Recurance · prevention of future deaths reports
Pre-inquest brief
Lack of electronic access to primary care medical notes
The earlier warning
Audrey Kelly · 8 Apr 2014 · John Pollard, Manchester (South)
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
judiciary.uk/prevention-of-future-death-reports/audrey-kelly
What was promised
Stated action 1 · response to Audrey Kelly (8 Apr 2014) · stated timescale: none stated
“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.”
judiciary.uk/…/2014-0155-Response-by-Department-of-Health.pdf
Stated action 2 · response to Audrey Kelly (8 Apr 2014) · stated timescale: none stated
“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”
judiciary.uk/…/2014-0155-Response-by-Department-of-Health2.pdf
What recurred
- 15 May 2017 · Stephen Leven · R Brittain · Identical hazard · confidence 0.90 (high)
- 28 Jan 2026 · Akhona Moyo · Hassan Shah · Identical hazard · confidence 0.95 (high)
The clearest link, quoted from both reports:
Earlier · Audrey Kelly · 8 Apr 2014
“neither they nor the hospital Emergency Departments, have direct access to GP [name redacted]”
Later · 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.”
What happened next
No web check of the stated actions has been published for this chain.