Fragmented NHS record access and information sharing
180 items
2 sources
Failures to share patient records and clinical information between NHS providers, including at transfer, discharge, and across organisational boundaries, leading to fragmented care and patient safety risks.
Cross-Source Insight
Fragmented NHS record access and information sharing has been flagged across 2 independent accountability sources:
32 inquiry recs
148 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (32)
BRIS-17 — Ensure patients receive copies of all inter-professional letters about their care
Recommendation: Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Unknown
BRIS-18 — Provide parents of young children with copies of all inter-professional healthcare letters
Recommendation: Parents of those too young to take decisions for themselves should receive a copy of any letter written by one healthcare professional to another about their child’s treatment or care.
Unknown
BRIS-19 — Require effective communication among healthcare professionals to avoid conflicting patient advice
Recommendation: Healthcare professionals responsible for the care of any particular patient must communicate effectively with each other. The aim must be to avoid giving the patient conflicting advice and information.
Unknown
44 — Church of England/Wales information sharing protocol
Recommendation: The Church of England and the Church in Wales should agree and implement a formal information-sharing protocol. This should include the sharing of information about clergy who move between the two Churches.
Gov response: On 24 June 2021, the Church of England announced that the updated version of the House of Bishops' handling of Clergy Personal Files policy covers data sharing between the Church of England and the Church …
Accepted
Delivered
45 — Local diocesan information sharing protocols
Recommendation: The Church of England, the Church in Wales and statutory partners should ensure that information-sharing protocols are in place at a local level between dioceses and statutory partners.
Gov response: On 29 March 2021, a joint response from the National Safeguarding Steering Group, the House of Bishops and the Archbishops' Council stated that it would develop template information-sharing agreements which may be adapted and used …
Accepted
No update 2+ yrs
85 — Access to records for former child migrants
Recommendation: The Chair and Panel have recommended that all institutions which sent children abroad as part of the child migration programmes should ensure that they have robust systems in place for retaining and preserving any remaining records that may contain information …
Gov response: Between January and July 2020, Action for Children, Barnardo's, Catholic Church in England and Wales, Cornwall Council, Father Hudson's Care, Salvation Army UK, Sisters of Nazareth, The Children's Society and The Prince's Trust committed to …
Accepted
Delivered
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 …
Gov response: Accepted in principle. The government is improving data flows to CQC and GMC to give them better oversight of consultants' full scope of practice. NHS England is developing a workforce repository and working with partner …
Accepted in Part
No update 2+ yrs
12b — Information sharing between providers
Recommendation: We recommend that if the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Gov response: Accepted in principle. Government supports principle of sharing concerns between employers. CQC registration conditions require providers to share relevant information. GMC guidance requires doctors to disclose concerns about their practice. NHS England working with independent …
Accepted in Part
No update 2+ yrs
IBI-4c(i) — Simplify External Regulation
Recommendation: Regulation: That external regulation of safety in healthcare be simplified. As a first step towards this, there should be a UK wide review by the four health departments of the systems of external regulation, with the aim of addressing all …
Gov response: UK Government In relation to recommendation 4c) i. the Secretary of State for Health and Social Care asked Dr Penny Dash to conduct a review of patient safety in the health and care landscape. The …
Accepted
In progress
IBI-4c(ii) — Safety Management Systems Coordination
Recommendation: Regulation: That the national healthcare administrations in England, Northern Ireland, Scotland and Wales explore, and if appropriate, support the development and implementation of safety management systems (“SMS”s) through SMS coordination groups (as recommended by the HSSIB), and do so as …
Gov response: UK Government In relation to Recommendation 4c) ii., DHSC agrees that it is important to explore approaches for enhancing the safety of services. In 2023, NHS England established an SMS coordination group with partners from …
Accepted
In progress
IBI-6a(i) — Hepatologist Oversight and Fibroscan Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
IBI-6a(ii) — Specialist Hepatology Centre Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
In progress
IBI-6a(iii) — Fibroscan Every Six Months
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
IBI-6a(iv) — Named Hepatology Nurse Specialist
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan [ultrasound] technology should be used for liver imaging, rather than alternatives
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
IBI-6a(v) — Annual GP Appointment for Co-morbidities
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
In progress
IBI-6a(vi) — Assessment for Hepatocellular Carcinoma
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
In progress
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
In progress
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: UK Government Progress against Transfusion 2024 recommendations has been initially reviewed jointly by NHS England and NHSBT and a wider four nations stakeholder review is being scheduled. The draft report was discussed with key stakeholders …
Accepted
In progress
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: UK Government 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 …
Accepted
In progress
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: UK Government 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 …
Accepted
In progress
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: UK Government 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 …
Accepted in Part
In progress
IHRD-11 — Patient Transfer Protocol
Recommendation: There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Gov response: Transfer protocols developed and implemented across HSC Trusts.
Accepted
Delivered
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: Electronic care record and digital health programmes progressing across Northern Ireland.
Accepted
No update 2+ yrs
IHRD-46 — Clinician Attendance at Post-Mortem Discussions
Recommendation: Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.
Gov response: Guidance issued on clinician attendance at clinico-pathological discussions.
Accepted
Delivered
IHRD-47 — Post-Mortem Reporting Standards
Recommendation: In providing post-mortem reports pathologists should be under a duty to: (i) Satisfy themselves, insofar as is practicable, as to the accuracy and completeness of the information briefed them. (ii) Work in liaison with the clinicians involved. (iii) Provide preliminary …
Gov response: Post-mortem reporting standards updated in line with these requirements.
Accepted
Delivered
F120 — Learning and information from complaints
Recommendation: Commissioners should require access to all complaints information as and when complaints are made, and should receive complaints and their outcomes on as near a real-time basis as possible. This means commissioners should be required by the NHS Commissioning Board …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted in Part
F123 — Responsibility for monitoring delivery of standards and quality
Recommendation: GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F244 — Common information practices shared data and electronic records
Recommendation: There is a need for all to accept common information practices, and to feed performance information into shared databases for monitoring purposes. The following principles should be applied in considering the introduction of electronic patient information systems: Patients need to …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
F35 — Need to share information between regulators
Recommendation: Sharing of intelligence between regulators needs to go further than sharing of existing concerns identified as risks. It should extend to all intelligence which when pieced together with that possessed by partner organisations may raise the level of concern. Work …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
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: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
COVID-M3.4 — Data Systems for High-Risk Individuals
Recommendation: The UK government, Scottish Government, Welsh Government and Northern Ireland Executive must ensure that health data and digital systems have the capability to identify individuals at high risk of morbidity or mortality from a pandemic disease quickly and accurately in …
Gov response: No formal response published by this government.
Unknown
LAMI-73 — Require inquiry and review of previous hospital admissions for suspected deliberate harm.
Recommendation: When a child is admitted to hospital and deliberate harm is suspected, the doctor or nurse admitting the child must inquire about previous admissions to hospital. In the event of a positive response, information concerning the previous admissions must be …
Unknown
PFD Reports (148) — showing 100 most recent
Akhona Moyo
Concerns: Hospital doctors lack electronic access to primary care medical notes, hindering comprehensive patient treatment and preventing a holistic view of patient medical history, especially for vulnerable individuals.
Pending
Colin Brown
Concerns: Crucial patient information, such as choking risk, was not reliably transferred with the patient or consistently communicated during hospital handovers, compounded by delays in electronic record accessibility.
Response: Yorkshire Ambulance Service will strengthen escalation and notification routes for patient safety incidents and reinforce through targeted clinical alerts that known high-impact risks like swallowing or choking should be explicitly …
Response: The Trust immediately implemented a policy ensuring patients in the Emergency Department are not given food without registered nurse oversight. They are also considering additional food mitigations and are rolling …
Responded
Amy Pugh
Concerns: Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
Response: NHS England has provided funding for EPR implementation and is actively working across the health system and with the SCR Programme to support greater integration and awareness of record sharing …
Responded
Ethel Robertson
Concerns: A critical communication gap exists as the Older People’s Mental Health Service is not routinely informed of their patients' ED admissions for non-mental health issues, risking delayed care and missed links to mental health decline.
Response: The Trust clarifies that Mental Health Liaison Teams already notify the Older People's Mental Health Service (OPMH) if mental ill health is evident in the Emergency Department. They dispute the …
Responded
Alan Mitchell
Concerns: A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.
Response: Optum disputes the factual accuracy of the concern, clarifying that their EMIS Web system does not automatically remove repeat prescriptions after 12 months without GP notification. They explain the system …
Responded
Amy Cross
Concerns: There is no system to ensure vital healthcare information, including medication and observations, is shared between criminal justice healthcare providers, and no standard, accessible medical records system.
Response: NHS England plans to commence a 'proof of concept' trial around February/March 2026 in specific regions, enabling healthcare providers to access the Digital Person Escort Record (DPER) system to improve …
Overdue
Amanda Wood
Concerns: No sepsis screen was performed before discharge from the Emergency Department, indicating a failure in early identification and treatment of sepsis.
Overdue
Sarah Heaver
Concerns: Critical neurological investigations and structured observations were omitted for a low GCS patient, compounded by inconsistent medical records. Additionally, patients are discharged to inadequate psychiatric care.
Responded
Suzanne Edwards
Concerns: Emergency Departments lack reliable access to patients' primary care records, leading to delayed or misdirected diagnoses and undermining patient safety due to incomplete medical history.
Overdue
Isaac Ingle-Gillis
Concerns: The Crisis Resolution and Home Treatment Team's lack of access to GP records poses a future risk by preventing comprehensive mental health assessments, despite not altering the outcome in this instance.
Responded
John Charles Spencer
Concerns: Incompatible computer systems prevent out-of-hours GP surgeries from accessing patient medical histories, even with consent, risking vital information not being conveyed for appropriate care.
Responded
Andrew Tizard-Varcoe
Concerns: Fragmented care across multiple health trusts resulted in clinicians lacking complete patient information and unclear responsibilities, compounded by untimely follow-up appointments and inappropriate discharge decisions for a progressing infection.
Responded
Paul Dunne
Concerns: Mental health professionals exhibited significant gaps in risk assessment judgment, mental health staff failed to follow A&E policies, and incompatible electronic record systems prevented crucial information sharing between departments.
Overdue
Ann Cotgrove
Concerns: There was an absence of formal documented processes and record-keeping for inter-hospital referrals, discussions, and the subsequent advice and actions taken.
Responded
David Bennett
Concerns: Mental health crisis and acute care staff lacked access to crucial patient records, leading to inadequate information sharing and failures in escalating deteriorating mental health, medication reviews, and proper risk assessment.
Responded
Antony Williamson
Concerns: A lack of formal communication frameworks between different NHS specialties and Trusts, especially in complex mental health and pain cases, resulted in fragmented patient care.
Responded
Patricia Curtis
Concerns: Non-uniform hospital discharge notes across Trusts risk critical patient information being unavailable during transfers. This can cause dangerous delays in providing life-saving care in new clinical settings.
Responded
Norma Tellam
Concerns: Decisions around patient transfers between hospitals failed to prioritise continuity of clinical care. This led to a patient with post-operative complications being treated by a different team and not returning to the operating hospital for essential follow-up.
Responded
Emma Sanders
Concerns: A High Intensity Use Care Plan was not shared with ambulance services or other hospitals. Upon admission, there were delays in accessing the patient's record, preventing adherence to her care plan and leaving staff unaware of her significant self-harm history.
Responded
Jaipreet Panesar
Concerns: A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.
Responded
John Doyle
Concerns: Non-specialist staff have varied understanding of when to contact specialist renal centres, unclear guidelines for information sharing, and inconsistent access to protocols for treating kidney transplant patients.
Responded
Neil Yates
Concerns: There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
Responded
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Responded
Margaret Daly
Concerns: A clinician prescribed a sedative without reviewing the patient's full medical records, leading to unawareness of her enhanced falls risk and demonstrating a risk of prescribing without adequate patient context.
Responded
Ian Hegarty
Concerns: A care plan designed to reduce falls risk for multiple patients was not followed, and the ongoing internal investigation provides insufficient reassurance that this critical risk has been addressed.
Responded
Chloe Every
Concerns: The Trust exhibited critical failings including inadequate staffing with learning disability training, poor record-keeping, absent clinical observations, a procedure without consent, and severe governance failures in incident reporting and investigation.
Responded
Alix Knowles
Concerns: Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
Responded
Suzanne Eccles
Concerns: Emergency Department clinicians lack easy access to patient records from the Virtual Ward, posing a concern despite post-incident investigations and work undertaken by the Trust.
Responded
Nisren Abdul-Karim
Concerns: Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the provision of neurology advice and overall patient management.
Responded
David Thompson
Concerns: Multiple systemic failures across Priory Dorking and Altrincham included absent safety plans, inadequate discharge procedures, poor communication between consultants, and lack of awareness of prior admissions or community support.
Responded
David Almond
Concerns: Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite the patient's history.
Responded
Michael Huggon
Concerns: Inadequate handover between GP and out-of-hours services, along with slow, inefficient 111 processes and poor urgent care response, led to significant delays in critical medical assessment and treatment.
Responded
James Cockburn
Concerns: National delays in cardiac appointments and diagnostic tests, exacerbated by staff shortages and incompatible inter-Trust IT systems, caused critical delays in treatment and assessment for life-saving surgery.
Responded
Isobel Stapleton
Concerns: Mental health practitioners lack easy access to complete patient records across Wales and NHS England. Acute and home treatment teams also suffer from a lack of clinical psychologists and lengthy psychotherapy waiting lists.
Responded
Linda Heath
Concerns: Inadequate hospital discharge summaries and a lack of GP follow-up procedures for recently discharged patients led to missed referrals for critical care. There was also an over-reliance on private care with insufficient oversight.
Responded
Alexander Reid
Concerns: An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early COVID-19 vaccination. The system lacked validation rules to challenge such data errors, contributing to his death.
Responded
Alan Smith
Concerns: GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT systems.
Responded
Kerri Mothersole
Concerns: Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The lack of an integrated imaging system for private providers led to missed diagnostic opportunities.
Responded
Oliver Beswetherick
Concerns: Mental health teams lack essential contact details for psychiatric liaison services and crisis teams in neighbouring boroughs, leading to repeated patient assessments and delayed urgent support.
Responded
Susan Young
Concerns: Ambulance crew failed to consider Co-codamol toxicity due to lack of access to GP records, resulting in a missed opportunity to administer a potentially life-saving antidote.
Responded
Ethel Reed
Concerns: Newly opened hospital wards suffered from peripatetic staffing and lack of leadership, hindering patient care and concern escalation. Additionally, electronic patient records failed to track author changes on discharge letters, risking miscommunication.
Overdue
Emily Harkleroad
Concerns: A new Emergency Department computer system lacks a clear RAG rating for patient acuity, making it difficult for clinicians to quickly identify critically ill patients, especially during peak demand.
Responded
Samuel Jordan
Concerns: Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding a prisoner's anxiety and medication was missing, contributing to their death.
Responded
Karmchand Gulzar
Concerns: Failures in following surgical referral pathways, performing necessary CT scans, and recognizing patient deterioration due to communication issues and disregarded family concerns, despite previous warnings.
Responded
Andrew Guillaume
Concerns: Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in patient discussion and transfer.
Responded
Katharine Fox
Concerns: A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.
Responded
Michael Daft
Concerns: There is a lack of effective communication between multi-disciplinary teams from different specialisms, leading to fragmented care for patients on multiple treatment pathways.
Responded
Christopher Allum
Concerns: Initial referral processes have gaps in recording past self-harm and family information. Private healthcare providers also struggle to access NHS notes, creating information deficits that compromise risk assessments and care plans.
Responded
Kai Takagi
Concerns: Critical abnormal blood results were not communicated to a discharged patient due to a failure in the hospital's call-back system and informal handover process between shifts, leading to delayed care.
Overdue
Marion Luckraft
Concerns: Cumulative diagnostic and treatment delays, failure to escalate care to a high dependency unit, fragmented treatment across hospital sites, and an unclear treatment pathway for biliary sepsis collectively increased mortality risk.
Overdue
Stephen Cassidy
Concerns: Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Responded
Jack Farrington
Concerns: Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic systems, and some records remain paper-based.
Overdue
Michael Amesbury
Concerns: Incompatible information systems and reliance on postal services delayed critical patient referrals and image transfers between trusts, compounded by a shortage of cardiology clinicians, hindering timely treatment.
Responded
Peter Fleming
Concerns: No specific safety issues or systemic failures were identified in the provided concerns text, which only stated that action should be taken to prevent future deaths.
Responded
Raquel Harper
Concerns: Inadequate history taking led to incorrect assumptions, nursing staff failed to follow NEWS policy for escalation, and there was confusion and non-compliance with the PE policy, highlighting a need for review.
Overdue
Eifion Huws
Concerns: Inadequate access to comprehensive patient records (due to electronic vs. hard copy discrepancies) hindered emergency staff decision-making. The Health Board's investigation also failed to address this critical information-sharing flaw or improve overall investigation timeliness.
Responded
Caroline Forte
Concerns: There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history in acute and mental health settings.
Responded
Amy Henderson
Concerns: Delays in private hospitals accessing NHS records prevented crucial information, like prior ligature practice, from being immediately known. There was also staff confusion regarding responsibility for removing banned items on admission.
Overdue
Patrick Soames
Concerns: Multiple agencies lacked a unified system for sharing critical information about the patient's serious self-harm across different geographic areas, compounded by no national 'risk flagging' system or out-of-hours GP access.
Overdue
Rachelle Ross
Concerns: GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.
Responded
Stephen Wells
Concerns: Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs lacking clear guidance on escalating concerns.
Responded
Philip Jones
Concerns: Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information sharing and holistic patient views.
Responded
John Kay
Concerns: Critical information about a patient's complex valve care was not shared with the care home, resulting in missed monitoring and increased health risks. The specialist nurse service's role was also poorly understood by community healthcare providers.
Responded
Hayley Smith
Concerns: Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.
Overdue
Fadzai Chitakunye
Concerns: Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.
Responded
Manon Jones
Concerns: Clinicians lacked access to comprehensive patient records from community care and the unit's internal records were fragmented, impairing assessment, observation setting, and safeguarding measures.
Overdue
Neil Parkes
Concerns: Police failures to identify an unconscious patient despite hospital requests and a missing person report meant critical medical history was inaccessible, hindering treatment.
Responded
Hannah Royle
Concerns: The 111 service failed to appropriately handle a complex case involving a disabled child due to non-compliant call handlers and an inadequate system for disabilities. The public is also misled about the service's diagnostic capabilities.
Overdue
Brooke Martin
Concerns: Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises risk assessments and specialist care.
Responded
Joanna Leven
Concerns: Gaps exist in national therapeutic pathways for Personality Disorders and trauma support services. Separate computer systems between hospital and mental health liaison create a risk of critical information loss.
Responded
Claire Lilley
Concerns: Risk assessments for Mental Health Act patients on Section 17 leave are fragmented across different records and tools, lacking a central, formulated document for comprehensive clinician review.
Responded
Ronald Tilley
Concerns: Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.
Responded
David Ball
Concerns: Different healthcare departments using incompatible patient care records and lacking inter-departmental communication led to reliance on "professional curiosity" for crucial patient information.
Responded
Amy Hogan
Concerns: Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical history was unavailable. This created significant risks for vulnerable patients, hindering comprehensive assessment.
Overdue
Gordon Fenton
Concerns: There are significant issues with information sharing and a lack of formalised decision-making processes between two NHS Trusts for psychiatric patients with acute medical problems, hindering optimal integrated care.
Responded
Irene Whittingham
Concerns: Conflicting guidance on Vitamin D and Calcium blood level monitoring for high-dose patients and confusing software interfaces allowed prescribing errors that exceeded national guidelines without GP notification.
Overdue
Anita Loi
Concerns: Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.
Responded
Suzanne Roberts
Concerns: The hospital's patient record management was "sub-optimal" and fragmented across multiple systems, leading to ineffective cross-department communication and potential future deaths. Mandatory rules and data quality assurance were lacking.
Overdue
Sandra Scott
Concerns: A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.
Overdue
Justin Gallagher
Concerns: Fragmented prison healthcare failed to obtain medical history, create care plans, or assign a single clinician, missing opportunities to diagnose cancer and cancelling vital appointments due to resource shortages across multiple agencies with separate databases.
Responded
Andrew McCall
Concerns: A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Responded
Lewis Doyle
Concerns: Discharge letters for patients with complex conditions are not being sent to all relevant medical attendants, leading to a lack of critical information for original prescribers regarding suspended medications.
Overdue
Mason Logue
Concerns: A lack of integrated care, an overarching supportive plan, and poor information sharing between health professionals on discharge led to an uncoordinated approach for a child with complex needs. Inconsistent understanding of protocols and the "red book" exacerbated these issues.
Overdue
Alexander Davidson
Concerns: NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Overdue
Jonathan Yates
Concerns: The nutritional status of patients, particularly those nil by mouth, is not effectively communicated to staff during hospital admissions.
Responded
Thomas Collings
Concerns: Further learning and explicit timescales are needed for implementing and refreshing training on the crucial maintenance of lead attachments for medical monitors.
Responded
Jennifer Lewis
Concerns: There was a failure to coordinate care between mental and physical health doctors, resulting in unsuitable and inadequate care for the patient's overall needs.
Responded
Archie Grieves
Concerns: No specific concerns were detailed in the provided text.
Overdue
Tina Tait
Concerns: Persistent issues with poor and illegible clinical record-keeping within the hospital compromise incident reviews and patient care, impeding crucial learning from deaths.
Overdue
Sophie Holman
Concerns: Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.
Overdue
Kirsty Walker
Concerns: Prolonged delays (months) in transferring prisoners requiring secure hospital care under the Mental Health Act, far exceeding recommended timeframes, are caused by a severe shortage of available beds.
Responded
Susan Longden
Concerns: The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Responded
John Delahaye
Concerns: National risk assessment templates are unclear on medication, and unreliable electronic records impede identifying past medical conditions. Healthcare staff are also inconsistently present or informed of crucial ACCT reviews.
Overdue
Theresa Button
Concerns: Inadequate nursing staff levels on a ward for complex patients resulted in poor implementation of treatment plans, insufficient patient support during mealtimes, and failures in maintaining contemporaneous records.
Responded
Michael Hopkins
Concerns: Hospital discharge practices need review to ensure patients receive adequate information regarding the risk of thromboembolisms following recent surgery after sustaining trauma.
Responded
Greg Hutchins
Concerns: Mental health telephone triage was undocumented and unrecorded, with no system for rapid information sharing for out-of-area patients, indicating significant gaps in record-keeping and inter-area communication.
Overdue
Robert Power
Concerns: A patient was "lost to follow-up" for eight years after an incorrect diagnosis, highlighting a risk of future deaths if outpatient care is not consistently maintained.
Responded
Jacob Sulaiman
Concerns: Incomplete information sharing between different care services meant response officers lacked a full picture of the patient's condition, potentially affecting assessment and management.
Responded
Grahame Searby
Concerns: The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
Overdue
Adrian Jennings
Concerns: Disjointed IT systems, lack of joined-up discharge planning, uncommissioned support services, and limitations in a national IT system hindered effective information sharing and patient care.
Responded