Amy Cross
22 Oct 2025 · Coroner Peter Harrowing · Avon
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of information transfer between healthcare providers
“There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare in the criminal justice system at the time a person is conveyed between the police, the court and the prison.”
2. absence of standard medical records system
“There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.”
Linked reports
Closely relatedConfidence 0.85 · high
Earlier report
“There were no protocols or agreements between healthcare staff and the prison service as to how best to respond to an unresponsive body.”
This report
“There is no system to ensure that important healthcare information including recent administration of medicines and the results of physical observations is passed between separate providers of healthcare”
Identical hazardConfidence 0.90 · high
Earlier report
“there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas”
This report
“There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.”
Closely relatedConfidence 0.92 · high
Earlier report
“ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.”
This report
“There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.”