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.
43 items
1 source
11 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
98match
F244 - Common information practices shared data and electronic records
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 be granted user friendly, real time and retrospective access to read their records, and a facility to enter...
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
We recommend that 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
80match
IHRD-27 - Electronic Patient Information Systems
Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
Matched on
terms: acces, information, record
Inquiry recommendation
77match
F120 - Learning and information from complaints
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 to undertake the support and oversight role of GPs in this area, and be given the resources to...
Matched on
terms: acces, information, nhs
Inquiry recommendation
73match
F35 - Need to share information between regulators
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 should be done on a template of the sort of information each organisation would find helpful.
Matched on
terms: information, sharing
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
SP31 - Response officer access to case information technology
1. Lancashire Constabulary should ensure response officers have access to effective technology providing clear, essential case information. 2. The National Police Chiefs’ Council, College of Policing and Home Office should review whether current policing information systems, particularly the limitations on cross‑force access, are suitable for modern policing needs.
Matched on
terms: acces, information
Inquiry recommendation
67match
IBI-7f(i) - Transfusion Outcome Framework
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 in achieving this will be measured by the extent to which the SHOT reports for the previous three...
Matched on
terms: information, nhs, record
Inquiry recommendation
65match
F36 - Use of information for effective regulation
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 of non-compliance. It must not only include statistics about outcomes, but must take advantage of all safety related...
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
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
60match
IBI-6a(i) - Hepatologist Oversight and Fibroscan Access
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 review, either nurse-led, consultant-led or, where appropriate, by a GP with a specialist interest in hepatitis
Matched on
terms: acces
Inquiry recommendation
56match
IBI-6a(v) - Consultant Hepatologist Access
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, rather than a more junior member of staff, wherever practicable
Matched on
terms: acces
Inquiry recommendation
56match
IBI-6a(ii) - Specialist Hepatology Centre Access
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
Matched on
terms: acces
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
51match
1 - Single consultant data repository
We recommend that there should be a single repository of the whole practice of consultants across England, setting out their practising privileges and other critical consultant performance data – for example, how many times a consultant has performed a particular procedure and how recently. This should be accessible and understandable to the public. It should be mandated for...
Matched on
terms: acces, nhs
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
IBI-7f(ii) - NHSBT Transfusion Outcome Funding
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.
Matched on
terms: nhs
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
47match
IBI-6a(vi) - Commissioning Hepatology Services
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 themselves that the services they are commissioning meet the particular needs of the group of people harmed by...
Matched on
terms: nhs
Inquiry recommendation
47match
IHRD-11 - Patient Transfer Protocol
There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Matched on
terms: information
Inquiry recommendation
43match
BRIS-19 - Require effective communication among healthcare professionals to avoid conflicting patient advice
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.
Matched on
terms: information
Inquiry recommendation
39match
IHRD-47 - Post-Mortem Reporting Standards
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 and final reports with expedition. (iv) Sign the post-mortem report. (v) Forward a copy of the post-mortem report...
Matched on
terms: information
Inquiry recommendation
38match
AC-2b - Share Clinical Assessor Advice
In respect of any case in which the advice of a clinical assessor has been given, in relation to the person concerned (and no more widely except with the consent of that person): that person should be told the factual basis on which that advice has been given; and the reasons for that advice. Such information must be...
Matched on
terms: information
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
35match
IBI-6a(iv) - Fibroscan for Liver Imaging
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be used for liver imaging, rather than alternatives
Matched on
classifier match
Inquiry recommendation
35match
IBI-6a(iii) - Uncertainty About Fibrosis
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
Matched on
classifier match
Inquiry recommendation
35match
BRIS-17 - Ensure patients receive copies of all inter-professional letters about their care
Patients should receive a copy of any letter written about their care or treatment by one healthcare professional to another.
Matched on
classifier match
Inquiry recommendation
35match
F123 - Responsibility for monitoring delivery of standards and quality
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 of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so...
Matched on
classifier match
Inquiry recommendation
31match
IBI-7f(iii) - Blood Tracking Systems Funding
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.
Matched on
classifier match
Inquiry recommendation
31match
BRIS-18 - Provide parents of young children with copies of all inter-professional healthcare letters
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.
Matched on
classifier match
Inquiry recommendation
31match
IBI-7a(iii) - Transfusion Performance Benchmarking
Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management
Matched on
classifier match
Inquiry recommendation
31match
IBI-4c(ii) - Safety Management Systems Coordination
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 a matter of priority.
Matched on
classifier match
Inquiry recommendation
31match
IBI-4c(i) - Simplify External Regulation
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 the points made earlier in this Report and in other reports since 2000.
Matched on
classifier match
Inquiry recommendation
27match
IHRD-46 - Clinician Attendance at Post-Mortem Discussions
Where possible, treating clinicians should attend for clinico-pathological discussions at the time of post-mortem examination and thereafter upon request.
Matched on
classifier match
Inquiry recommendation
23match
IBI-7b - Transfusion 2024 Review Progress
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 a view to determining next steps.
Matched on
classifier match