social care should define a single common dataset for their purposes, and commit to using it, to relieve the pressure on first line managers and other staff.
Health & Social Care
Goldacre Review — Rec Cur 13
Develop portable representations of data management code There is a need for portable representations of data management actions, as described above. This will ensure that curation code is readable, understandable, re-usable, and portable between teams and settings, and let organisations communicate dataset specifications, or clinical popup and alert specifications, between …
Health & Social Care
Goldacre Review — Rec Cur 12
Develop standard tools to convert raw data into analysis-ready datasets The conversion of raw data into analysis-ready datasets should be done with common tools, regardless of setting, to ensure that all data management code is intelligible and re-usable by others. This will require the rapid development of standard functions and …
Health & Social Care
Goldacre Review — Rec Cur 11
Create and enforce standards for local TREs Local TREs should be either one single open source NHS TRE design, or conform to an extensive range of open standards, as per the TRE chapter (recognising that developing such standards in isolation may be more complex than developing a template open source …
Health & Social Care
Goldacre Review — Rec Cur 10
Create and enforce consistent standards for local implementations of national datasets Wherever possible the same health data should always be held in the same form wherever it is stored or made accessible, not the many slightly different cuts, data models, or even column names that are seen across different settings. …
Health & Social Care
Goldacre Review — Rec Cur 9
Require use of national TREs for tasks using national datasets wherever possible This is likely to address a large number of local analyses, especially those aimed at benchmarking local activity against national activity.
Health & Social Care
Goldacre Review — Rec Cur 8
Use consistent environments to facilitate re-usable curation code Currently national datasets such as GP data and HES/SUS are stored and made available in many very different ways in a huge number of different national and local data centres. The system should aim to minimise variation wherever possible. This means minimising …
Health & Social Care
Goldacre Review — Rec TRE 54
Standard, national, shared, core compute infrastructure There is - with narrow exceptions - no technical or regulatory justification for any cohort, centre, university or other organisation to insist that all research data they hold should sit on their own machine in their own data centre. Cloud infrastructure is the standard …
Health & Social Care
Goldacre Review — Rec TRE 45
Start with Data Pioneers who can demonstrate computational maturity in research cohorts There have been many attempts by various organisations to harmonise the data hosting and access arrangements around research cohort datasets. There have also been some complex and labour intensive approaches proposed for “harmonising” these diverse datasets. Overall, the …
Health & Social Care
Goldacre Review — Rec TRE 43
All academic TREs should aim to use shared standard infrastructure Where possible all academic TREs should share a common, core, scalable underlying compute infrastructure to avoid needless duplication in procurement and provisioning: this should be discussed in close collaboration with those who have experience in this domain, including SERP for …
Health & Social Care
Goldacre Review — Rec TRE 42
Academic TREs should use standard NHS TRE and curation approaches where possible NHS data is complex to manage. Wherever any standard approaches have been created by the NHS for TREs or data curation, these should be used by any academic DAE or TRE that is ingesting complex raw NHS patient …
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 38
Review the current Registry and Audit landscape; work towards wider access and use More broadly these datasets are likely an under-used resource, and a very dispersed set of projects, of very varying scale: it would be wise to commission a deep dive to describe for each project the data flows, …
Health & Social Care
Goldacre Review — Rec TRE 36
Use the same TRE approach as above In terms of technical implementation and service wrapper, these projects present essentially the same challenges as local NHS TREs and academic TREs. They are therefore amenable to all the same interventions as above.
Health & Social Care
Goldacre Review — Rec TRE 34
NHS Trusts and Data access Environments Many NHS trusts have arrangements for academic and service analysts to use their internal data for a range of projects involving research and service improvement. These projects should be encouraged to adopt the standard NHS TRE service wrapper, and standard NHS TRE technical approaches, …
Health & Social Care
Goldacre Review — Rec TRE 33
Ensure local analysts use a national TRE wherever possible Many local NHS service analytics tasks entail using only a local cut of NHS patient record datasets that are currently held at national scale by NHS Digital (in the case of SUS/HES, which is then sent out to local NHS users); …
Health & Social Care
Goldacre Review — Rec TRE 31
Ensure all datasets extracted from national datasets in NHS Digital are requested using standard data management code As discussed in Data Curation, much of the data used by local NHS service analysts in local NHS data centres has been provided from NHS Digital; often this is provided in different forms …
Health & Social Care
Goldacre Review — Rec TRE 30
Ensure all local implementations of national or commonly used datasets such as SUS/HES conform to a single standard As discussed in Data Curation, much local work is done using national datasets such as HES/ SUS and GP data. At present the same data is needlessly held in different structures, models, …
Health & Social Care
Goldacre Review — Rec TRE 29
Manage diverse local datasets by creating and sharing standard data curation tools and methods As discussed above, local NHS service analysts work with a diverse array of local datasets that can vary widely between regions. Examples include: detailed data about admissions and discharges as bespoke feeds from specific local hospital …
Health & Social Care
Goldacre Review — Rec TRE 28
Ensure any other local NHS TREs use the same standard TRE approach There is currently a diverse array of local NHS data aggregation projects as legacy from a range of prior commissioning choices. Many of these are delivering strong service; some may warrant further review. All should be strongly encouraged …
Health & Social Care
Goldacre Review — Rec TRE 27
Ensure all ICSs use a standard TRE approach Integrated Care Systems (ICSs) are new organisations in the NHS, and are now the primary locus of work for local planning and delivery of care across a region. All ICSs are expected to use data to improve the quality, safety and efficiency …
Health & Social Care
Goldacre Review — Rec TRE 26
Create a single Service Wrapper model for local NHS TREs Based on the work for the National TRE, a standard service wrapper should be created by the same team - in consultation with local NHS and academic TREs - to cover access to work on data in these environments. All …
Health & Social Care
Goldacre Review — Rec TRE 4
Manage diverse local datasets by creating and sharing standard data curation tools and methods 5. Ensure all local implementations of national or commonly used datasets such as SUS/HES conform to a single standard 6. Ensure all datasets extracted from national datasets in NHS Digital are requested using standard data management …
Health & Social Care
Goldacre Review — Rec TRE 25
Work to rapidly standardise local TRE and DAE provision, starting with ICSs Currently local data analysis work is conducted with highly variable working methods, in highly variable computational environments, with even the same national datasets stored and used in very different ways. This is not informative or fertile diversity: it …
Health & Social Care
Goldacre Review — Rec TRE 24
Create a Local NHS TRE Programme This programme should have a single clear leader and coordinate work on local NHS TREs ensuring that they follow a common governance wrapper, and a single common open technical model to facilitate portability of code, staff, analyses, curation, and (where needed) federated analytics.
Health & Social Care
Goldacre Review — Rec TRE 23
Ideally one national TRE, never more than three Ideally there should be one national TRE. This will minimise duplication of effort around the IG service wrapper, the underlying technical infrastructure, and cybersecurity risks, and minimise unnecessary variation in implementation that has historically obstructed re-use of code. However, in pragmatism, the …
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 34
Treat “Data Infrastructure” as Open Code Recent work from UKRI increasingly recognises that modern infrastructure is less about computers and buildings, and more about about code and teams. It is crucial that data infrastructure is handled in this way, with delivery of open code at its core, accompanied by detailed …
Health & Social Care
Goldacre Review — Rec Open 33
Open funding calls for projects and programmes around Code for Health Data. Work related to technical infrastructure, data management, and TREs is not universally regarded as legitimate academic or methodological activity. There are multiple sources of funding for Individuals and teams to address specific single clinical research questions, but almost …
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 S14
Use TREs as an opportunity to impose standards on how commonly used datasets are stored, and curated into analysis-ready tables.
Health & Social Care
Goldacre Review — Rec S13
Meet this challenge with systematic curation work, devoted teams, shared working practices, shared code, shared tools, and shared documentation; driven by open competitive funding to develop new shared curation methods and tools, and to manually curate data for individual datasets and fields.
Health & Social Care
Goldacre Review — Rec S12
Stop doing data curation differently, to variable and unseen standards, duplicatively in every team, data centre, and project: recognise NHS data curation as a complex, standalone, high status technical challenge of its own.
Health & Social Care
Bubb Report — Rec 11
Action on the recommendations above should be accompanied by improved collection and publication of performance data, and a monitoring framework at central and local level. Data on key indicators (such as admissions rates, length of stay, delayed transfers, number of beds by commissioning organisation) should be collected and published. Both …
Health & Social Care
Wanless Review — Rec 7
Stringent standards should be set from the centre to ensure that systems across the UK are fully compatible with each other (6.21).
Health & Social Care
LGO / SPSO decisions(7)
PSOW-202407175 — Hywel Dda University Health Board
Mrs X complained that Hywel Dda University Health Board failed to provide regular monitoring of her ophthalmic condition. Mrs X also complained that the Health Board had not responded to her letter to the Consultant and found the follow-up responses to her email to be inadequate. The Ombudsman found that …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407486 — Aneurin Bevan University Health Board
Mrs X complained that Aneurin Bevan University Health Board failed to respond to his complaint that was submitted to it in June 2024. The Ombudsman concluded that whilst the Health Board had issued several holding letters, it had failed to provide a formal complaint response in line with its internal …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407409 — Aneurin Bevan University Health Board
Mr C complained that Aneurin Bevan University Health Board had failed to respond to the complaint he submitted in May 2024. The Ombudsman decided that there had been a significant delay by the Health Board to provide Mr C with a response. She said this had caused frustration and uncertainty …
PSOW (Public Services Om…
Health
Feb 2025
PSOW-202408113 — Cwm Taf Morgannwg University Health Board
Ms M complained that Cwm Taf Morgannwg University Health Board failed to respond to a complaint she raised on 6 June 2024. The Ombudsman found that there had been a significant delay by the Health Board in concluding the complaint. This caused additional frustration and inconvenience for Ms M. She …
PSOW (Public Services Om…
Health
Feb 2025
PSOW-202408229 — NHS Wales Shared Services Partnership
Mr A complained that NHS Wales Shared Services Partnership failed to respond to the complaint he made to it in November 2024 relating to access to GP services. The Ombudsman found that NWSSP had provided a brief initial response signposting Mr A to make a complaint to his local Health …
PSOW (Public Services Om…
Health
Feb 2025
21-004-987 — Birmingham City Council
Summary: The Council is not making consistent decisions about whether housing applicants can bid on properties with one less bedroom than they need. The Council has agreed to take action to ensure its decisions are consistent in future.
LGO (Local Government & …
Housing
Upheld
Apr 2022
21-009-514 — Lancashire County Council
Summary: Ms X complained the Council is failing to meet her eligible care needs, has not properly assessed her financial situation and has given her inconsistent information about her care costs. The Council has failed to show how Ms X’s eligible needs are met through her support plan and has …
LGO (Local Government & …
Adult Care Services
Upheld
Aug 2022
Domestic Homicide Reviews(21)
East Sussex — recommendation 6
That there is a Sussex wide agreement of Safeguarding Template Consultation Recording and Coding. This would make the information management more useful within the consultation and in the analysis and communication of the information within the practice and beyond. If this were successfully implemented in Sussex, it could form the …
NHS Sussex Integrated Care Board
NHS Sussex ICB
Tower Hamlets — recommendation 6
That the senior management team of Tower Hamlets Specialist Addictions Services should review the migration strategy between EDM and Nebula and analyse the risks and benefits of further migration of all EDM patient data
East London Foundation Trust
East London NHS Foundation …
Ealing — recommendation 2A
Seek to rectify the patient information systems used across all clinical settings so that attendances at health care settings can be linked and viewed in their entirety.
Department of Health
Department of Health and …
Bassetlaw — recommendation 7.3
The suppliers of the Systmone system make the necessary upgrade to provide a WNB code and this is communicated to all users of the system, along with the reasons for using this new code. This is a national recommendation for NHS Digital (via the Department of Health) as the Panel …
suppliers of the Systmone system | …
NHS England
Chiltern — recommendation Panel Recommendation
Department of Health to consider a central database for hospitals to access accurate and timely information about treatments and medications a patient has received when attending either their GP or another hospital.
Department of Health
Department of Health and …
Bristol — recommendation 29
Review the process of key information from Locata being transferred to Northgate and EDRMS at the start of a tenancy to provide background knowledge for Housing Officers
Bournemouth Borough Council – Strategic Housing …
East Sussex — recommendation 14
That a Digital Data recovery mechanism needs to be available for patient records that have failed to transfer. NHS England and NHS Digital need to work with General practice information system suppliers to provide a process for migrating and merging records that are fragmented.
NHS England
NHS England
East Sussex — recommendation 8
That the NHS Sussex Integrated Care Board continues to work towards a long term, sustainable solution to the issue of information sharing with GPs.
NHS Sussex Integrated Care Board
NHS Sussex ICB
Lincoln — recommendation 10.7.3
The Trust to review all the clinical systems that it currently uses in relation to how information is stored and shared between teams within the same organisation operating on different electronic record keeping systems. This is with a view to ensuring a more holistic assessment of risk can be achieved …
Lincolnshire Partnership NHS Foundation Trust
Lincolnshire Partnership NHS Foundation …
South Norfolk — recommendation 17.3
Norwich and Norfolk University Hospitals Trust and Norfolk and Suffolk Foundation Trust to explore how best to share information instantly in a reliable way, considering the use of electronic referrals and implement an effective system.
Norwich and Norfolk University Hospitals Trust …
Norfolk and Suffolk NHS …
Croydon — recommendation 6.1.7.n
NPS London to ensure that Probation Sentence Notification results undertaken at court are verified against LIBRA (Magistrates Court) XHIBIT (Crown Court) recording systems.
National Probation Service
National Probation Service
Dudley — recommendation 3
Dudley Safe and Sound to forge links with the Black Country Healthcare NHS Foundation Trust and support the Trust in its endeavour to secure ‘real-time-surveillance’ data on suicide, and also support the Trust to develop a plan to promptly deliver support to family and friends, as appropriate.
Dudley Safe and Sound | Black …
Black Country Healthcare NHS …
Dudley — recommendation 2
Dudley Safe and Sound to promote the connection between suicide and domestic abuse with the Dudley Suicide Prevention Partnership and jointly consider the recommendations for local areas promoted by the Zero Suicide Alliance, as follows: • “Include Domestic Abuse as an explicit priority within your local multi-agency Suicide Prevention Strategy. …
Dudley Safe and Sound | Dudley …
Norfolk — recommendation 18.6.3
For NCHC to explore if improvements can be made to the SystmOne recording visibility between teams who are accessing different SystmOne units.
Norfolk Community Health and Care
Norfolk Community Health & …
Portsmouth — recommendation 1
All referrals made by 111 and the emergency operations centre to be referred electronically.
Southcoast Ambulance Service (SCAS)
Sheffield — recommendation 4.1.1.3
Sheffield CCG to recommend to practices that GP and health visitor records should be shared where clinical systems allow but concerns should be communicated directly.
Sheffield ICB
Kirklees — recommendation 18
To develop new or adapt existing management information tools to ensure the quality and information gathered by SPA is fit for purpose.
Kirklees Council Single Point of Access
Kirklees Council
Harrow — recommendation 6
Improve management overview of domestic violence by creating domestic violence specific flag on Care Path to enable reports to be run for service level audit and review purposes
Compass
Lincoln — recommendation 9.3.4
To approach NHS England to request that the National Medical Computer System includes a nationally agreed icon or symbol for safeguarding concerns that would appear on every page of the medical record rather than the front page alone.
Community Safety Partnership
West Cumbria — recommendation Lancashire and South
Information sharing and recording processes for MARAC for all LSCFT services to be consistent across all LSCFT localities.
Lancashire and South Cumbria Foundation Trust
Lancashire and South Cumbria …
West Cumbria — recommendation 8
All clinicians to be advised to ensure consistency in using clinical templates and system prompts. The practice will request that prompts contain reference to drug and alcohol misuse.
Primary Care Practice