Inability to access GP medication records across systems
Essex Partnership University NHS Foundation Trust received 3 coroners' reports about this hazard between 28 Jun 2021 and 17 Feb 2025.
They came from 3 different coroners. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 1 specific action.
The story, report by report
Spacing grows with the time between reports.
“Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as the electronic systems were presently configured, readily access information held by GP practices regarding individual patients”
Original on judiciary.uk ↗ No published response from Essex Partnership University NHS Foundation Trust was found for this report.
- 2 years 5 months laterClosely relatedConfidence 0.90 · higha different coroner
“some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county”
Original on judiciary.uk ↗ Essex Partnership University NHS Foundation Trust responded, stating 1 specific action.Response (PDF) ↗
“The Psychological Services Care Unit have been advised of this concern and have provided the following assurance. Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner.”
Stated timescale: 2023
- 1 year 2 months laterClosely relatedConfidence 0.85 · higha different coroner
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
Original on judiciary.uk ↗ Essex Partnership University NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Essex Partnership University NHS Foundation Trust
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2021 → 2023Katharine Fox2 years 5 months after Fiona Humberstone · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight a lack of interoperable electronic systems that prevents clinicians from accessing essential patient information held elsewhere. This gap creates a risk of unsafe care due to incomplete records.
Fiona Humberstone · 28 Jun 2021
“Further, oral evidence from a senior EPUT witness confirmed that the Trust could not, as the electronic systems were presently configured, readily access information held by GP practices regarding individual patients”
Original on judiciary.uk ↗ Katharine Fox · 7 Dec 2023
“some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county”
Original on judiciary.uk ↗ 2023 → 2025David Bennett1 year 2 months after Katharine Fox · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight that staff cannot access necessary mental health records across different service settings, risking gaps in information sharing.
Katharine Fox · 7 Dec 2023
“I am concerned about the fact, if that is indeed right, that some clinicians in the psychology service may not be able to access notes made by clinicians in either other hospitals or other parts of the county.”
Original on judiciary.uk ↗ David Bennett · 17 Feb 2025
“Evidence was heard that the mental health crisis staff do not appear to have appropriate access to the primary care mental health System One records and there is a risk that vital information is not being shared.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The Psychological Services Care Unit have been advised of this concern and have provided the following assurance. Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner.”
No published response from Essex Partnership University NHS Foundation Trust was found for this report.
Stated action · timescale: 2023
“The Psychological Services Care Unit have been advised of this concern and have provided the following assurance. Every patient who is receiving psychological intervention on an inpatient unit and is in need of continued psychological intervention post discharge, will have a handover of care from the inpatient psychologist (verbal/in writing) to the Community Team psychological practitioner.”
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to Essex Partnership University NHS Foundation Trust at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2021 → 2023 | 0.69 | 0.10 | Closely related · 0.90 | different |
| 2023 → 2025 | 0.70 | 0.04 | Closely related · 0.85 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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Other chains for Essex Partnership University NHS Foundation Trust
- Inadequate risk assessment documentation and inaccurate record keeping6 reports · 2018–2026
- Incomplete investigation of patient observations2 reports · 2023–2025
- Absence of mental health liaison during 72‑hour hold and missing discharge note2 reports · 2024–2025
- Lack of discharge plan responsibility and unclear care coordinator allocation2 reports · 2022–2025
This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.