Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Felicity Clough · 26 Nov 2021 · Rachael Griffin, Dorset
“There are different systems used by healthcare trusts across England and Wales for holding patients records and information.”
judiciary.uk/…/felicity-clough-prevention-of-future-deaths-repo…
What was promised
Stated action 1 · response to Judith Obholzer (12 Jul 2024) · stated timescale: none stated
“The National Care Records Service (NCRS) is the successor to the Summary Care Record application (SCRa) and by design removes a large amount of the reported barriers to adoption within many care settings including the private sector.”
Stated action 2 · response to Judith Obholzer (12 Jul 2024) · stated timescale: none stated
“we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment”
What recurred
- 14 Sept 2023 · Jack Farrington · Robert Simpson
- 12 Jul 2024 · Judith Obholzer · Ellie Oakley
- 2 Oct 2024 · Alix Knowles · Emma Serrano · Identical hazard · confidence 0.95 (high)
- 22 Oct 2025 · Amy Cross · Peter Harrowing · Closely related · confidence 0.92 (high)
The clearest link, quoted from both reports:
Earlier · Felicity Clough · 26 Nov 2021
“There are different systems used by healthcare trusts across England and Wales for holding patients records and information.”
Later · Alix Knowles · 2 Oct 2024
“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
What happened next
No evidence found either way · stated action 1
“Improve communication across services. Use shared information to support multidisciplinary working and escalation between teams. How to access this service.”
National Care Records Service · digital.nhs.uk/services/national-care-records-service
No evidence found does not mean the action did not happen.
Evidence found · stated action 2
“The government has announced it has [recruited 8,500 additional mental health workers”
'Government must now set a more ambitious goal': We ... · rethink.org/…/government-must-now-set-a-more-ambitious-goal-we-…
“We've hit our target of recruiting 8,500 more mental health workers in the NHS, three years ahead of schedule”
We promised to recruit 8500 more mental health workers ... · facebook.com/…/1301324875518440