Skip to content
recurance

Brooke Martin

2 Jul 2021 · Coroner Tom Osborne · Milton Keynes

A similar concern from this report was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. incompatible NHS systems

    “it is not always possible for each healthcare provider to access the notes and records of the patient”
  2. 2. incomplete patient history on referral

    “when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient's history”

Linked reports

Raised again laterAndrew Heys24 Jan 2025 · 3 years 7 months later
Identical hazardConfidence 0.96 · high

This report

“it is not always possible for each healthcare provider to access the notes and records of the patient.”

Later report

“the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other".”
Original on judiciary.uk ↗
Full chain: Incompatible IT systems block cross provider record access

Responses

2021-0299-Response-from-Department-of-Health-and-Social-Care_Published.pdf ↗· Department of Health and Social Care

Stated action · September 2021

“Through the national Shared Care Records programme, by September this year, we expect the majority of Integrated Care Systems (ICS's) to have a basic shared care record in place.”

Stated action · March 2023

“The aim is to have this largely in place by March 2023.”

Stated action

“in the South East region, where electronic sharing of patient information is not yet possible, to support patient care each ICS has adopted a set of Continuity of Care Principles regarding the commissioning of acute and psychiatric intensive care out of area placements.”
  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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