"GDPR Says Yes"

Nisren died after falling over while she was an inpatient in hospital. She had been under the care of the neurology service at a different hospital, but their records were (a) extremely limited and (b) only available via Patient Pass rather than as part of her main hospital record. This meant that clinicians at the hospital where she was an inpatient were unaware of her neurological needs, so weren't observing her as they should have been when she fell.

Jacob was stabbed in the neck while out for the night. His attacker had been recently released from prison, but with no co-ordinated plans to manage his serious mental health condition and the risk he posed to others. Along with the lack of integrated working across services, the Coroner identified a specific problem with the healthcare system used in prisons, which had no access to other relevant healthcare records and which didn't display key information in an accessible format.

Jacob was stabbed in the neck while out for the night. His attacker had been recently released from prison, but with no co-ordinated plans to manage his serious mental health condition and the risk he posed to others. Along with the lack of integrated working across services, the Coroner identified a specific problem with the healthcare system used in prisons, which had no access to other relevant healthcare records and which didn't display key information in an accessible format.

"...the mental health liaison nurse undertook her assessment without having access to City Hospital records, which contained essential information that would have impacted on her assessment."

Susan was a resident in a care home who develo-ped pressure ulcers. She was under the care of District Nurses, who asked a GP and the tissue viability team for input, but they were shown out-of-date photographs and didn't appreciate the extent of her deterioration. As a result Susan wasn't precribed antibiotics when she should have been. She deteriorated rapidly and was admitted to hospital, where she died two months later. The DNs also failed to share information with the care team or Susan's family.

Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address. Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk. Shortcomings in software and communication systems amongst agencies. Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.

Serious communication failures between the ambulance dispatcher, the ambulance service and the police over the delay in getting an ambulance to Michael's address. Failure to update Michael's Fast Action Response Plan to reflect the actual level of risk. Shortcomings in software and communication systems amongst agencies. Poor interpretation, misunderstanding and poor analysis of the information available to agencies concerned.

Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home. Lack of system integration or clinical communication between the commissioning MH trust and The Priory Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.

Lauren had been sectioned and placed with The Priory at a distance of approx 260 miles from home. Lack of system integration or clinical communication between the commissioning MH trust and The Priory Failure to record Lauren on a list of out-of-area patients, leading to a failure to find her a place nearer home when she was ready for step-down from PICU.

Jacqueline's hospital record may or may not have included a flag about her risk of medication abuse. She was discharged home from hospital with an excess prescription of her medication despite a warning note on her [GP?] record stating that she should only be given 7 days' supply.

“Mr Cassidy died from a known drug allergy because its existence was not obtained by hospital medical staff from his Summary Care Record.”

“Mr Cassidy died from a known drug allergy because its existence was not obtained by hospital medical staff from his Summary Care Record.”

“Mr Cassidy died from a known drug allergy because its existence was not obtained by hospital medical staff from his Summary Care Record.”

The concerns about James's death were "further exacerbated by delays in communication between two different trusts – NCA and MUFT. Their IT systems are completely separate and cannot transmit information into the others patient records easily. This meant that it was almost a month before the system at MUFT was updated with the test results from Salford Royal."

"Although the Queens Hospital Burton Upon Trent and the the Royal Derby Hospital are governed by the same hospital trust, they have different electronic patient records. Entries made by the renal team at the Royal Derby Hospital are not automatically visible to medical staff at the Queens Hospital, “allergies” do not automatically cross populate despite entries being made on the Lorenzo system and the GP records being updated on 6th & 12th February 2020."

Trevor was admitted to psychiatric hospital “in an agitated, even psychotic state” and unable to give staff his medical history His sister told staff that he was suffering heart problems, but they did not record this. Trevor died from his heart condition within 48 hours of being admitted to the psychiatric unit.

"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."

"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."

"Lack of integration between mental health and physical healthcare systems... Whilst there have been significant advances in developing shared clinical records systems across primary and secondary care since Ms Davison’s death in 2017, none of the shared records systems extends to organisations which are deemed to be private providers, such as The Priory. The perception of healthcare providers such The Priory as “private” providers is a fallacy, because a high percentage of patients looked after by such providers are, like Ms Davison, NHS patients. I heard evidence from the Chief Medical Officer of The Priory that record sharing which includes private providers would help to prevent future deaths."

"Multiple pieces of relevant information regarding [REDACTED] current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular. "I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS."

"Multiple pieces of relevant information regarding [REDACTED] current illness were contained in disparate record ‘silos’. It was difficult for clinicians to access this information and, as such, it was not available to the reviewing psychiatric team, in particular. "I am concerned that the previous focus on access to medical records, which was to occur through the NHS Programme for IT, has been lost and that the new focus on patient access to GP records will not address the risks posed by the current state of record sharing within the NHS."

"The...support available [to police] from a mental health tactical adviser, is not provided by a clinically qualified member of staff and does not have access to the PARIS mental health records system."

The inquest heard that independent doctors did not have access to the CareNotes and relied upon printed copies of extracts from the notes which the AMHP considered pertinent to the Mental Health Act Assessment. Training is now available for independent s.12 doctors which, once completed, allows them access to CareNotes, but this training is not a mandated condition of their inclusion on the list of approved s.12 doctors. There remains a risk that, should a Trust doctor not be available to conduct the assessment, an independent doctor with no access to the patient’s records would be called upon to conduct an assessment.

"...it is a matter of concern that no system currently operates whereby clinicians working in the Emergency Department can easily access records made by colleagues working on the Virtual Ward. "

Rachel was discharged from an informal admission to a MH unit with too much medication. Her GP record stated that she was at risk of stockpiling and overdosing on pain relief, but she was sent home with 14 days' supply rather than 7. The Coroner noted that the practice of emailing the GP to notify what medication had been dispensed at discharge, was a point of weakness in the system.

Rachel was discharged from an informal admission to a MH unit with too much medication. Her GP record stated that she was at risk of stockpiling and overdosing on pain relief, but she was sent home with 14 days' supply rather than 7. The Coroner noted that the practice of emailing the GP to notify what medication had been dispensed at discharge, was a point of weakness in the system.

"...the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson’s GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson’s long term health issues as well as contact with his GP as recent as a week before going in to prison. "...I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone’s record by hand. "...I am also concerned that key information could be missed by virtue of these systems not communicating with each other."

"...the jury heard evidence about the difficulty in information being transferred over from Mr Finlayson’s GP surgery system, which uses SystmOne to the prison system (also SystmOne). The evidence was that information was not able to be freely shared between the two and it meant that there was a delay in healthcare staff in the prison accessing relevant information about Mr Finlayson’s long term health issues as well as contact with his GP as recent as a week before going in to prison. "...I heard evidence that if someone goes to prison and is linked to a surgery that uses another system (like EMIS) the notes have to be printed and scanned on to SystmOne and key information has to be input onto someone’s record by hand. "...I am also concerned that key information could be missed by virtue of these systems not communicating with each other."

“…at a weekend and out of hours the Consultant Orthopaedic and Trauma Surgeon involved was not able to access the electronic records of other departments within the hospital.”

· I heard evidence that when Ms GARLAND was on the Cardiac High Dependency Unit ‘HDU’ (part of the Intensive Care Unit) she was receiving intravenous antibiotics · When she then transferred from HDU to the Cardiac Ward there was a transcription error, and these antibiotics were accidentally omitted from the list of medications that she should be given on the new ward · As a result Ms GARLAND’s antibiotics were discontinued accidentally. · I heard evidence from an ICU Consultant (who I found to be both a reliable and an impressive witness), who told me, among other things, that: – “… Transcription errors have always been a problem…” the ideal way to get rid of them would be to have a system [in the rest of the hospital] that speaks to ours – The ICU retains lists of its patients’ medication on a computerised/electronic system – The rest of the wards in the hospital do not operate the same system – The available systems do not speak to each other (to put it in somewhat colloquial terms) – Efforts to address that problem have proved fruitless – As a result, every time an inpatient moves from ICU to another department in the hospital, an appropriately qualified member of staff has to physically transcribe that patient’s medication list – With (for instance) 10 patients moving per day, 15-20 medications per patient, and multiple elements for each medication (name; dose; timing; indication; start date; signature etc.), “at a conservative estimate 1,500 to 2,000 elements [are transcribed] daily” (Coroner’s comment: for obvious reasons this creates enormous potential for human error)

"During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death."

"During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death."

Ambulance service and Emergency Operations Centre only have access to GP records, not CMHT records. Evidence was presented that there were technical obstacles to this in respect of interoperability of systems (EMIS/RiO). Evidence also suggested that a person's consent may be needed for this information to be shared across NHS systems including the ambulance service - a clear case of "GDPR Says No".

"The provision to Ms. MITCHELL of 28 days’ worth of prescribed medication in less than a 48-hour period (14 days’ worth of medication dispensed on each occasion she was discharged hospital on the 3rd and 4th of August 2022). This occurred at a time when, due to concerns about Ms. MITCHELL hoarding medication and taking an overdose, she was receiving weekly medication prescriptions from her GP to control this risk. "The evidence heard at Inquest indicated that there was no process in place whereby accident and emergency staff could access Ms. MITCHELL’s medical records detailing the medication she was receiving and the rationale behind the dispensing regime in place."

Trevor died in prison. His cause of death was Sudden Unexpected Death in Epilepsy (SUDEP). His epilepsy was known to prison healthcare staff but not to prison staff. There was no seizure care plan, no seizure diary, and no means of monitoring his condition. Response from prison healthcare provider: “As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

Trevor died in prison. His cause of death was Sudden Unexpected Death in Epilepsy (SUDEP). His epilepsy was known to prison healthcare staff but not to prison staff. There was no seizure care plan, no seizure diary, and no means of monitoring his condition. Response from prison healthcare provider: “As with patients in the community, medical records are highly sensitive and personal to the individual. They are not shared with prison staff for reasons of medical confidentiality.”

– Evidence was heard that at the time of the inquest radiologists do not have access to patient’ medical notes and base their reporting on a summary document submitted by the department requiring imaging. The summary document in Mr MORETON’s case was seen to be deficient in that it omitted his symptom of fever. It was heard in evidence a radiologist would need to telephone the department in question or go there to inspect the notes. Their awareness of a patient’s condition is based on a telephone call referral followed by a summary document which can be at odds with each. – It is of concern that the use of telephone referral system and summary could contain errors and the radiologist must rely on this information, with no quick way to inspect a patient’s notes. – The evidence also dealt with radiologists working in 2 hour triage shifts in a hectic environment where those clinicians receiving the referral seldom were the clinicians who carried out the imaging. The inference was the arrangement was susceptible to error. – Over the course of the inquest evidence was heard on a number of issues where information passed to and from clinicians involved in Mr MORETON’s care was inaccurate and misleading. – Assumptions were made that, Mr MORETON was improving clinically when a surgical opinion was sought, this was incorrect. – It was assumed Mr MORETON would be referred for a surgical opinion by ED department clinicians, when in fact none took place. – Clinicians in Newcastle Upon Tyne when asked for advice were under the impression treatment was working as it was mentioned his discharge from hospital was comptemplated – this was not the case. – Overall I am concerned by the poor and misleading communications between clinicians, departments and Hospital Trusts on matters of vital importance to patient care.

(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug [REDACTED], should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support.

(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug [REDACTED], should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support.

(1) There is no specific protocol or policy in place to ensure that patients are warned of the acute risk of respiratory depression and death following administration of the drug [REDACTED], should they drink alcohol or misuse drugs. (2) There appears to be a lack of a joined up process between acute clinicians, alcohol and drug treatment teams, and mental health teams, to consider the safety of a discharge, and to ensure that crucial information relevant to risk is shared appropriately (which may also be, to an extent, hampered by a continuing inability to see each other’s records), and whether discharge should be delayed or care stepped down, until a place of safety is identified, and to ensure that a robust safety plan is in place upon discharge. (3) There was no consideration given by either the acute or mental health teams to contacting the deceased’s family or friends, which may have provided an essential safety net in the absence of accessible professional support.

Down Syndrome is the most common genetic disorder associated with immune defects. Children with Down Syndrome need to be managed with a heightened sense of awareness in the setting of sepsis. This was not however known by Isaac’s parents or by the GP registrar. Health advisers with NHS111 do not have access to GP electronic summaries. They do not therefore have the background diagnoses of the patient concerned. The inquest heard that a different disposition would have been reached, had the health adviser been aware of the diagnosis of Down Syndrome. Had the health adviser been aware of the diagnosis, Isaac would have been assessed by a clinician during the evening of the 30 May 2023. Had this happened, Isaac’s death would have been avoided.

The Court heard evidence despite a warning ‘flag’ being present on the computerised records identifying the existence of an individualised care plan for Darnell, the care plan was hard to locate in the records, and was not considered during his admission.

Mental health practitioners are not easily able to access all of a patient’s relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation. Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper. Mental health practitioners in Wales currently have no way easily to access NHS England clinical records.

Mental health practitioners are not easily able to access all of a patient’s relevant clinical records pending the introduction of a “Once for Wales” solution, for which there is currently no timetable for implementation. Mental health practitioners may not be aware of the existence of all such records, some of which may be in paper. Mental health practitioners in Wales currently have no way easily to access NHS England clinical records.

a.[REDACTED] evidence is that on several occasions during Ms. Woodman’s inpatient admission to Spenser Ward he was in communication with her and [REDACTED] of which treating clinicians were aware. On at least one of those occasions [REDACTED] spoke with Spenser Ward staff. I noted that Ms. Woodman had not [REDACTED] given consent for staff to contact [REDACTED] concerning her treatment. Notwithstanding this, I found that there were missed opportunities to gather important collateral history from [REDACTED]; Ms. Woodman’s partner and who knew her well in the lead up to her admission. It would seem that staff speaking with [REDACTED] on these occasions failed to think laterally or innovatively as to how to collect important, relevant collateral history whilst still respecting Ms. Woodman’s wish that her condition not be discussed with . The ability of mental health clinicians to gain a complete picture of Ms. Woodman’s medical history was hampered by the fact that the information management systems holding these records at her GP practice was not accessible to secondary mental health services. This resulted in gaps in information available to mental health clinicians which was not necessarily filled by measures taken by secondary mental health services to gather collateral information from the family and Ms. Woodman herself. The handling of the Single Combined Assessment of Risk Form (SCARF) within the Community Mental Health Team (CMHT) on 29th of March 2021. The SCARF was categorised Amber and had been received by SABP from the Police via Surrey County Council Adult Social Services. It concerned a patient on the CMHT’s books. Several witnesses gave evidence that best practice would involve the family of Ms. Woodman being contacted when the SCARF was received and considered. This did not occur. The failure to consider the SCARF in a more timely manner or refer the details to Ms. Woodman’s family is of concern; both in relation to timeliness of consideration and actions on receipt of the SCARF. The care planning and recording of care plans within Ms. Woodman’s notes raises a further area of concern. Questions exist as to the adequacy of the manner in which Ms. Woodman’s care plan was recorded. It required anyone wishing to understand the care plan for Ms. Woodman to consult her SystmOne medical record and read the detailed note recorded following the Discharge CPA meeting on the 25th of March 2021, extrapolating from this to deduce the broad care plan. There was, it would seem, no single document that drew together multiple inputs from either MDT meetings (where risk had been considered), or aspects of care and crisis contingency planning (such that this had been considered). The result was a failure to present a holistic view of how Ms. Woodman’s care and risk would be managed in the community. Although not causative of the death and I noted [REDACTED} ’ very clear expert evidence that had a Crisis and Contingency Management Plan (CCMP) been in place it would have been unlikely to have averted the death, the failure to produce such a clear plan in accordance with Trust policies is a concern. Multiple witnesses observed that there is frequent tension between inpatient staff and the CMHT in the context of decisions relating to the discharge of inpatients. I note the explanations provided as to why such tension exists given the role of each team. However, in the context of Ms. Woodman’s care, these tensions led to gaps and breakdowns in communication between inpatient and CMHT with respect to diagnosis and formulation of both the care plan and CCMP.

The possible toxicity from the Co-codamol tablets was not a considered by the ambulance crew who attended to Mrs Young following a 999 call. The Ambulance Service was not aware that Mrs Young had recently been prescribed Co-Codamol as the Ambulance service does not currently have access to GP records. There was a short period of time in which the Naloxdone antidote could have been given and evidence was heard from the expert at the Inquest that if the toxicity had been recognised earlier and Naloxodone administered there was a good chance that Mrs Young would have survived. As the Ambulance Service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately.