John Johnson
6 May 2025 · Coroner James Thompson · Gateshead and South Tyneside
The coroner's concerns
1. overlooked significant findings due to fragmented IT systems
“During the course of my investigation I heard evidence of the Hospital Trust operating a variety of IT systems to document a patient's stay in hospital. There was not one system which contained all the information generated during a patient's stay in hospital including, but not limited to, test results. It required clinical users to switch between systems to gather all the necessary information and raised the potential risk of significant findings being overlooked. It also slows down clinical decision making and makes it more difficult to follow a patient's overall care.”
2. unsafe transfer of care due to report routing to wrong department
“In Mr [name redacted] case, the X Ray report was returned to a department not then involved in his care. The use of multiple systems can create a risk around safe transfers of care for discharge or handover.”
3. national risk of fragmented IT systems endangering patient safety
“I was told this issue is not confined to one individual Trust and the use of multiple systems is widespread across the National Health Service. Their use is well known to the national NHS responsible bodies.”