Inconsistent Healthcare Data Infrastructure
153 items
2 sources
Lack of a consistent and mature data infrastructure across NHS providers, hindering technological adoption and data sharing.
Cross-Source Insight
Inconsistent Healthcare Data Infrastructure has been flagged across 2 independent accountability sources:
36 inquiry recs
117 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (36)
BRIS-109 — Create single, unified system for reporting and analysing sentinel events
Recommendation: There should a single, unified, accessible system for reporting and analysing sentinel events, with clear protocols indicating the categories of information which must be reported to a national database.
Unknown
BRIS-148 — Implement a single, trusted system for collecting clinical and administrative data
Recommendation: The current ‘dual’ system of collecting data in the NHS in separate administrative and multiple clinical systems is wasteful and anachronistic. A single approach to collecting data should be adopted, which clinicians can trust and use and from which information …
Unknown
BRIS-149 — Improve clinician confidence in Patient Administration Systems data through collaboration
Recommendation: Steps should be taken nationally and locally to build the confidence of clinicians in the data recorded in the Patient Administration Systems in trusts (which is subsequently aggregated nationally to form the Hospital Episode Statistics). Such steps should include the …
Unknown
BRIS-150 — Support Hospital Episode Statistics as a reliable national resource for monitoring outcomes
Recommendation: The Hospital Episode Statistics database should be supported as a major national resource which can be used reliably, with care, to undertake the monitoring of a range of healthcare outcomes.
Unknown
BRIS-151 — Improve status, training, and qualifications of clinical coding staff for data accuracy
Recommendation: Systems for clinical audit and for monitoring performance rely on accurate and complete data. Competent staff, trained in clinical coding, and supported in their work are required: the status, training and professional qualifications of clinical coding staff should be improved.
Unknown
BRIS-152 — Review incentives for data quality; include trust performance in validation process
Recommendation: The system of incentives and penalties to encourage trusts to provide complete and validated data of a high quality to the national database should be reviewed. Any new system must include reports of each trust’s performance in terms of the …
Unknown
BRIS-154 — Invest in world-class IT systems for efficient healthcare data collection and feedback
Recommendation: The need to invest in world-class IT systems must be recognised so that the fundamental principles of data collection, validation and management can be observed: that data be collected only once; that the data be part and parcel of systems …
Unknown
FR-1 — Single Core Data Set
Recommendation: The Inquiry recommends that the UK government and the Welsh Government improve data collected by children's social care and criminal justice agencies concerning child sexual abuse and child sexual exploitation by the introduction of one single core data set covering …
Gov response: We accept that robust data collection on the scale and nature of child sexual abuse is critical to underpin and drive a more effective response to child sexual abuse. We have made a number of …
Accepted in Part
In progress
1 — Single consultant data repository
Recommendation: 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 …
Gov response: Accepted in principle. The government is improving data flows to CQC and GMC to give them better oversight of consultants' full scope of practice. NHS England is developing a workforce repository and working with partner …
Accepted in Part
No update 2+ yrs
P2-25 — Postgraduate training governance clarity
Recommendation: Postgraduate training providers using donors should ensure clarity in their governance and information-sharing, in particular where the providers are linked to both university and NHS settings. This clarity should include formal agreements, where relevant, including management, governance and Human Tissue …
Gov response: This recommendation is under consideration.
Response Unclear
IBI-7a(iii) — Transfusion Performance Benchmarking
Recommendation: Consideration be given to standardising and benchmarking transfusion performance between hospitals in order to deliver better patient blood management
Gov response: In relation to the recommendation on standardising and benchmarking, a review of current benchmarking practices and associated data collection and ongoing intelligence and analysis requirements, including model health dashboard and national clinical audit, has been …
Accepted
In progress
IBI-7b — Transfusion 2024 Review Progress
Recommendation: 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 …
Gov response: UK Government Progress against Transfusion 2024 recommendations has been initially reviewed jointly by NHS England and NHSBT and a wider four nations stakeholder review is being scheduled. The draft report was discussed with key stakeholders …
Accepted
In progress
IBI-7f(i) — Transfusion Outcome Framework
Recommendation: 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 …
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted
In progress
IBI-7f(ii) — NHSBT Transfusion Outcome Funding
Recommendation: 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.
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted
In progress
IBI-7f(iii) — Blood Tracking Systems Funding
Recommendation: 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.
Gov response: UK Government Implementing these sub recommendations is particularly challenging and requires substantial investment, as it involves working across the four nations and with multiple system partners. To support an effective long term implementation plan that …
Accepted in Part
In progress
IBI-9f — National Haemophilia Database Support
Recommendation: That the National Haemophilia Database, run by the UKHCDO, merits the support of additional central funding.
Gov response: UK Government Recommendation 9f: NHS England currently provides ‘central’ funding of approximately 40% of the total annual cost for running the National Haemophilia Database. A task and finish group relating to the database has been …
Accepted
In progress
IHRD-27 — Electronic Patient Information Systems
Recommendation: Electronic patient information systems should be developed to enable records of observation and intervention to become immediately accessible to all involved in care.
Gov response: Electronic care record and digital health programmes progressing across Northern Ireland.
Accepted
No update 2+ yrs
IHRD-91 — Synchronise Patient Safety Systems
Recommendation: The Department, HBSC, PHA, RQIA and HSC Trusts should synchronise electronic patient safety incident and risk management software systems, codes and classifications to enable effective oversight and analysis of regional information.
Gov response: Work progressing on synchronisation of patient safety incident systems across organisations.
Accepted
No update 2+ yrs
F258 — Role of the Health and Social Care Information Centre
Recommendation: The Information Centre should continue to develop and maintain learning, standards and consensus with regard to information methodologies, with particular reference to comparative performance statistics.
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
F260 — Information standards
Recommendation: The standards applied to statistical information about serious untoward incidents should be the same as for any other healthcare information and in particular the principles around transparency and accessibility. It would, therefore, be desirable for the data to be supplied …
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 in Part
F261 — Information standards
Recommendation: The Information Centre should be enabled to undertake more detailed statistical analysis of its own than currently appears to be the case.
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
F262 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All healthcare provider organisations, in conjunction with their healthcare professionals, should develop and maintain systems which give them: Effective real-time information on the performance of each of their services against patient safety and minimum quality standards; Effective real-time information of …
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
F263 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: It must be recognised to be the professional duty of all healthcare professionals to collaborate in the provision of information required for such statistics on the efficacy of treatment in specialties.
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
F264 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In the case of each specialty, a programme of development for statistics on the efficacy of treatment should be prepared, published, and subjected to regular review.
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
F265 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: The Department of Health, the Information Centre and the Care Quality Commission should engage with each representative specialty organisation in order to consider how best to develop comparative statistics on the efficacy of treatment in that specialty, for publication and …
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
F266 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: In designing the methodology for such statistics and their presentation, the Department of Health, the Information Centre, the Care Quality Commission and the specialty organisations should seek and have regard to the views of patient groups and the public about …
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
F267 — Enhancing the use analysis and dissemination of healthcare information
Recommendation: All such statistics should be made available online and accessible through provider websites, as well as other gateways such as the Care Quality Commission.
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
F268 — Resources
Recommendation: Resources must be allocated to and by provider organisations to enable the relevant data to be collected and forwarded to the relevant central registry.
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
F269 — Improving and assuring accuracy
Recommendation: The only practical way of ensuring reasonable accuracy is vigilant auditing at local level of the data put into the system. This is important work, which must be continued and where possible improved.
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
F270 — Improving and assuring accuracy
Recommendation: There is a need for a review by the Department of Health, the Information Centre and the UK Statistics Authority of the patient outcome statistics, including hospital mortality and other outcome indicators. In particular, there could be benefit from consideration …
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
F271 — Improving and assuring accuracy
Recommendation: To the extent that summary hospital-level mortality indicators are not already recognised as national or official statistics, the Department of Health and the Health and Social Care Information Centre should work towards establishing such status for them or any successor …
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
F272 — Improving and assuring accuracy
Recommendation: There is a demonstrable need for an accreditation system to be available for healthcare-relevant statistical methodologies. The power to create an accreditation scheme has been included in the Health and Social Care Act 2012, it should be used as soon …
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
F36 — Use of information for effective regulation
Recommendation: 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 …
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
WATE-(70) — Strengthen national statistics services in Wales for management information system
Recommendation: The national statistics services in Wales should be strengthened to provide a comprehensive management information system.
Unknown
POH-13 — Close HSS Dispute Resolution Procedure when HSSA opens
Recommendation: The current Dispute Resolution Procedure in HSS should be closed once all claimants currently within the Procedure have either (a) settled their claims or (b) transferred to HSSA. No claimant who is not in the Dispute Resolution Procedure when HSSA …
Gov response: Department for Business and Trade rejects this recommendation as it conflicts with the principle of providing "full and fair" redress. Postmasters should retain the choice between continuing with the dispute resolution procedure or transferring to …
Not Accepted
LAMI-78 — Implement single set of records for each child across health professionals.
Recommendation: Within a given location, health professionals should work from a single set of records for each child.
Unknown
PFD Reports (117) — showing 100 most recent
Roger Leadbeater
Concerns: Inadequate and unrecorded handovers between police forces and a mental health trust meant critical risk information about a patient was lost, impacting leave decisions and risking public safety.
Overdue
Philip Hoggarth
Concerns: A lack of consistent guidelines and processes for pre-operative iron administration to chronically anaemic patients, alongside no funding agreement, risks damaging delays in surgery.
Response: The Health Board has an existing Standard Operating Pathway for managing surgical patients with anaemia or iron deficiency, which includes guidelines for pre-operative IV iron administration and follow-up. The funding …
Responded
Ashana Charles
Concerns: Critical medical equipment was not retained for forensic investigation, and there is inconsistent national guidance on parenteral nutrition filters, alongside fragmented risk management between manufacturers and health providers.
Response: NHS England notes the British Pharmaceutical Nutrition Group (BPNG) has issued a position statement recommending 1.2 μm filters for all parenteral nutrition admixtures and has written to BAPEN and RCN …
Overdue
John Kirkman
Concerns: Inconsistent IT systems prevent immediate sharing of mental health screening assessment results across regions, leading to a lack of vital background information and incorrect prioritisation for referrals.
Responded
Charlotte Alderson
Concerns: Inconsistent infection scoring systems, a lack of rapid sepsis identification tools, and failures in the 111/999 information handover system risk critical delays and errors in patient care.
Responded
Malcolm Morris
Concerns: Incompatible electronic systems prevent efficient patient referrals from regional hospitals to out-of-area district nursing, leading to delayed or absent post-discharge care, risking patient deterioration and readmission.
Responded
John Johnson
Concerns: Hospital Trusts use multiple IT systems that don't integrate, leading to fragmented patient information, a risk of critical findings being missed, and slowed clinical decision-making. This systemic issue affects safe patient care and transfers.
Responded
Maria Simpson
Concerns: GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.
Responded
William Hare
Concerns: Significant and systemic delays occurred in diagnosis, biopsy, MDT reviews, and treatment due to fragmented systems, poor inter-hospital coordination, and procedural errors.
Responded
Jaipreet Panesar
Concerns: A patient was discharged without a care coordinator or key worker, and critical information sharing is hampered because different clinical note systems cannot access each other's records.
Responded
John Cogdon
Concerns: Fragmented and non-integrated record-keeping and prescribing systems across hospital wards pose risks by hindering cohesive patient information management.
Responded
Richard Roe
Concerns: A critical lack of a system to ensure routine CT scan reports are reviewed by clinicians, despite previous similar incidents, poses an ongoing risk until a long-term IT solution is implemented.
Responded
Sean Heath
Concerns: Concerns include inadequate police training for mental health calls, poor coordination between international and UK mental health services, and a lack of integrated information sharing between mental health agencies.
Responded
Alix Knowles
Concerns: Incompatible computer systems prevent bank staff and different NHS Trusts from accessing critical patient notes before assessments, hindering coordinated care.
Responded
Leighton Dickens
Concerns: Police officers face severely limited access to qualified mental health advice and patient records when responding to mental health crises, due to withdrawn triage support and unimplemented alternative services.
Responded
Ryan Ouslem
Concerns: Police officers lacked crucial mental health training and understanding of their powers, failed to conduct thorough inquiries, and there was inadequate timely information sharing and joint working protocols between police and mental health services.
Responded
Nisren Abdul-Karim
Concerns: Neurology notes, stored on a separate, limited "patient pass" system, lead to disjointed care and poor clinician oversight. This lack of integration negatively impacts the provision of neurology advice and overall patient management.
Responded
Mary Horgan
Concerns: Discrepant understandings between medical teams regarding Patient Pass operations create confusion and a risk of future patient harm, highlighting a need for clearer inter-hospital transfer protocols.
Responded
Regan Smith
Concerns: An ineffective verbal-only handover, incompatible IT systems, and high A&E acuity caused critical clinical information to be missed. A lack of national handover protocols for emergency departments exacerbated this risk.
Responded
Ruth Eggleton
Concerns: The absence of an evidence-based protocol for managing Direct Oral Anticoagulants (DOACs) and alternative anticoagulants has led to inconsistent clinical practice, risking patient safety.
Responded
Glennis Connelly
Concerns: Incompatible electronic patient record systems within the same hospital trust led to critical information, such as allergies and renal team entries, not being automatically visible across different sites.
Responded
David Riley
Concerns: Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.
Responded
Michael Briggs
Concerns: Dentists in England and Wales face limited and conflicting guidance on antibiotic prophylaxis for patients at high risk of infective endocarditis, leading to inconsistency and potential patient harm.
Responded
Joseph Miller
Concerns: Inconsistent call categorisation pathways across different ambulance services result in varying responses and can significantly impact the timely dispatch of life-saving care.
Responded
Kerri Mothersole
Concerns: Private ultrasound reports and images were not consistently provided to treating clinicians or uploaded to hospital notes. The lack of an integrated imaging system for private providers led to missed diagnostic opportunities.
Responded
Paula Elsley
Concerns: GPs failed to routinely record accessible smoking status and consistently apply NICE guidelines for chest x-rays, and the lack of a formal policy for referral thresholds risks missed cancer diagnoses.
Responded
Susan Bracegirdle
Concerns: Poor communication and information sharing between District Nurses, care home, GP, and family hindered effective joint care for pressure ulcers. Inadequate internal reviews and remote expert input further compromised timely intervention for a deteriorating patient.
Responded
Philip Taylor
Concerns: Insufficient information sharing, poor discharge planning, and delayed documentation transfer between the Health Board and private out-of-area psychiatric units were identified. The absence of written agreements for minimum standards and communication protocols creates a significant risk of future deaths.
Responded
Meghan Chrismas
Concerns: Inadequate supervision of police control room operators and the absence of effective information-sharing structures between NHS and private healthcare providers posed significant risks.
Responded
Shiya Collins
Concerns: A computer system's "locking facility" prevented clinicians from accessing and upgrading a patient's ambulance response, despite multiple calls highlighting their deteriorating condition.
Responded
Sienna Monterio
Concerns: A lack of national standardisation means blood gas analysers in neonatal resuscitation settings often fail to analyse haemoglobin levels, hindering critical decision-making and risking preventable infant deaths.
Overdue
Richard Griffiths
Concerns: A deficient investigation and unfinalized transfer of care policy highlight systemic failures. Persistent reliance on paper-based mental health notes prevents wider access to critical patient information, risking future harm.
Responded
Jack Farrington
Concerns: Fragmented electronic medical record systems prevent timely access to patient history across NHS trusts, impacting clinical decision-making. Handover records are not consistently integrated into electronic systems, and some records remain paper-based.
Overdue
Lynsey Smalley
Concerns: Fragmented governance processes and significant delays in acting on investigation findings impede learning. The lack of electronic medical records across mental health teams risks lost notes and poor continuity of patient care.
Responded
Lee Dryden
Concerns: NHS Trusts lack understanding of guidance for external image reporting, and the ambulance service experienced significant delays in responding to a category 2 call due to high escalation and hospital handover issues.
Responded
Dumile Thompson
Concerns: Insufficient national guidance and training on angioedema types, risk factors (including ethnicity), and diverging treatments, alongside poor medical record sharing between Trusts, hindered appropriate emergency care.
Overdue
Corinne Haslam
Concerns: Barriers to physical health input for mental health patients, incompatible electronic record systems, and unclear VTE risk assessment guidance for ward staff pose significant patient safety risks.
Overdue
Christine Dickinson
Concerns: Inconsistent and fragmented chemotherapy administration record-keeping systems led to errors, including misattributing patient details, and there was a lack of recent audits on recording practices.
Responded
Helen Coogan
Concerns: Missing qFIT test results for a patient with prolonged abdominal symptoms indicate a potential systemic issue requiring investigation, especially given the cause of death.
Responded
Maria Shafighian
Concerns: An inefficient internal postal system for communication between departments caused significant delays in escalating urgent changes in a patient's condition, specifically dysphagia, to the relevant team.
Responded
Sara Jones
Concerns: A patient transfer occurred without a radiologist's report, which was then delayed in transmission and subsequently not acted upon by receiving doctors, highlighting a critical lack of protocol for radiology report delivery.
Responded
Philip Day
Concerns: Severe Emergency Department waiting times and poor communication between community and hospital services hindered prompt assessment. A lack of awareness for neutropenic sepsis guidance also led to missed red flags and delayed critical treatment.
Responded
Philip Jones
Concerns: Significant backlogs for neurology appointments and delays in consultant communications were exacerbated by national clinician shortages. Incompatible IT systems between hospitals also hindered crucial information sharing and holistic patient views.
Responded
Hayley Smith
Concerns: Inadequate communication and fragmented clinical record systems across multiple healthcare organisations led to a critical lack of information sharing, preventing crucial details like a patient's CTO from being known.
Overdue
Vilem Bock
Concerns: While the Trust improved interpreter identification locally, a lack of national protocols means language barriers could still prevent patients in other Trusts from accessing necessary care.
Responded
Martha Mills
Concerns: Delayed referral to paediatric intensivists and a suboptimal paper-based early warning score system contributed to a preventable death. A critical program to improve inter-departmental collaboration has stalled.
Responded
Carol Cole
Concerns: A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.
Responded
Jack Taylor
Concerns: Mill View Hospital critically lacks staff and transport to safely return absconding mental health patients, over-relying on police. Ineffective joint policies and poor communication between hospital and police hinder the swift recovery of high-risk individuals.
Responded
Jos Tartese-Joy
Concerns: A combination of poor communication regarding high-risk pregnancy, lack of clear national guidance for CTG monitoring, and inadequate support and escalation policies for student midwives contributed to critical care gaps.
Responded
Ziggy Mitchell-Stagg
Concerns: Inconsistent terminology for meconium, incomplete medical records, lack of centralised CTG monitoring policy, and a trust policy for "fresh eyes" review that deviates from national guidance are concerns.
Overdue
Hurrun Maksur
Concerns: Failure to perform a recommended Point-of-Care Ultrasound scan on a collapsed woman led to inappropriate thrombolytic treatment for undiagnosed intra-abdominal bleeding. Obstetricians also lack specific training in identifying such bleeding.
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
Cherry Dunn
Concerns: National guidance is needed for VTE risk assessment when bilateral leg swelling obscures DVT, and inconsistencies exist in VTE assessment forms and discharge letters across trusts.
Overdue
Jacob Owczarek
Concerns: Concerns include low compliance with paediatric sepsis screening, lack of consultant review prior to discharge, and absent alert systems for test results, along with poor recording of radiology discussions.
Overdue
Brooke Martin
Concerns: Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises risk assessments and specialist care.
Responded
Fiona Humberstone
Concerns: A consultant psychiatrist was unaware of a patient's powerful painkiller prescription due to relying solely on self-reporting, impacting risk assessments. Incompatible electronic systems prevent routine access to full medication records between primary and secondary care.
Overdue
Timothy Steele
Concerns: Inefficient processes led to a patient being lost to follow-up and failure to appoint a Lead Practitioner, exacerbated by fragmented and inconsistent application of the Care Programme Approach (CPA).
Overdue
Jamie Poole
Concerns: It is not standard practice across all trusts to regularly test magnesium levels in transplant patients on immunosuppressive medication, despite a known life-threatening side effect, posing an inconsistent risk.
Responded
Pardeep Plahe
Concerns: A technical fault in the EMIS system caused GP consultation lists to not update, leading to a missed appointment. Reliance on manual workarounds creates a risk of further missed appointments.
Responded
Ronald Tilley
Concerns: Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.
Responded
Ann Schuetz
Concerns: Critical allergy information was not consistently recorded across multiple disparate electronic patient systems in primary and secondary care, which lack interoperability and require manual input.
Overdue
Michael Robert Collins
Concerns: The CERNER system's flaw in consistently sending results to the correct clinician and radiologists' inability to confirm critical report delivery poses a significant communication risk.
Responded
Thomas King
Concerns: Incompatible software used by the Health and Justice Team prevented crucial mental health information sharing with other teams, risking inaccurate risk assessments and patient harm.
Responded
Malyun Karama
Concerns: There is a lack of national learning regarding the increased risk of uterine rupture in multi-gravida mothers from misoprostol. Additionally, the absence of computers in delivery suites hinders contemporaneous observation recording.
Responded
Mark Jarvis
Concerns: The prison's SystmOne prescription system was difficult to use and incompatible, preventing medical staff from clearly verifying patient medication history, repeat prescriptions, and potential drug misuse.
Overdue
Maia Strachan
Concerns: The inability to store sequential scan data and provide sonographer alerts hindered comparison and further investigation, potentially delaying necessary changes to patient care plans.
Overdue
Kevin McDonald
Concerns: Discharge paperwork from the clinical decision-making unit lacks clarity regarding follow-up advice, leaving patients uncertain about their post-discharge care and increasing risks.
Overdue
Edward Hearn
Concerns: A system failure led to a critical high globulin blood test result in A&E not being followed up, delaying diagnosis. Additionally, prescribing information needs clearer guidance on cardiac monitoring.
Responded
Alexander Davidson
Concerns: NHS 111 pathways use unsuitable language for children and cause confusion, while GP surgeries experience delays in uploading 111 notes. There is also a lack of standardized lipase/amylase testing for children and inconsistent ED return patient reviews.
Overdue
Deborah Hopkinson
Concerns: Frequent equipment failures and significant delays in specialist consultant involvement due to lack of expertise and communication issues severely impacted patient diagnosis and treatment.
Responded
Tarek Chowdhury
Concerns: There is a failure to share critical prisoner information between HMPPS and immigration detention facilities, alongside issues with the SystmOne records system's functionality and staff training.
Overdue
Janice Davies
Concerns: Missing documented observations and pain scores before discharge, alongside absent formal guidance for prescribing oramorph to discharging patients, led to inconsistent and potentially inappropriate medication.
Responded
Susan Longden
Concerns: The NHS Pathways algorithm fails to prompt questions about recent surgery for severe abdominal pain, and NHS 111 advisors don't adequately prioritise speaking to patients directly. These systemic issues have been repeatedly raised.
Responded
Robert Wrinch
Concerns: The pathology department lacked systems for tracking samples and documenting clinician communications, causing delays and unclear chronologies. Incompatible IT systems between trusts and national pathologist shortages also contributed to backlogs.
Overdue
Alfie Scambler-Holt
Concerns: The absence of a national PEWS scoring system creates inconsistency across trusts, leading to varied escalation processes and potential risks for children transferred between hospitals.
Overdue
Angela Byrne
Concerns: W-CDAS staff are not applying training, leading to inadequate risk assessment for vulnerable patients, and there are poor communications between inpatient and community services with inconsistent records.
Overdue
Gail Bannister
Concerns: The assigned Care Co-ordinator failed to see the patient, undermining their care plan. Additionally, a known single phone line problem severely hampered crisis communication with the care team.
Responded
Edwin Hooper
Concerns: Concerns exist regarding ensuring timely CT scanning for head injury patients on anti-coagulants, in line with NICE guidelines, especially when facing service issues with on-site CT scanners.
Responded
Gwendoline Halfpenny
Concerns: County Hospital lacked surgical cover, and there was inconsistency in MEWS systems, duty policies, and equipment between hospitals within the same Trust.
Responded
Mildred Griffiths
Concerns: The care home's pressure sore risk assessment tool (Braden Score) underestimates risk and creates confusion with a national standard, as it doesn't account for existing lesions and uses an inverse scoring method.
Responded
Michael Giles
Concerns: Inconsistent handover processes, lack of senior weekend patient reviews, absence of leadership during crises, and poor medical record-keeping created risks in patient care.
Responded
Patrick Clifford
Concerns: Lack of clear patient supervision policy in toilets, difficulties transferring radiology images between hospitals, and refusal to perform requested X-rays caused treatment delays.
Overdue
David Hamilton
Concerns: Healthy Minds lacked documentation for therapy selection, clarity on referral triggers, and a formal escalation process for concerns. Limited information sharing between health professionals meant an incomplete patient picture.
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
Natalie Thornton
Concerns: Inadequate monitoring and analysis of blood sugar data from insulin pumps, coupled with a lack of formal pump agreements and variable national support, posed a risk to patient safety.
Overdue
Captain James Bedforth
Concerns: Inadequate DVT scanning guidelines and poor safety-netting led to missed diagnosis. Delayed assessment in ED, issues with anticoagulation management, and poor note-keeping further compromised care.
Overdue
Leslie Carswell
Concerns: Technical difficulties in transmitting CT scans between trusts caused critical delays in deciding treatment plans for urgent conditions. These unresolved issues risk delaying life-saving care.
Overdue
Anna Masson
Concerns: A new mental health referral screening pathway, conducted by junior staff, may not be robust enough to identify urgent cases, and there is inconsistent practice across the Trust's mental health teams.
Responded
Amy Cooper
Concerns: Commissioned maternity services lacked compatible, digitally available record-keeping and scan systems, leading to inefficient paper-note transfers and hindering seamless patient care and referrals.
Overdue
Antony Briggs
Concerns: Incompatible hospital IT systems prevented urologists from accessing patient test results, leading to a dangerous gap in follow-up when local GPs failed to act on information for aggressive malignancy.
Responded
Edward Gascoigne
Concerns: Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.
Responded
Naiya Diarra
Concerns: Relevant patient information was inaccessible to clinicians due to being stored in disparate record systems, highlighting systemic failures in inter-NHS record sharing.
Overdue
Harry Pryal
Concerns: A significant lack of recorded medical advice between trusts, conflicting interpretations of service agreements, and failure to hold mandated liaison meetings resulted in poor inter-trust communication.
Responded
Michael Quinn
Concerns: Hospital guidance for pre-operative blood glucose levels was inconsistent with national guidelines and research, highlighting confusion about optimal levels for surgical patients and increasing infection risk.
Overdue
Masoud Ghaderi
Concerns: Inconsistent record-keeping for service user engagement and the absence of a dedicated staff member for reviewing risk assessments prevented identification of changing patient risks. Ward rounds relied on inadequate, brief summaries, risking errors and omissions in care.
Overdue
Elizabeth Godwin
Concerns: Critical issues exist in mental health care regarding incomplete information gathering for assessments, poor urgency monitoring, inadequate inter-agency communication, unclear care responsibilities, and a lack of audit trails for patient transfers.
Responded
George Richardson
Concerns: Lack of a consolidated catheterisation record meant staff were unaware of previous challenges, and national standards may be needed for safe catheterisation skills.
Responded
Jayne Jowett
Concerns: PIC staff lack adequate training in interpreting and escalating National Early Warning Scores, and struggle to understand critical clinical signs. There's no clear protocol for GP collaboration or for communicating patient physical conditions to GPs.
Responded
Hilda Harris
Concerns: The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.
Overdue
Paige Bell
Concerns: Fragmented patient records, a lack of electronic access to all notes, and inconsistent engagement policies across trusts compromise patient care. Outdated guidance on Borderline Personality Disorder also requires updating.
Responded