Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Alix Elizabeth Knowles who died on 9 December 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 October 2024 concerning the death of Alix on 9 December 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alix’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Alix’s care have been listened to and reflected upon. The first concern raised in your Report was that bank staff are not able to access patient notes before assessments. Individual healthcare providers determine the access levels that different members of staff have to different parts of their electronic patient records systems. This decision will be in line with each Trust’s access policy and risk assessment, and is determined solely by individual healthcare providers. I note that you have also addressed your Report to Derby and Burton Hospital (Royal Derby Hospital) and Royal Stoke University Hospital and refer you to their responses on this matter. Your second concern raised that different NHS Trusts are unable to access patient notes because the different computer systems in use do not allow this. NHS Trusts are at differing levels of digital maturity regarding their Electronic Patient Records (EPR) system capabilities, with some having legacy systems that are not able to transmit information between systems in line with today's standards and expectations. As a response to this, NHS England set up the Frontline Digitisation Programme (FLD) in 2021 and has been supporting NHS and Foundation Trusts in acquiring modern EPR systems and helping them develop their system’s effectiveness once deployed. The FLD programme comes with substantial financial and specialist IT support to bring all Trusts to an optimum level of digital maturity. The next phase of optimising digitisation in England is for the FLD programme to support increased EPR convergence across Integrated Care Boards (ICBs). National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

3 March 2025

Implementation of this will be subject to assurance by Trust Boards collectively, which are required to have the appropriate leadership, governance and capacity for their safe delivery. For information, local healthcare providers make the decision on which Electronic Patient Records (EPR) system to procure and deploy, and their decision may apply to either a single NHS organisation or across multiple NHS organisations within a single Integrated Care System (ICS) where convergence of EPR systems across an ICB or ICS is seen as the most beneficial model. These decisions are based on many factors including the required functionality, a system’s suitability for the service specialities on offer, user experience, cost, and ease of information sharing. Today, there are already many examples where EPR records are shared seamlessly between provider organisations to enhance care provision. However, there remain multiple reasons as to why information may not be openly accessible or shared with other healthcare providers. For example, this could be due to incompatibility between the version of the systems being used thus not enabling full data sharing, permission not being granted between organisations to share data due to concerns about data security or sensitivity of the material or not having patient permission to share data. Patient handover and referral are two processes that are central to care and are expected to be effective regardless of the availability of digital records. I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Alix, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.

Dear Madam

Alix Knowles: Regulation 28 Report Response

I am writing in response to the Regulation 28 Report dated 2 October 2024, following the Inquest into Alix Knowles' death. The Regulation 28 report was addressed to NHS England, Midlands Partnership University NHS Foundation Trust (MPFT) and University Hospitals of Derby and Burton NHS Foundation Trust (UHDB).

At the outset, and in the knowledge that her family will read this report, I want to first begin by reiterating the Trust's condolences and offering my own.

We have taken these concerns seriously and have considered whether there are any improvements we can make at UHDB. In order to support this, discussion has taken place between MPFT and UHDB.

Scope

Within your report, you identified the following concerns:

1. Bank Staff are not able to access patient notes before assessments;

2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.

Trust Response

["MPFT"] Bank Staff are not able to access patient notes before assessments

Liaison Psychiatry is provided by MPFT and the team work in the Emergency Department of the Queen's Hospital in Burton on Trent. Their role is to assess and plan interventions needed for people in the Emergency Department who present with mental health problems. PRIVATE & CONFIDENTIAL Miss Emma Serrano HM Coroner for Staffordshire & Stoke- on-Trent Stoke Town Hall Kingsway Staffordshire ST4 1HH

Access to Meditech V6, the electronic patient record that is used at Queen's Hospital, is provided to staff within the Liaison Psychiatry team at MPFT, allowing them to review our Emergency Department records and to make their own records onto the system. Access is granted at MPFT's request. As was confirmed by MPFT in court, their substantive staff in Liaison Psychiatry do have access to Meditech V6 records at UHDB, and they have subsequently confirmed that long- term bank staff also have access to Meditech V6. The issue that arose in this case is that the individual MPFT bank nurse from the Liaison Psychiatry team did not have access to the Meditech V6 records as UHDB had not been notified of the need for access on this occasion and therefore UHDB were not aware of until after Miss Knowles' death. As we heard during the inquest hearing, MPFT explained that they mitigate the risk of bank staff not having access to Meditech V6 by always ensuring that they are on shift with a member of staff who does have access. The bank nurse confirmed in her evidence that the Meditech V6 notes were accessed by a colleague from MPFT Liaison Psychiatry team on the night in question. If it had been communicated to UHDB at the time that the bank staff member from MPFT could not access Meditech V6, Emergency Department staff could have shown the bank staff member themselves, printed a copy out on request, or with sufficient notice, have arranged emergency IT access for them using the same processes we have in place when using agency or bank staff at UHDB. We have re-iterated to MPFT that these are options available to them if emergency access is required, and to formalise this, we are in the process of developing a written standard operating procedure for both organisations.

We are also working together with MPFT to arrange access to Meditech V6 for any of their current short term bank staff in the Liaison Psychiatry team who do not already have access. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.

Across the NHS in England there are health and care services using different clinical systems that do not interact with each other, and it is accepted that there is a need for interoperability across the system. This is a national issue whose feasibility is being looked at as part of the long-term plan for the NHS. Given the broader context that applies and the complexities around digital infrastructure and transformation, we are unable to comment any further on this, except to say that we recognise the importance of effective information sharing between organisations. It is for this reason that we arrange access where possible and having sharing protocols in place as described above. The focus of our response is therefore on the post death review processes that took place and access to Miss Knowles' medical records for these purposes, which is the context for which the Coroner's concerns arose.

UHDB seeks input and shares outcomes of investigations with all external providers that have been involved or contributed to an investigation. This is a standard practice in the Trust. Conversely, if an external provider is conducting an investigation that requires input from UHDB, it is our standard practice to actively participate and share information where this is requested. We understand from our recent discussions with MPFT that their processes have now changed, so we hope that provides assurance that such information will be shared as standard practice in the future.

Dear Emma Serrano,

Regulation 28 Report to Prevent Future Deaths regarding the death of Miss Alix Elizabeth Knowles.

I am writing to you on behalf of Midlands Partnership University Foundation NHS Trust (“MPFT”) in response to your Prevention of Future Deaths report dated 2 October 2024, following the inquest touching the death of Miss Alix Elizabeth Knowles.

At the outset I would like to express my sincere condolences on behalf of MPFT to Miss Knowle’s family and friends.

This letter is MPFT’s formal response to your PFD report.

1. Bank Staff are not able to access patient notes before assessments;

It is accepted that at the time of Miss Knowle’s death bank members of staff did not have access to University Hospitals of Derby and Burton NHS Foundation Trust’s (“UHDB”) Emergency Department notes, but if there was a bank member of staff on duty, they were always with a permanent member of the Mental Health Liaison team who could facilitate access. MPFT Liaison staff would also routinely contact the patients local Mental Health team as part of their assessment to determine if there was any current or previous Mental Health involvement.

Following this inquest, several meetings have taken place between MPFT and UHDB to consider the most efficient way for bank staff to obtain access to patient notes. As a result of these meetings, it has been agreed that a list of all liaison bank staff and Crisis Home Treatment staff have been provided to UHDB who will allow them access to their patient notes system V6. A joint Standard Operating Procedure for the ‘Referral Process to Liaison Psychiatry Team and Crisis Resolution and Home Treatment Team for patients 16 years old and over within the Emergency Department’ has also been developed to outline the referral process for all staff.

2. Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this. While MPFT recognises this as an ongoing issue, we work closely with other trusts to ensure we have processes and safeguards in place to allow staff to access patient notes when required. We are unable to comment on the

NHS Nationally but locally, we are actively working with other trusts to ensure staff have access to the records they need to deliver effective and safe patient care.

We wish to assure you and Miss Knowle’s family that the actions described above are being taken forward with considerate attention.