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
Source spread
Where this theme appears
Fragmented NHS record access and information sharing has been flagged across 1 independent accountability source:
79 inquiry recs
This theme has been identified in one data source. As more data is added, cross-references may emerge.
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 (79) — showing 50 strongest matches
57 — Intimate Order to police and Reporter
Recommendation: 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).
Unknown
12 — Agencies share information in joint approach
Recommendation: 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).
Unknown
78 — Guide on disclosure by healthcare staff
Recommendation: 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 …
Unknown
59 — OASys assessor access to prior behaviour
Recommendation: OASys assessors should have access to information relating to prisoners’ behaviour while serving previous sentences and to information held in security files.
Unknown
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
40 — Written notice to wings of prisoner arrival
Recommendation: 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.
Unknown
38 — Wing files required for admission to wing
Recommendation: 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.
Unknown
37 — Checklist for files on transfer
Recommendation: 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 …
Unknown
36 — Telling receiving prison reason for transfer
Recommendation: 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.
Unknown
35 — Police National Computer link to prisons
Recommendation: 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 …
Unknown
33 — Policy on disclosing medical reports to prisons
Recommendation: 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.
Unknown
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 …
Words of: Yvette Cooper, Secretary of State for Health and Social Care, oral statement to the House of Commons, 15 September 2026 (text as published on GOV.UK)
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
R2 — Coroners to send post mortem reports to consultants
Recommendation: 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 …
Words of: Virginia Bottomley, Secretary of State for Health, reporting the Home Secretary's acceptance, in a statement to the House of Commons, 11 February 1994
Gov response: The report makes 12 detailed recommendations to tighten procedures to safeguard children in hospital. I have instructed immediate action to be taken on the 11 that are my responsibility. The Home Secretary has accepted the …
Accepted in part
R93 — Regional service map with vacancies
Recommendation: 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 …
No response yet
R24 — Clear records and disclosure policies
Recommendation: 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.
No response yet
R13 — Full staff access to care plans
Recommendation: All staff involved in delivering care, including healthcare assistants (HCAs), must have full access to the care plan.
No response yet
165 — Reporter to obtain police information
Recommendation: 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 …
Unknown
13 — University audit trail to clinical record
Recommendation: University records shall provide a confidential audit trail back to the clinical record.
Unknown
12 — Review and update medical records
Recommendation: 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 …
Unknown
115 — Consistent background information for interviewers
Recommendation: 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).
Unknown
18 — School information on children in writing
Recommendation: 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).
Unknown
58 — OASys use in all establishments
Recommendation: 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.
Unknown
50 — Prisoner escort record handbook and completion
Recommendation: 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 …
Unknown
46 — Completing discharge reports
Recommendation: 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.
Unknown
41 — Vetting security files
Recommendation: 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 …
Unknown
39 — Missing cell-sharing risk assessment form on arrival
Recommendation: 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.
Unknown
32 — Transcripts of judges' remarks to prison
Recommendation: 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 …
Unknown
31 — Court responsibility for warrant and conviction documents
Recommendation: 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.
Unknown
30 — Reports accompanying prisoners from court
Recommendation: 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 …
Unknown
26 — Security Departments entering shareable information on NOMIS
Recommendation: 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.
Unknown
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.
No response yet
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.
No response yet
32 — Send internal safeguarding reviews to national body
Recommendation: 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).
No response yet
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. …
Words of: Northern Ireland Executive, Executive Response to Module 4 Report October 2026, 7 October 2026
Gov response: Accepted in Principle The DHSC and Medicines and Healthcare products Regulatory Agency (MHRA) are leading on the response to this recommendation. The Covid-19 pandemic highlighted the importance of ensuring that the Medicines and Healthcare Products …
Accepted in part
SP50 — Healthcare trust risk information visibility
Recommendation: 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: …
Words of: HM Government, Government Response to Phase 1 of the Southport Inquiry (CP 1623), presented to Parliament by the Home Secretary, 2 July 2026
Gov response: The Department of Health and Social Care (DHSC) and NHS England are the lead organisations. Progress and next steps: - The Single Patient Record is currently being designed and scoped. - This is part of …
Accepted
11 — Review records and develop audit trail
Recommendation: Records should be reviewed and updated and an audit trail should be developed and put in place.
Unknown
161 — Local guidelines on information to Reporter
Recommendation: 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).
Unknown
78 — Mutual understanding between authorities
Recommendation: 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 …
Unknown
76 — Constable to intimate removal likewise
Recommendation: Correspondingly any constable or other person removing a child should give a like intimation to the Social Work Department (17.6).
Unknown
75 — Intimate removal to Social Work Department
Recommendation: 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).
Unknown
64 — Written background on the child
Recommendation: 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).
Unknown
43 — Obtaining security files of returning prisoners
Recommendation: Where prisoners have served a sentence before, the Security Department should always obtain their security files from the establishment from which they were discharged.
Unknown
34 — Facts of offences in conviction lists
Recommendation: 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.
Unknown
27 — NOMIS alert for sensitive security information
Recommendation: 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 …
Unknown
R6 — Sickness records available to occupational health
Recommendation: 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).
Words of: Virginia Bottomley, Secretary of State for Health, in a written answer to Richard Spring MP, House of Commons, 2 November 1994
Gov response: Guidance on occupational health is to be issued shortly which will cover all these recommendations. Together with the English National Board's new guidelines, this guidance will establish better procedures for selection of student nurses for …
Accepted in part
SP54 — National guidance on SMART action points
Recommendation: 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 …
Words of: HM Government, Government Response to Phase 1 of the Southport Inquiry (CP 1623), presented to Parliament by the Home Secretary, 2 July 2026
Gov response: The Department of Health and Social Care (DHSC) and NHS England are the lead organisations and expect to complete the implementation of this recommendation by 31 March 2027. Progress and next steps: - DHSC and …
Accepted
SP53 — GMMH and Alder Hey joint SMART audit
Recommendation: 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 …
Words of: HM Government, Government Response to Phase 1 of the Southport Inquiry (CP 1623), presented to Parliament by the Home Secretary, 2 July 2026
Gov response: DHSC has limited powers to direct NHS Foundation Trusts to implement recommendations 51 and 53. The Secretary of State for Health and Social Care has written to Greater Manchester Mental Health NHS Foundation Trust and …
Accepted
In progress
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 …
Words of: UK government (Department of Health and Social Care), UK government response to the Covid-19 Inquiry Module 3 report (CP 1664), 14 September 2026
Gov response: The government agrees with the Inquiry that data systems need to be improved to identify individuals at high risk during a pandemic. The government’s 10 Year Health Plan and existing data policy work provide a …
Accepted
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
12b — Information sharing between providers
Recommendation: If the healthcare professional also works at another provider, any concerns about them should be communicated to that provider.
Words of: Department of Health and Social Care, Government response to the independent inquiry report into the issues raised by former surgeon Ian Paterson, 16 December 2021
Gov response: Accept in principle The government agrees that, where patient safety is at risk, information should be shared with other providers. However, there must be an element of judgement by providers as they will be taking …
Accepted in part
In progress