Incompatible IT systems block cross provider record access
Department of Health and Social Care received 7 coroners' reports about this hazard between 25 Jul 2018 and 24 Jan 2025.
They came from 5 different coroners in 5 coroner areas. A similar concern was raised again 6 times after the first warning.
A published response was found for 3 of the 6 earlier reports, stating 11 specific actions.
The story, report by report
Spacing grows with the time between reports.
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Original on judiciary.uk ↗ No published response from Department of Health and Social Care was found for this report.
- 11 months laterIdentical hazardConfidence 0.90 · high
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
Original on judiciary.uk ↗ Repeated from the earlier report:trustsmeantinformationdifficult
No published response from Department of Health and Social Care was found for this report.
- 2 years later
“it is not always possible for each healthcare provider to access the notes and records of the patient.”
Original on judiciary.uk ↗ Department of Health and Social Care responded, stating 3 specific actions.Response (PDF) ↗
“Through the national Shared Care Records programme, by September this year, we expect the majority of Integrated Care Systems (ICS's) to have a basic shared care record in place.”
Stated timescale: September 2021
Web search (Tavily): Evidence suggests the action was not carried out as stated
[Withdrawn] [Withdrawn] Data saves lives: reshaping health and social care with data (draft) - GOV.UK ↗“The aim is to have this largely in place by March 2023.”
Stated timescale: March 2023
Web search (Tavily): No evidence found either way
Shared Care Records And Digital Health Interoperability ↗1 more stated action in the Promises tab.
- 1 year 2 months laterClosely relatedConfidence 0.96 · high
“The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult.”
Original on judiciary.uk ↗ Repeated from the earlier report:systemsHospitalinformationdifficult
Department of Health and Social Care responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗
“the NHS is working tirelessly to reduce the backlog of planned treatment. In February 2022, the NHS published its Delivery Plan for Tackling the COVID-19 Backlog of Elective Care.' This plan sets out the action that will be taken and is already underway to support the healthcare system in England as it recovers from the disruption caused by the pandemic, as well as to deliver the necessary reforms that are important to the NHS's long-term future.”
Stated timescale: February 2022
Web search (Tavily): No evidence found either way
[PDF] Strategies to reduce waiting times for elective care - The King's Fund ↗“The Neurology service has always had more referral demand than capacity, our current capacity modelling reflects an approx. deficit of 1500 new patient slots per month. A comprehensive action plan detailing the steps being taken as a service to bring down the current waiting list to acceptable levels (attached) has been developed and the current situation is scoring highly on the trust risk register. (Copy attached).”
Web search (Tavily): No evidence found either way
Neuro must be prioritised in elective recovery as NHS waiting times remain high – The Neurological Alliance ↗ - 8 months laterClosely relatedConfidence 0.90 · higha different coroner
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him.”
Original on judiciary.uk ↗ Repeated from the earlier report:Trustsinformation
No published response from Department of Health and Social Care was found for this report.
- 5 months laterClosely relatedConfidence 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:transferinformationdifficult
Department of Health and Social Care responded, stating 6 specific actions.Response (PDF) ↗Response (PDF) ↗
“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.”
“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.”
4 more stated actions in the Promises tab.
- 1 year 4 months laterIdentical hazardConfidence 0.96 · higha different coroner
“the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other".”
Original on judiciary.uk ↗ Department of Health and Social Care responded.Response (PDF) ↗Response (PDF) ↗
- All reports to Department of Health and Social Care
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 → 2019Mason Logue11 months after Robert Wrinch · same coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that the absence of a unified/compatible IT system across NHS trusts hinders the sharing of patient information.
Robert Wrinch · 25 Jul 2018
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Original on judiciary.uk ↗ Mason Logue · 19 Jun 2019
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
Original on judiciary.uk ↗ 2018 → 2022Philip Jones4 years 1 month after Robert Wrinch · same coronerClosely relatedConfidence 0.96 · high
Closely relatedConfidence 0.96 · highBoth reports highlight that incompatible IT systems between hospitals hinder the transfer of patient information and second opinions. The earlier report focuses on pathology department systems, while the later report concerns district general and tertiary centre systems affecting broader patient data sharing.
Robert Wrinch · 25 Jul 2018
“The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
Original on judiciary.uk ↗ Philip Jones · 17 Aug 2022
“The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult.”
Original on judiciary.uk ↗ 2019 → 2022Philip Jones3 years 2 months after Mason Logue · same coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight problems with IT systems that hinder information sharing between healthcare providers. The earlier report cites a missing single IT system across NHS trusts, while the later report points to incompatible/different IT systems between a district general hospital and a tertiary centre.
Mason Logue · 19 Jun 2019
“lack of a single IT system across NHS trusts meant that information sharing was more difficult”
Original on judiciary.uk ↗ Philip Jones · 17 Aug 2022
“incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult”
Original on judiciary.uk ↗ 2019 → 2023Patrick Soames3 years 10 months after Mason Logue · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that fragmented information sharing across multiple NHS or agency units hinders a complete view of a patient's risk or needs. The earlier report cites missing a single IT system, while the later cites disparate geographic agencies preventing a unified picture.
Mason Logue · 19 Jun 2019
“The inquest heard evidence that the lack of a single IT system across NHS trusts meant that information sharing was more difficult.”
Original on judiciary.uk ↗ Patrick Soames · 18 Apr 2023
“5 NHS Trusts and 3 police forces in different geographic areas had contact with [the deceased] in the final month of his life and each thereby gained some information about the risk to him.”
Original on judiciary.uk ↗ 2018 → 2023Lauren Bridges (1)5 years 2 months after Robert Wrinch · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports highlight that incompatible or multiple IT systems hinder the transfer and sharing of clinical information between organisations. The earlier report focuses on pathology IT incompatibility between trusts, while the later report notes multiple software programmes preventing direct sharing.
Robert Wrinch · 25 Jul 2018
“. The I.T systems of the pathology department of the Trust and other hospital Trusts were incompatible with each other. This meant that transfer of information between trusts to obtain a second opinion were more difficult.”
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 ↗ 2022 → 2023Lauren Bridges (1)1 year 1 month after Philip Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that differing or multiple IT systems prevent easy sharing of clinical information between organisations. This creates barriers to communication and hampers coordinated patient care.
Philip Jones · 17 Aug 2022
“incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult”
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 ↗ 2021 → 2025Andrew Heys3 years 7 months after Brooke Martin · different coronerIdentical hazardConfidence 0.96 · high
Identical hazardConfidence 0.96 · highBoth reports highlight that NHS IT systems are not interoperable, preventing healthcare professionals from accessing patient records held elsewhere. The core concern is the lack of compatible systems that block cross‑provider record access.
Brooke Martin · 2 Jul 2021
“it is not always possible for each healthcare provider to access the notes and records of the patient.”
Original on judiciary.uk ↗ Andrew Heys · 24 Jan 2025
“the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other".”
Original on judiciary.uk ↗ 2022 → 2025Andrew Heys2 years 5 months after Philip Jones · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that incompatible IT systems prevent health professionals from accessing patient records across different trusts. The core issue is the lack of interoperability between systems.
Philip Jones · 17 Aug 2022
“The Inquest heard evidence that incompatible/different IT systems at the District General Hospital and Tertiary Centre made communication and information sharing in relation to patients more difficult.”
Original on judiciary.uk ↗ Andrew Heys · 24 Jan 2025
“the manager of the 111 Helpline agreed that the various IT systems do not”
Original on judiciary.uk ↗
No published response from Department of Health and Social Care was found for this report.
No published response from Department of Health and Social Care was found for this report.
Stated action · timescale: September 2021
“Through the national Shared Care Records programme, by September this year, we expect the majority of Integrated Care Systems (ICS's) to have a basic shared care record in place.”
What happened next: Evidence suggests the action was not carried out as stated
The Department of Health and Social Care announced that by September 2021, most Integrated Care Systems should have a basic shared care record in place. However, subsequent reporting indicates that only 37 of 42 systems had implemented such records, and the original draft strategy was later withdrawn and replaced.
“This draft strategy has been replaced by the final version, [Data saves lives: reshaping health and social care with data](https://www.gov.uk/government/publications/data-saves-lives-reshaping-health-and-social-care-with-data).”
“NHSX has revealed that 37 of 42 integrated care systems (ICSs) now have basic shared care records in place, meaning that five missed the”
Stated action · timescale: March 2023
“The aim is to have this largely in place by March 2023.”
What happened next: No evidence found either way
The Department of Health and Social Care did not specify a completion date for the shared care records initiative in the provided sources.
“At present your medical information exists in a unique record per healthcare organisation or provider you visit, be it your local GP, the pharmacy, a physiotherapist, or A&E. This means organisations need to request access to your existing information to build up a patient profile and your bigger health picture.”
“The Centers for Medicare & Medicaid Services July 30 [announced](https://www.cms.gov/newsroom/press-releases/white-house-tech-leaders-commit-create-patient-centric-healthcare-ecosystem) the creation of a "digital health ecosystem" that includes partnerships”
“HHS is advancing the Make America Healthy Again agenda by putting nutrition at the center of health. President Trump and Secretary Kennedy flipped the food pyramid to encourage Americans to Eat Real Food.”
No evidence found does not mean the action did not happen.
Stated action
“in the South East region, where electronic sharing of patient information is not yet possible, to support patient care each ICS has adopted a set of Continuity of Care Principles regarding the commissioning of acute and psychiatric intensive care out of area placements.”
What happened next: No evidence found either way
The Department of Health and Social Care has not publicly confirmed a specific commitment to implement continuity of care principles for out-of-area placements in the South East region.
No evidence found does not mean the action did not happen.
Stated action · timescale: February 2022
“the NHS is working tirelessly to reduce the backlog of planned treatment. In February 2022, the NHS published its Delivery Plan for Tackling the COVID-19 Backlog of Elective Care.' This plan sets out the action that will be taken and is already underway to support the healthcare system in England as it recovers from the disruption caused by the pandemic, as well as to deliver the necessary reforms that are important to the NHS's long-term future.”
What happened next: No evidence found either way
The NHS published a delivery plan in February 2022 outlining actions to reduce the elective care backlog.
“Strategies to reduce waiting times for elective care About this report i Strategies to reduce waiting times for elective care 5 1 2 3 4 6 About this report This report was funded by the National Institute for Health and Care Research (NIHR) Policy Research Programme (grant number NIHR200702) as part of the Partnership for Responsive Policy Analysis and Research (PREPARE) - a collaboration between”
No evidence found does not mean the action did not happen.
Stated action
“The Neurology service has always had more referral demand than capacity, our current capacity modelling reflects an approx. deficit of 1500 new patient slots per month. A comprehensive action plan detailing the steps being taken as a service to bring down the current waiting list to acceptable levels (attached) has been developed and the current situation is scoring highly on the trust risk register. (Copy attached).”
What happened next: No evidence found either way
The Department of Health and Social Care did not state a specific timeframe for reducing the neurology waiting list deficit.
“The Neurological Alliance is warning that people affected by neurological conditions are at risk of avoidable harm as they continue to face long delays for diagnosis and treatment unless neurology and neurosurgery are prioritised within national elective recovery plans, following the latest NHS waiting times data published today.”
No evidence found does not mean the action did not happen.
No published response from Department of Health and Social Care was found for this report.
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.
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 Department of Health and Social Care 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 → 2019 | 0.79 | 0.19 | Identical · 0.90 | same |
| 2018 → 2022 | 0.80 | 0.17 | Closely related · 0.96 | same |
| 2019 → 2022 | 0.83 | 0.19 | Closely related · 0.90 | same |
| 2019 → 2023 | 0.73 | 0.27 | Closely related · 0.90 | different |
| 2018 → 2023 | 0.79 | 0.18 | Closely related · 0.90 | different |
| 2022 → 2023 | 0.79 | 0.17 | Identical · 0.90 | different |
| 2021 → 2025 | 0.83 | 0.23 | Identical · 0.96 | different |
| 2022 → 2025 | 0.82 | 0.12 | 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.