Inaccessible multi-agency patient information
Critical patient information (e.g., 'familiar faces plans') being inaccessible to emergency services due to technology limitations.
176 items
12 sources
4 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
97match
Michael Brennan
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.
Matched on
terms: information, multi, patient
PFD report
89match
Sophie Wilson
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.
Matched on
terms: agency, information, multi, patient
Committee recommendation
81match
#20 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
NHS health and publicly funded social care services are legally required, by the Accessible Information Standard, published under section 250 of the Health and Social Care Act 2012, to provide health and care information to patients and service users in a way they can understand. The aim is to ensure a consistent approach to identifying and meeting the...
Matched on
terms: inaccessible, information, patient
PFD report
77match
Daniel Maher
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.
Matched on
terms: information, patient
PFD report
73match
Stephen Cassidy
Hospital staff lacked routine access to patient Summary Care Records, preventing critical allergy information from being integrated into electronic systems and causing avoidable harm.
Matched on
terms: information, patient
PFD report
73match
Andrew Bowles
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.
Matched on
terms: information, patient
Inquiry recommendation
73match
BRIS-29 - Require trusts to provide clear patient access to information and explanation
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.
Matched on
terms: information, patient
PFD report
69match
Felicity Clough
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.
Matched on
terms: information, patient
PFD report
69match
Derek Larkin
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.
Matched on
terms: information, patient
PFD report
69match
Evie Davies
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.
Matched on
terms: information, patient
PFD report
69match
John Charles Spencer
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.
Matched on
terms: information, patient
PFD report
65match
Jean Groves
Emergency responders assisting ambulance services are not provided with crucial access details for vulnerable patients, potentially endangering lives during medical interventions.
Matched on
terms: patient
PFD report
61match
Audrey Kelly
The coroner reported that the attending doctor and nurse at the Out of Hours Service could not access the patient's GP electronic notes, describing this as a serious lapse in procedures that could lead to future loss of life.
Matched on
terms: patient
PFD report
61match
John Matthews
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.
Matched on
terms: patient
PFD report
61match
John Griffiths
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.
Matched on
terms: patient
PFD report
61match
Lee Thrumble
Prison clinical staff lack mandatory training for the critical NOMIS system, preventing them from accessing vital prisoner information and compromising safety.
Matched on
terms: information
PFD report
61match
Liam McCarlie
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.
Matched on
terms: patient
PFD report
61match
Lee Armstrong
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.
Matched on
terms: patient
PFD report
61match
Chloe Ellis
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.
Matched on
terms: information
PFD report
57match
Rita Paton
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.
Matched on
terms: patient
PFD report
57match
Robert Brown
Information in central NOMIS records, medical system records, and the security department was not available to all prison staff who may have benefitted from having it.
Matched on
terms: information
PFD report
57match
Ketheeswaren Kunarathnam
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.
Matched on
terms: information
PFD report
57match
Daniel Ludlam
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.
Matched on
terms: patient
PFD report
57match
Paul Gander
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.
Matched on
terms: patient
PFD report
57match
Kwabena Amoateng
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.
Matched on
classifier match
PFD report
57match
Amy Pugh
Clinical staff could not access important mental health records from partner institutions, compromising the patient's assessment and subsequent management.
Matched on
terms: patient
PFD report
57match
Akhona Moyo
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.
Matched on
terms: patient
IOPC learning recommendation
55match
Recommendation - Hampshire Constabulary, September 2024
The IOPC recommends that Hampshire Constabulary creates and implements a memorandum of understanding (MOU) regarding sharing patient information with University Hospital Southampton NHS Foundation Trust. This follows an investigation in which a man was found by police in a hospital gown and wheelchair in central Southampton. The man was arrested for an outstanding warrant, but the police were...
Matched on
terms: information, patient
PFD report
53match
Dimitar Shtarbov
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.
Matched on
classifier match
Committee recommendation
53match
#15 - Second Report - Disability employment gap
We heard that more needs to be done to improve the way a disabled person’s communication preferences are recorded by Jobcentre Plus. DWP should take inspiration from the Accessible Information Standard model used in the NHS and create an automated process which can record a disabled person’s preferred communication method and provide the correct support accordingly.
Matched on
terms: information
Inquiry recommendation
53match
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
Committee recommendation
52match
#14 - Second Report - Disability employment gap
It is unacceptable that some disabled people still face barriers when trying to access services through Jobcentre Plus. It is particularly shocking that services provided by the Department for Work and Pensions, whose ministerial team includes the Minister for Disabled People and which is responsible for a significant proportion of the Government’s work on disability, remain inaccessible to...
Matched on
terms: inaccessible
PFD report
49match
Vera Williams
Emergency Department doctors and staff lack a digital system to support their work.
Matched on
classifier match
IMB recommendation
48match
Gartree (2023)
The following question is repeated from last year’s annual report: will the Prison Service work with the Board to ensure that it has access to necessary information, such as healthcare data, for example, so that the Board is able to monitor more effectively how well the prison is meeting the standards and requirements placed on it and what...
Matched on
terms: information
Committee recommendation
47match
#10 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
The widespread adoption of continuous facemask wearing in health and social care settings has made effective communication impossible for patients and healthcare professionals who lip-read, and much more difficult for Deaf people who use British Sign Language and people with disabilities which mean they are more reliant on facial expressions for communication. We therefore strongly welcome the development...
Matched on
terms: patient
PFD report
45match
Caroline and Bernard Cleall
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.
Matched on
classifier match
Inquiry recommendation
43match
LAMI-32 - Ensure single, compatible electronic database for all children and families services
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 at least compatible with it, so as to facilitate the sharing of information, as appropriate.
Matched on
terms: information
Committee recommendation
40match
#19 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
The accessibility of the Government’s communications to disabled people during the pandemic has been poor from the outset of lockdown in March. The Government has been far too slow to address concerns, notably about the lack of British Sign Language interpretation of government television briefings. Accessibility should have been baked in from the start. Much of what is...
Matched on
classifier match
IOPC learning recommendation
40match
Recommendation - Metropolitan Police Service, December 2025
The IOPC recommends that the Metropolitan Police Service (MPS) review relevant policies and/or procedures to ensure they make clear the need to set up a password with nursing staff when officers have transported a medical emergency to hospital. A password enables officers to easily obtain updates on the individual’s condition over the phone. Any changes that are made...
Matched on
classifier match
IMB recommendation
40match
Gatwick IRC (2024)
Ensure that suitable training and support is provided so that professional interpretation services are used effectively in communications with the detained men, particularly during critical safeguards such as initial screening, and Rule 34 and 35 appointments.
Matched on
classifier match
Committee recommendation
39match
#15 - Forty-Third Report - Reducing the backlog in criminal courts
Since the start of the pandemic, the Department and HMCTS have significantly increased the use of hearings held remotely using video technology, and plan to continue to use them to reduce the backlog in the courts.25 We asked what impact the increased use of remote hearings has had on different groups of victims and witnesses, particularly those with...
Matched on
classifier match
IMB recommendation
39match
Dartmoor (2023)
What more can be done to ensure that Foreign National Prisoners, some of whom have little or no English, have access to notices and information provided in their own language(s)?
Matched on
terms: information
PHSO casework decision
39match
P-003043 - Birmingham Community Healthcare NHS Foundation Trust
Mrs E complains that since 2018 the Trust has held multi-disciplinary team meetings and discussions about the care of her son without her. She also complains that since 2020, the Trust has made decisions about his epilepsy treatment without seeing him.
Matched on
terms: multi
IMB recommendation
39match
Chelmsford (2025)
Launchpad has been a great success in allowing prisoners to check and verify personal information. Will the Prison Service commit to adding a feature so prisoners can book and manage their medical appointments? If so, what timeline do you anticipate for implementation?
Matched on
terms: information
PHSO casework decision
39match
P-003038 - Mid and South Essex NHS Foundation Trust
Miss U complains Mid and South Essex NHS Foundation Trust did not appropriately assess her symptoms during visits to its emergency department on 20 January and 5 April 2023. She also complains it refused to call her multiple sclerosis nurse during the same visits.
Matched on
terms: multi
Committee recommendation
36match
#21 - Fourth report: Unequal impact? Coronavirus, disability and access to services: full Report
We agree with organisations representing Deaf British Sign Language users that we should set a good example in the accessibility of our public oral evidence sessions. It is regrettable that we did not provide live BSL interpretation and subtitles via www.parliamentlive.tv, particularly as we were scrutinising the accessibility of the Government’s communications during the pandemic. It is reasonable...
Matched on
classifier match
IMB recommendation
36match
London STHF (2024)
Delays and unavailability of certain languages in The Big Word translation service need to be addressed.
Matched on
classifier match
PHSO casework decision
36match
P-004381 - Buckinghamshire, Oxfordshire and Berkshire West Integrated Care Board
Ms P complains about the BSL interpreting service provided by the ICB. She complains the ICB failed to commission an interpreting service that meets her needs as a deafblind person.
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classifier match
Committee recommendation
35match
#11 - Sixth Report - Coronavirus: lessons learned to date
Arrangements should be established and tested to allow immediate flows of data between bodies relevant to an emergency response with a mechanism to resolve immediately and decisively any disputes.
Matched on
classifier match
Committee recommendation
35match
#5 - Forty-Third Report - Reducing the backlog in criminal courts
Vulnerable users and people from ethnic minority backgrounds are potentially impacted disproportionately by efforts to tackle the Crown Court backlog, which the Department and HMCTS have not done enough to understand. Since the start of the pandemic, HMCTS significantly increased the number of hearings held remotely using video technology. However, it only published its formal evaluation of remote...
Matched on
classifier match