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recurance

Amy Hogan

31 Jul 2020 · Coroner Christopher Morris · Manchester South

This report repeats 3 earlier warnings, and was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. incomplete transfer of patient data

    “delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories”
  2. 2. lack of electronic access to regular GP records

    “inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients”

Linked reports

Repeats an earlier warningTimothy Smedley16 Nov 2017 · 2 years 8 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“The lack of (joint) access to NHS records by 'out of hours' services such as GPs, Urgent Care Centres etc.”
Original on judiciary.uk ↗

This report

“Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients.”
Full chain: Lack of joint access to NHS records by out of hours services
Repeats an earlier warningDavid Buttriss12 Jan 2018 · 2 years 7 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
Original on judiciary.uk ↗

This report

“the out of hours GP reviewing Miss [name redacted] had no electronic access to her regular GP records”
Full chain: Out-of-hours clinicians cannot access regular GP records
Repeats an earlier warningRoss Reeves29 Mar 2018 · 2 years 4 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“The transfer of this patient to his new GP was likely 'unsafe'. lam particularly concerned because in Brighton and Hove we have an”
Original on judiciary.uk ↗

This report

“delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories.”
Full chain: Incomplete transfer of patient data between GP practices
Raised again laterPatrick Soames18 Apr 2023 · 2 years 9 months later
Closely relatedConfidence 0.85 · high

This report

“It is a matter of concern that delayed, incomplete or non-existent transfer of patient data from one practice to another on moving places an unfair burden on patients to accurately recall and relay their own medical histories.”

Later report

“However, I heard evidence at inquest from accident and emergency consultants that it is either not possible to access information held by a GP practice out of GP surgery hours or where it is possible to do so that is only available if the GP is in the same geographic area as the accident and emergency department.”
Original on judiciary.uk ↗
Full chain: Out-of-hours clinicians cannot access regular GP records

Responses

2020-0147-Response-from-NHS-England.pdf ↗· NHS England

Stated action · March 2022

“We are working with GP system suppliers and NHS England and NHS Improvement continue to make progress.”
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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error