Jack Farrington
14 Sept 2023 · Coroner Robert Simpson · Hampshire, Portsmouth and Southampton
A similar concern from this report was raised again 2 times later. See the linked reports.
The coroner's concerns
1. lack of electronic medical records sharing
“no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas and the Care and Health Information Exchange (CHIE) operating in the local area contains limited information”
2. missing handover records
“these handovers were not stored in the same way as other patient records and, in [the deceased]'s case, were missing entirely.”
3. paper records not scanned
“paper forms for some observations and record keeping within the mental health unit.”
4. inadequate handover on arrival
“no specific structure in place at Queen Alexandra Hospital Emergency Department for ensuring the full and accurate handover of information about a patient who arrives whilst subject to detention under the Mental Health Act”
5. risk not flagged
“patient risks to be 'flagged' within the Oceana records system to ensure that all staff are made aware of these. This was not done in [the deceased]'s case”
6. mandatory security presence not enforced
“'Mental Health Primary Disturbance Survey' tool was used to assess [the deceased] on his arrival at ED. This indicated that his risk level was 'level 5+ black' and this in turn set out a requirement of the mandatory presence of security guards. However when [the deceased] absconded there was evidence that no security guards were present”
Linked reports
Closely relatedConfidence 0.90 · high
This 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”
Later report
“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
Identical hazardConfidence 0.90 · high
This 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”
Later 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.”
Responses
2023-0436-Response-from-Portsmouth-Hospitals-University-NHS-Trust.pdf ↗· Portsmouth Hospitals University NHS Trust
2023-0436-Response-from-Solent-NHS-Trust.pdf ↗· Solent NHS Trust