Felicity Clough
26 Nov 2021 · Coroner Rachael Griffin · Dorset
A similar concern from this report was raised again 3 times later. See the linked reports.
The coroner's concerns
1. lack of access to patient records across healthcare trusts
“There are different systems used by healthcare trusts across England and Wales for holding patients records and information. Each trust has their own system which other trusts do not have access to. This means that vital and important information recorded on one trust database may not be available to a different trust who is caring for a patient. This applies to both physical and mental healthcare trusts. The lack of access to this information could prove to be life threatening.”
2. lack of access to police force information across forces
“I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces, especially neighbouring forces who may both have contact with individuals. Whilst I understand there is some work being done on a regional basis to address this, I would request that the issue is considered nationally as to how information held on all Police systems, not just the Police National Database, can be shared to assist in the management and assessment”
3. lack of access to healthcare records
“I have concerns with regard to the following: i. There could be future deaths nationally due to the lack of accessibility to records held by different healthcare trusts. I would request consideration is given to the sharing of records between healthcare trusts”
4. missing vital information in emergency department admission documentation
“I have concerns that future deaths could occur at Yeovil District hospital due to the missing of vital information within the pre 3 admission documentation due to the fact the staff within the Emergency Department at Yeovil District Hospital are not always accessing admission documentation, especially the paramedic records when a person is brought into the Accident and Emergency department. I request that consideration is given to issuing further guidance to remind staff of the need to review this”
Linked reports
Closely relatedConfidence 0.90 · high
This report
“I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces, especially neighbouring forces who may both have contact with individuals.”
Later report
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him.”
Identical hazardConfidence 0.95 · high
This report
“There are different systems used by healthcare trusts across England and Wales for holding patients records and information.”
Later report
“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
Closely relatedConfidence 0.90 · high
This report
“I have concerns that future deaths could occur due to the lack of access to information held on individual Police force systems by other forces, especially neighbouring forces who may both have contact with individuals.”
Later report
“The concern I have is that there is difficulty for front line officers in police forces across the country to easily access the police national database to check on individuals who are suspected of domestic abuse.”
Responses
2021-0402-Response-from-Secretary-of-State-for-Health-and-Social-Care-Minister-for-Crime-and-Polici.pdf ↗· Department of Health and Social Care