Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Leah Ratheram · 15 Mar 2017 · Louise Hunt, Birmingham and Solihull
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
judiciary.uk/prevention-of-future-death-reports/leah-ratheram
What was promised
Stated action 1 · response to Peter Fleming (14 Jul 2023) · stated timescale: none stated
“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
Stated action 2 · response to Peter Fleming (14 Jul 2023) · stated timescale: none stated
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
Stated action 3 · response to Lauren Bridges (1) (19 Sept 2023) · stated timescale: 2023/24
“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”
7 further stated actions are listed on the full chain page.
What recurred
- 14 Jul 2023 · Peter Fleming · James Bennett · Closely related · confidence 0.90 (high)
- 19 Sept 2023 · Lauren Bridges (1) · Andrew Bridgman · Identical hazard · confidence 0.90 (high)
- 2 Jul 2024 · James Cockburn · Alison Mutch · Identical hazard · confidence 0.90 (high)
The clearest link, quoted from both reports:
Earlier · Leah Ratheram · 15 Mar 2017
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
Later · Peter Fleming · 14 Jul 2023
“different health organisations use different digital systems that do not communicate with each other.”
What happened next
No evidence found either way · stated action 3
“We will support local decision making, empowering local leaders to make the best decisions for their local populations and have set out fewer, more focused national objective”
2023/24 priorities and operational planning guidance · england.nhs.uk/…/PRN00021-23-24-priorities-and-operational-plan…
No evidence found does not mean the action did not happen.