Fragmented NHS record access and information sharing
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.
79 items
1 source
16 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Inquiry recommendation
100match
COVID-M4.4 - Proportionate Access to Linked Healthcare Records
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. In particular, the Medicines and Healthcare products Regulatory Agency should be granted specific and proportionate access to comprehensive...
Matched on
terms: acces, information, record
Inquiry recommendation
97match
SP50 - Healthcare trust risk information visibility
The Department of Health and Social Care / NHS England should ensure that all healthcare trusts involved in the care of children and young people who are at risk of acts of violence against others have systems that ensure that: 1. Key information regarding current and historic risk information is readily visible to treating clinicians in a summarised...
Matched on
terms: information, nhs, record
Inquiry recommendation
86match
12b - Information sharing between providers
If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Matched on
terms: information, sharing
Inquiry recommendation
82match
45 - Local diocesan information sharing protocols
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.
Matched on
terms: information, sharing
Inquiry recommendation
82match
44 - Church of England/Wales information sharing protocol
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.
Matched on
terms: information, sharing
Inquiry recommendation
74match
59 - OASys assessor access to prior behaviour
OASys assessors should have access to information relating to prisoners’ behaviour while serving previous sentences and to information held in security files.
Matched on
terms: acces, information
Inquiry recommendation
70match
R13 - Full staff access to care plans
All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
Matched on
terms: acces
Inquiry recommendation
69match
12 - Review and update medical records
The Chief Executive and the Trust Board shall review and update medical and pathology records to include, preferably on computer and cross-referenced, the following information: – name, medical record reference number and date of birth; – date, place of death and death certificate; – name and address of next of kin; – whether Coroner’s or hospital post mortem...
Matched on
terms: information, record
Inquiry recommendation
69match
5 - Operating systems (interoperability)
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 systems should be taken forward and implemented as soon as possible. This should mean that data relating to...
Matched on
terms: information, nhs
Inquiry recommendation
66match
12 - Agencies share information in joint approach
In a joint approach while investigation of a case is properly a matter for the police each agency should share fully with each other the whole information relevant to their particular responsibilities (15.30-31).
Matched on
terms: information
Inquiry recommendation
64match
SP54 - National guidance on SMART action points
Nationally, the Department of Health and Social Care and NHS England should consider whether nationwide guidance should be issued on the importance of action points from all relevant meetings involving healthcare agencies, discharge plans and management plans after risk assessments being recorded in a SMART-compliant (specific, measurable, achievable, relevant and time-bound) way.
Matched on
terms: nhs, record
Inquiry recommendation
64match
SP53 - GMMH and Alder Hey joint SMART audit
At the local level, Greater Manchester Mental Health NHS Foundation Trust and Alder Hey Children’s NHS Foundation Trust should by no later than 13 October 2026 carry out and report on a joint audit to ensure that for cases involving both Trusts, the action points from multi agency meetings, healthcare meetings, discharge plans and management plans after risk...
Matched on
terms: nhs, record
Inquiry recommendation
64match
COVID-M3.4 - Data Systems for High-Risk Individuals
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 a future pandemic. This should include action to improve health data systems and patient record-keeping by: improving patient...
Matched on
terms: record, sharing
Inquiry recommendation
62match
42 - Security information before NOMIS covers it
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 already been done, and the systems should be networked across the prison estate.
Matched on
terms: information
Inquiry recommendation
62match
R24 - Clear records and disclosure policies
Policies must be specific as to records to be kept and for routes to disclosure for relevant family members and people with learning disabilities and autistic people themselves where possible.
Matched on
terms: record
Inquiry recommendation
61match
13 - University audit trail to clinical record
University records shall provide a confidential audit trail back to the clinical record.
Matched on
terms: record
Inquiry recommendation
61match
18 - School information on children in writing
Any information about children which is to be used for the purposes of their compulsory care and which is provided by their school-teacher should be provided in writing (15.38).
Matched on
terms: information
Inquiry recommendation
61match
26 - Security Departments entering shareable information on NOMIS
Although there are no plans for security information to be entered onto NOMIS in its first phase, Security Departments should enter any information which can be shared with the majority of staff when the first phase of NOMIS becomes operational.
Matched on
terms: information
Inquiry recommendation
60match
41 - Vetting security files
Each Security Department should establish a proper system for vetting security files to ensure that they are read by the end of the working day following their arrival, that any relevant information is relayed in writing to the wings, and that a record is kept of who vetted them, with the date and time.
Matched on
terms: information, record
Inquiry recommendation
59match
165 - Reporter to obtain police information
An express statutory provision should be made enabling the Reporter to obtain from the police any information or articles held by them so that they may be available for the conduct of a proof under Section 42, subject to their being immediately required for purposes of criminal proceedings (18.53).
Matched on
terms: information
Inquiry recommendation
57match
115 - Consistent background information for interviewers
Each interviewer should wherever possible have consistent and relevant background information about the child and in particular about his or her emotional, physical and mental development (17.54), and an assessment of the child’s wider family (17.55).
Matched on
terms: information
Inquiry recommendation
57match
50 - Prisoner escort record handbook and completion
The handbook giving guidance on how to complete the prisoner escort record should be revised to make it clear that it is not merely of use while a prisoner is in transit, but it is also intended to inform the prisoner’s management in the receiving establishment. It should give clear guidance to staff as to when a box...
Matched on
terms: record
Inquiry recommendation
57match
39 - Missing cell-sharing risk assessment form on arrival
If prisoners arrive on a wing without a copy of the cell-sharing risk assessment form, they should be placed in a single cell until the form is found or a new one completed.
Matched on
terms: sharing
Inquiry recommendation
57match
78 - Guide on disclosure by healthcare staff
The Prison Service should prepare a readable guide, which explains the circumstances in which personal information about a prisoner should be disclosed by healthcare staff to officers on the wing. The guide should contain practical examples of situations where disclosure should or should not be made.
Matched on
terms: information
Inquiry recommendation
53match
11 - Review records and develop audit trail
Records should be reviewed and updated and an audit trail should be developed and put in place.
Matched on
terms: record
Inquiry recommendation
53match
161 - Local guidelines on information to Reporter
It should be clearly stated in all local guidelines in what form if any information requires to be given to the Reporter (18.48-49).
Matched on
terms: information
Inquiry recommendation
53match
27 - NOMIS alert for sensitive security information
NOMIS should include a facility for an alert to appear if information is held by the Security Department on prisoners which could affect their management but which is too sensitive for wider dissemination. An officer at the grade of senior officer or above should be able to ask for that information, and the request should be considered by...
Matched on
terms: information
Inquiry recommendation
53match
R6 - Sickness records available to occupational health
We recommend that the possibility be reviewed of making available to Occupational Health departments any records of absence through sickness from any institution which an applicant for a nursing post has attended or been employed by (para 5.5.14).
Matched on
terms: record
Inquiry recommendation
52match
46 - Completing discharge reports
The discharge report which used to be prepared on prisoners on their discharge should be completed as a matter of course, and a copy included in their main prison file. It should be accessible on NOMIS when NOMIS becomes operational.
Matched on
terms: acces
Inquiry recommendation
49match
R2 - Coroners to send post mortem reports to consultants
We recommend that in every case Coroners should send copies of post mortem reports to any consultant who has been involved in the patient's care prior to death whether or not demanded under Rule 57 of the Coroner's Rules 1984 (para 4.2.9)
Matched on
classifier match
Inquiry recommendation
49match
R93 - Regional service map with vacancies
There needs to be a clear regional view of all services available in the community, especially given the variety of services and providers of services now available. The service map recommended in 2022 must be regularly updated to reflect available services and vacancies, searchable by both families and care managers.
Matched on
classifier match
Inquiry recommendation
48match
30 - Reports accompanying prisoners from court
To avoid prisoners leaving court without being accompanied by bail information reports or pre-sentence reports, the probation officer should ensure that a copy of the report is available for the escort contractor, and there should be someone in court whose responsibility it is to ensure that the dock officer gets it. Escort contractors should have a list of...
Matched on
terms: information
Inquiry recommendation
48match
LAMI-73 - Require inquiry and review of previous hospital admissions for suspected deliberate harm.
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 obtained from the other hospitals. The consultant in charge of the case must review this information when making...
Matched on
terms: information
Inquiry recommendation
45match
37 - Checklist for files on transfer
To ensure that all files accompany prisoners on their transfer to another establishment, they should be ticked off at the reception of the sending establishment against a checklist. Prisoners should not be allowed to leave unless all their files have been ticked as present, except with the permission of a governor. Staff on reception at the receiving establishment...
Matched on
classifier match
Inquiry recommendation
45match
36 - Telling receiving prison reason for transfer
Whenever a prisoner is transferred to another establishment, the receiving establishment should be told what the reason for the transfer is. If the transferring prisoner is a particularly problematic one, the receiving establishment should be warned beforehand.
Matched on
classifier match
Inquiry recommendation
44match
64 - Written background on the child
Where practicable written information should be available about the background of the child for the use of the social worker or police officer removing the child (16.37).
Matched on
terms: information
Inquiry recommendation
41match
57 - Intimate Order to police and Reporter
A Child Protection Order together with the form of application and any supporting documentation should be intimated both to the police and to the Reporter (16.30).
Matched on
classifier match
Inquiry recommendation
41match
40 - Written notice to wings of prisoner arrival
All establishments should have a procedure for notifying wings in writing that a prisoner is currently charged with, or has been convicted of, an offence under the Protection from Harassment Act 1997.
Matched on
classifier match
Inquiry recommendation
41match
38 - Wing files required for admission to wing
Prisoners should not be admitted to a wing without their current wing file, save with the permission of a governor or the approval of the night orderly officer. Important entries in it should be made in red.
Matched on
classifier match
Inquiry recommendation
41match
35 - Police National Computer link to prisons
The Police National Computer should be linked to the whole of the prison estate. In the meantime, any intelligence the police may have about prisoners which could affect their management in prison should be sent to the police liaison officers for the establishments at which the prisoners are being held. A decision can then be made whether the...
Matched on
classifier match
Inquiry recommendation
41match
33 - Policy on disclosing medical reports to prisons
In the light of such legal advice as the Courts Service receives, it should publish a policy on the disclosure to the prison of medical or psychiatric reports on a prisoner submitted to the court.
Matched on
classifier match
Inquiry recommendation
40match
78 - Mutual understanding between authorities
Where a child is placed outside the area of the child’s own local authority the Social Work Departments of the two areas should have a clear mutual understanding of the roles and responsibilities of those involved in the care of the child (17.8).
Matched on
classifier match
Inquiry recommendation
36match
58 - OASys use in all establishments
OASys should be used by all establishments to identify the risks posed by prisoners to staff and other inmates, and the risks which are identified should be fed back to the wings.
Matched on
classifier match
Inquiry recommendation
36match
32 - Transcripts of judges' remarks to prison
When a judge asks for any remarks which they make to be brought to the attention of the Prison Service, the court should assume responsibility for commissioning a transcript of what has been said and sending a copy to the prison.
Matched on
classifier match
Inquiry recommendation
36match
31 - Court responsibility for warrant and conviction documents
There should be someone in court whose responsibility it is to ensure that the dock officer gets copies of the warrant authorising the prisoner’s detention, the list of their convictions, and the indictment or charge sheet.
Matched on
classifier match
Inquiry recommendation
36match
32 - Send internal safeguarding reviews to national body
If religious organisations have undertaken internal reviews or enquiries into individual safeguarding incidents, their findings should be sent to the national review body (set up under the Children and Social Work Act 2017).
Matched on
classifier match
Inquiry recommendation
36match
43 - Obtaining security files of returning prisoners
Where prisoners have served a sentence before, the Security Department should always obtain their security files from the establishment from which they were discharged.
Matched on
classifier match
Inquiry recommendation
32match
76 - Constable to intimate removal likewise
Correspondingly any constable or other person removing a child should give a like intimation to the Social Work Department (17.6).
Matched on
classifier match
Inquiry recommendation
32match
75 - Intimate removal to Social Work Department
Any Order authorising the removal of a child should require the person so authorised to intimate the removal and the whereabouts of the child to the appropriate Social Work Department (17.5).
Matched on
classifier match
Inquiry recommendation
32match
34 - Facts of offences in conviction lists
The list of a prisoner’s convictions sent to the prison should include a short statement of the facts of each offence and the charges the prisoner is facing.
Matched on
classifier match