Lack of electronic access to primary care medical notes
Department of Health and Social Care received 3 coroners' reports about this hazard between 8 Apr 2014 and 28 Jan 2026.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 2 of the 2 earlier reports, stating 2 specific actions.
The story, report by report
Spacing grows with the time between reports.
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“The CCG have confirmed that [the deceased] had a shared record which was available to view and which included her allergy to the antibiotic specified in your report.”
“Stockport CCG is already enagaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures: © to seek formal assurance from Mastercall about processes for new starters and contingency plans for when practitioners do not have Smartcards”
- 3 years 1 month laterIdentical hazardConfidence 0.90 · higha different coroner
“lack of access to GP information regarding Mr [name redacted] diagnosis of haemophilia, could have caused or contributed to his death”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗
- 8 years 8 months laterIdentical hazardConfidence 0.95 · higha different coroner
“Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc.”
Original on judiciary.uk ↗ Repeated from the earlier report:HospitalEmergencyaccess
Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
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.
2014 → 2017Stephen Leven3 years 1 month after Audrey Kelly · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight the inability of healthcare staff to access patients' GP records, which could lead to avoidable harm.
Audrey Kelly · 8 Apr 2014
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
Original on judiciary.uk ↗ Stephen Leven · 15 May 2017
“lack of access to GP information regarding Mr [name redacted] diagnosis of haemophilia, could have caused or contributed to his death”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“Stockport CCG is already enagaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures: © to seek formal assurance from Mastercall about processes for new starters and contingency plans for when practitioners do not have Smartcards”
2014 → 2026Akhona Moyo11 years 10 months after Audrey Kelly · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight that hospital doctors, including those in Emergency Departments, cannot access patients' GP or primary care notes. This lack of access is described as a safety gap that could lead to avoidable harm.
Audrey Kelly · 8 Apr 2014
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
Original on judiciary.uk ↗ Akhona Moyo · 28 Jan 2026
“Hospital doctors, including in the Emergency Department and Paediatrics, do not have electronic access to primary care medical notes e.g. GP notes, community mental health notes etc.”
Original on judiciary.uk ↗
Stated action
“The CCG have confirmed that [the deceased] had a shared record which was available to view and which included her allergy to the antibiotic specified in your report.”
Stated action
“Stockport CCG is already enagaged in continual improvement work in this area. However, as a result of this investigation, the CCG is also planning the following measures: © to seek formal assurance from Mastercall about processes for new starters and contingency plans for when practitioners do not have Smartcards”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
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 Department of Health and Social Care 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 |
|---|---|---|---|---|
| 2014 → 2017 | 0.65 | 0.23 | Identical · 0.90 | different |
| 2014 → 2026 | 0.86 | 0.24 | Identical · 0.95 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Next
Other chains for Department of Health and Social Care
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.