Inaccessible multi-agency patient information
32 items
2 sources
Critical patient information (e.g., 'familiar faces plans') being inaccessible to emergency services due to technology limitations.
Cross-Source Insight
Inaccessible multi-agency patient information has been flagged across 2 independent accountability sources:
4 inquiry recs
28 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (4)
BRIS-29 — Require trusts to provide clear patient access to information and explanation
Recommendation: NHS trusts and primary care trusts must have systems which ensure that patients know where and to whom to go when they need further information or explanation.
Unknown
DM-20 — HOLMES access for independent panels
Recommendation: All independent panels and inquiries examining police investigations should be given full access to the associated HOLMES accounts at their secure premises when they begin their work.
Gov response: Since 2020, police HOLMES databases have become Cloud-based, making the system accessible for the first time via a corporately managed device for those with the appropriate security clearance and purpose.
Accepted
Delivered
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
LAMI-32 — Ensure single, compatible electronic database for all children and families services
Recommendation: Local authority chief executives must ensure that only one electronic database system is used by all those working in children and families’ services for the recording of information. This should be the same system in use across the council, or …
Unknown
PFD Reports (28)
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
Jean Groves
Concerns: Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Response: Norfolk County Council is issuing a communication to all Operational Managers and Reablement Liaison Officers to remind staff that every referral, whether accepted or declined, must be recorded on the …
Overdue
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
Kwabena Amoateng
Concerns: A critically important paediatric respiratory action plan was mislabelled and misfiled in online records, preventing emergency healthcare professionals from accessing vital guidance for a rare condition.
Overdue
Chloe Ellis
Concerns: Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.
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
Caroline and Bernard Cleall
Concerns: Adult Social Care's inability to access NHS hospital discharge assessment records for telecare prevents proper review of client needs, risking inadequate support and missed opportunities to revise safety packages.
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
Sophie Wilson
Concerns: Ambulance crews lacked crucial patient information from multi-agency plans due to electronic device data limits, necessitating manual contact with control. This compromises accessibility in emergencies for vulnerable individuals.
Responded
Liam McCarlie
Concerns: Mental health professionals in Emergency Operations Centres lack access to vital community mental health records, hindering informed triage and ambulance dispatch for patients with mental health needs.
Responded
Evie Davies
Concerns: A mental health crisis line operating in isolation from core mental health teams lacked access to patient history and risk factors, resulting in inadequate assessments and poor information sharing.
Responded
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
Andrew Bowles
Concerns: A mental health liaison nurse lacked direct access to essential hospital records, leading to a critical information gap that compromised the patient's assessment and could risk other patients' lives.
Responded
Derek Larkin
Concerns: Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.
Responded
Daniel Ludlam
Concerns: The NHS Pathways triage system lacks specific protocols for patients with learning disabilities, leading to inaccurate symptom communication, potential incorrect triage, and delayed medical assistance.
Overdue
Ketheeswaren Kunarathnam
Concerns: Detained prisoners awaiting deportation lack adequate access to legal information and support. Ineffective communication and incompatible systems between prison, Home Office, and immigration staff lead to lost information and delayed actions.
Responded
Felicity Clough
Concerns: Incompatible patient record systems hinder information sharing between NHS trusts, and police forces lack automatic welfare information exchange, both posing risks to patient and public safety.
Overdue
Lee Thrumble
Concerns: Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
Overdue
Robert Brown
Concerns: Critical prisoner information from different systems (NOMIS, medical, security) was not consistently accessible to all prison staff, highlighting a systemic failure in information sharing.
Responded
Paul Gander
Concerns: A consultant was unable to access crucial electronic patient records from other hospital departments out-of-hours. Full access for authorised personnel is imperative to prevent future deaths.
Overdue
John Griffiths
Concerns: The Emergency Department lacked a system to check patients' recent attendances or access previous medical records and investigation results, leading to missed opportunities for comprehensive care.
Responded
Daniel Maher
Concerns: Critical information sharing failures exist between inter-county mental health services, with professionals unable to access out-of-county patient records or routinely share s.136 assessment paperwork, hindering timely, comprehensive care.
Overdue
Michael Brennan
Concerns: A critical backup plan for emergency patient transfer failed due to unavailability of a satellite hospital bed, highlighting a lack of real-time bed status information for clinicians across the Trust's multiple sites.
Responded
Vera Williams
Concerns: Emergency Department doctors and staff lack a digital system to support their work.
Overdue
Rita Paton
Concerns: There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.
Overdue
John Matthews
Concerns: Emergency department care was compromised by a nurse triaging without the PRF, a locum doctor's inability to access patient records, omitted neurological observations, and an unnecessary CT scan delay.
Responded
Audrey Kelly
Concerns: Out of Hours services and hospital emergency departments critically lacked direct access to patients' electronic GP notes, a systemic failure risking patient safety and future deaths.
Responded
Dimitar Shtarbov
Concerns: Seasonal agricultural workers lacked awareness of and access to GP and emergency services in the UK. Many also self-medicated with prescription-only medicines obtained from their home countries.
Overdue