Incompatible IT systems hinder information sharing
NHS England received 4 coroners' reports about this hazard between 15 Mar 2017 and 2 Jul 2024.
They came from 4 different coroners in 2 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 2 of the 3 earlier reports, stating 10 specific actions.
The story, report by report
Spacing grows with the time between reports.
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
Original on judiciary.uk ↗ No published response from NHS England was found for this report.
- 6 years 4 months laterClosely relatedConfidence 0.90 · higha different coroner
“different health organisations use different digital systems that do not communicate with each other.”
Original on judiciary.uk ↗ Repeated from the earlier report:differentorganisationssystems
NHS England responded, stating 3 specific actions.Response (PDF) ↗
“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
1 more stated action in the Promises tab.
- 2 months laterIdentical hazardConfidence 0.90 · higha different coroner
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Original on judiciary.uk ↗ Repeated from the earlier report:recordkeepingorganisationsinformation
NHS England responded, stating 7 specific actions.Response (PDF) ↗Response (PDF) ↗
“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”
Stated timescale: 2023/24
Web search (Tavily): No evidence found either way
2023/24 priorities and operational planning guidance ↗“The Trust has undertaken a comprehensive review to ensure that all patients who are receiving acute care funded by the Trust in Out of Area beds are accurately identified as such on our clinical system.”
5 more stated actions in the Promises tab.
- 9 months laterIdentical hazardConfidence 0.90 · higha different coroner
“Their IT systems are completely separate and cannot transmit information into the others patient records easily.”
Original on judiciary.uk ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗
- All reports to NHS England
Each row is one judged link between an earlier and a later report. Open a row to read both quotes, found word for word in the originals.
2017 → 2023Peter Fleming6 years 4 months after Leah Ratheram · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that separate organisations use incompatible IT systems, hindering effective information sharing. This creates a risk that important patient data is missed during handovers or prescribing.
Leah Ratheram · 15 Mar 2017
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
Original on judiciary.uk ↗ Peter Fleming · 14 Jul 2023
“different health organisations use different digital systems that do not communicate with each other.”
Original on judiciary.uk ↗ 2017 → 2023Lauren Bridges (1)6 years 6 months after Leah Ratheram · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that incompatible record‑keeping systems hinder effective sharing of clinical information between organisations. This creates a risk that important risk factors are missed during patient handover.
Leah Ratheram · 15 Mar 2017
“Both organisations use different record keeping systems. There is a real risk that information will not be shared effectively and key risk factors will be missed in the handover process.”
Original on judiciary.uk ↗ Lauren Bridges (1) · 19 Sept 2023
“There are multiple software programmes for record keeping for these organisations, which makes transfer and sharing of clinical information cumbersome and difficult, as direct sharing is not possible.”
Original on judiciary.uk ↗ 2023 → 2024James Cockburn1 year after Peter Fleming · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that separate digital IT systems used by different health organisations cannot exchange information, causing delays in patient care.
Peter Fleming · 14 Jul 2023
“different health organisations use different digital systems that do not communicate with each other.”
Original on judiciary.uk ↗ James Cockburn · 2 Jul 2024
“Their IT systems are completely separate and cannot transmit information into the others patient records easily.”
Original on judiciary.uk ↗
No published response from NHS England was found for this report.
Stated action
“The NHS is working to further improve this capability to enable information to be automatically added into the GP [name redacted] record as appropriate.”
Stated action
“medication. The dispensing notification used by pharmacies is for payment purposes and does not link back to the prescribing system. It is not used consistently by pharmacies as some use the notification system for when an item has been dispensed and is ready for collection, meaning the patient has not yet collected the medication and in fact may not collect it. Therefore, the system would not be a reliable way for the GP to check the patient's compliance with medication as there is no confirmation on”
Stated action · timescale: June this year
“In June this year, the NHS published its Long Term Workforce Plan, setting out how we will ensure that staffing is put on a sustainable footing over the next fifteen years to improve patient care.”
Stated action · timescale: 2023/24
“All Integrated Care Boards (ICBs) were asked to work towards eliminating the practice in NHS England's 2023/24 Priorities and Operational Planning Guidance.”
What happened next: No evidence found either way
The NHS England 2023/24 Priorities and Operational Planning Guidance requires Integrated Care Boards to work towards eliminating a specific practice, but no source confirms that this action was completed within the stated timeframe.
“We will support local decision making, empowering local leaders to make the best decisions for their local populations and have set out fewer, more focused national objective”
No evidence found does not mean the action did not happen.
Stated action
“The Trust has undertaken a comprehensive review to ensure that all patients who are receiving acute care funded by the Trust in Out of Area beds are accurately identified as such on our clinical system.”
Stated action
“We have enhanced the daily Hospital Overview situation report which is accurate at the point it is sent, with the purpose of providing a summary at the start of the working day across the organisation to key colleagues including senior clinicians and managers.”
Stated action
“In addition, the Trust has also added a specific section to the daily Hospital Overview template showing patients who are in out of area beds who require repatriation to a local bed.”
Stated action
“We have updated the electronic admission form template that is embedded in the patient record system so that when a patient requires admission, we capture more robust information, which is then also reportable in a bed state automated report.”
Stated action
“The Trust has implemented a new Standard Operating Procedure (SOP) for Enabling Purposeful Admissions. This clearly sets out the required process, roles and responsibilities of key staff and the required recording in respect of inpatient flow decisions.”
Stated action
“We have reviewed our daily clinical meeting that takes place in respect of bed flow and set out requirements in the meeting's terms of reference, including standard items for discussion and recording standards.”
No specific action could be extracted with a verified quote.
No specific action could be extracted with a verified quote.
- Each report's concerns were extracted by Nemotron 3 Nano on Nebius Token Factory, each with a quote copied from the report.
- Concerns from reports to NHS England at least six months apart were compared by meaning (Qwen3 embeddings) and wording (TF-IDF).
- The closest pairs were judged by Nemotron 3 Super with reasoning on. Only identical or closely related, with confidence of at least 0.70, are shown.
- Every quote was checked by code as an exact substring of the original text. Names of staff and family are redacted, and the deceased are named by report title only.
| Link | Meaning | Wording | Judge | Coroner |
|---|---|---|---|---|
| 2017 → 2023 | 0.71 | 0.19 | Closely related · 0.90 | different |
| 2017 → 2023 | 0.79 | 0.23 | Identical · 0.90 | different |
| 2023 → 2024 | 0.77 | 0.09 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
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This shows that a similar concern was raised again after an earlier report. It does not say why, and it is not a finding about any organisation or person. To report an error, see the corrections route.