Incompatible electronic records hinder mental health information sharing
Pennine Care NHS Trust received 4 coroners' reports about this hazard between 19 Apr 2018 and 21 Jul 2023.
They came from 3 different coroners in 2 coroner areas. A similar concern was raised again 3 times after the first warning.
A published response was found for 3 of the 3 earlier reports, stating 8 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded, stating 3 specific actions.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
Stated timescale: next two to three and a half years
“We revised the Code of Practice in 2015 and set out guiding principles to ' hups://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983 improve the care for patients.”
Stated timescale: 2015
1 more stated action in the Promises tab.
- 7 months laterClosely relatedConfidence 0.90 · high
“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services.”
Original on judiciary.uk ↗ Repeated from the earlier report:MentalHealthTrustevidence
Pennine Care NHS Trust responded, stating 4 specific actions.Response (PDF) ↗
“We will develop a process and protocol for escalation to be used within the borough of Stockport by the end of February 2019.”
Stated timescale: end of February 2019
“Following review with the Lead Consultant [name redacted] the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above.”
Stated timescale: end of February 2019
2 more stated actions in the Promises tab.
- 1 year 5 months later
“There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts.”
Original on judiciary.uk ↗ Pennine Care NHS Trust responded, stating 1 specific action.Response (PDF) ↗
“It is planned that his will go live at the end of August 2020”
Stated timescale: end of August 2020
- 3 years 3 months laterClosely relatedConfidence 0.90 · higha different coroner
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems.”
Original on judiciary.uk ↗ Repeated from the earlier report:Trustsrecords
Pennine Care NHS Trust responded.Response (PDF) ↗
- All reports to Pennine Care NHS Trust
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.
2018 → 2018Matthew Craven7 months after Adrian Jennings · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight failures in sharing patient information across mental health services within the same trust. The earlier report cites the absence of a unified IT system, while the later report notes that information from an alcohol worker encounter was not communicated to wider services.
Adrian Jennings · 19 Apr 2018
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
Original on judiciary.uk ↗ Matthew Craven · 22 Nov 2018
“On one admission to the acute hospital following an overdose, he was seen by an alcohol worker from the Mental Health Trust. There was no evidence that that worker had checked to see or understand any previous engagements with Mental Health Services.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
2020 → 2023Corinne Haslam3 years 3 months after Gordon Fenton · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with sharing clinical information between different healthcare providers due to incompatible or unreliable record‑keeping systems. The earlier report focuses on poor record sharing between two specific trusts, while the later report notes a broader incompatibility between mental health and acute trust electronic records.
Gordon Fenton · 23 Apr 2020
“There does not appear to be a reliable and consistent method of sharing medical records and information between the two Trusts.”
Original on judiciary.uk ↗ Corinne Haslam · 21 Jul 2023
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems.”
Original on judiciary.uk ↗ Stated action in the response to the earlier report
“The joint SOP which is scheduled to be trialled in August 2020 will apply to all patients within PCFT's older peoples' mental health inpatient wards. Both organisations will continue to work in partnership to identify, agree and establish working parameters for the Digital Health Team at TGH to support the physical health needs of older people receiving mental health care and treatment on Summers & Hague wards, of which Mr [name redacted] was a patient. The offering of Digital Health services will be conducted”
2018 → 2023Corinne Haslam5 years 3 months after Adrian Jennings · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that incompatible electronic record systems hinder information sharing between mental health and physical health professionals.
Adrian Jennings · 19 Apr 2018
“The inquest heard evidence that the Mental Health Trust had not introduced one IT system across the Trust, which impacted on information sharing between professionals involved in his care;”
Original on judiciary.uk ↗ Corinne Haslam · 21 Jul 2023
“It is a matter of concern that Mental Health Trusts and Acute Trusts operate different (apparently incompatible) electronic records systems. The absence of such a unified records system creates obstacles as to the transfer of important clinical information between mental health and physical health specialists (and vice versa),”
Original on judiciary.uk ↗
Stated action · timescale: next two to three and a half years
“we recognise that there are challenges across the service in enabling secure record sharing and there are a number of steps being taken, fed by NHS England.”
Stated action · timescale: 2015
“We revised the Code of Practice in 2015 and set out guiding principles to ' hups://www.gov.uk/government/publications/code-of-practice-mental-health-act-1983 improve the care for patients.”
Stated action · timescale: process of investing
“The Tameside and Glossop Strategic Commissioning Board has recognised the need to develop and expand mental health support and is in the process of investing in additional services”
Stated action · timescale: end of February 2019
“We will develop a process and protocol for escalation to be used within the borough of Stockport by the end of February 2019.”
Stated action · timescale: end of February 2019
“Following review with the Lead Consultant [name redacted] the agreed target timescales for routine appointments is 12 weeks. Clear communication of the target timescales will form part of the action above.”
Stated action · timescale: end of February 2019
“Stockport borough will produce an escalation protocol for staff to use when there is disagreement regarding the need for a face to face appointment with a psychiatrist. This will be completed by the end of February 2019.”
Stated action · timescale: end of February 2019
“Pennine Care's alcohol liaison practitioners are moving to be based at Stepping Hill Hospital with the all age liaison mental health service and will form part of the same team which will significantly reduce the likelihood of any such concern arising again. The new model will be in place by the end of February 2019.”
Stated action · timescale: end of August 2020
“It is planned that his will go live at the end of August 2020”
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 Pennine Care NHS Trust 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 |
|---|---|---|---|---|
| 2018 → 2018 | 0.73 | 0.07 | Closely related · 0.90 | same |
| 2020 → 2023 | 0.79 | 0.04 | Closely related · 0.90 | different |
| 2018 → 2023 | 0.75 | 0.07 | Closely related · 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.