Inaccessible patient information in SystmOne
Central and North West London NHS Foundation Trust received 3 coroners' reports about this hazard between 19 Feb 2014 and 21 Feb 2020.
They came from 3 different coroners in 3 coroner areas. A similar concern was raised again 2 times after the first warning.
A published response was found for 1 of the 2 earlier reports, stating 10 specific actions.
The story, report by report
Spacing grows with the time between reports.
“There are issues of poor communication which need to be addressed. I acknowledge that even the most detailed communication in this instance may not have averted Mr McAndrews' actions and subsequent death.”
Original on judiciary.uk ↗ No published response from Central and North West London NHS Foundation Trust was found for this report.
- 3 years 5 months laterClosely relatedConfidence 0.80 · moderatea different coroner
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'”
Original on judiciary.uk ↗ Central and North West London NHS Foundation Trust responded, stating 10 specific actions.Response (PDF) ↗Response (PDF) ↗
“psychiatric reports. Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to , Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re- issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has”
Stated timescale: July 2017
“The ACCT document is currently being redesigned with a view to its nationwide re- introduction in early 2018. As part of this redesign, we will consider your suggestion that a summary sheet of ACCT observations and conversations be included”
Stated timescale: early 2018
8 more stated actions in the Promises tab.
- 2 years 7 months laterIdentical hazardConfidence 0.90 · higha different coroner
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
Original on judiciary.uk ↗ Central and North West London NHS Foundation Trust responded.Response (PDF) ↗
- All reports to Central and North West London NHS Foundation 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.
2014 → 2017Sarah Reed3 years 5 months after Simon McAndrew · different coronerClosely relatedConfidence 0.80 · moderate
Closely relatedConfidence 0.80 · moderateBoth reports highlight that important clinical information is recorded electronically but not accessible to all relevant staff who need it. The earlier case concerns missing cross‑trust access to psychiatric records; the later case concerns prison officers unable to view observations entered in SystemOne.
Simon McAndrew · 19 Feb 2014
“better method must surely be devised to ensure that key clinical staff can access important information held electronically in a different NHS Trust”
Original on judiciary.uk ↗ Sarah Reed · 28 Jul 2017
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'”
Original on judiciary.uk ↗ 2017 → 2020Andrew Goldstraw2 years 7 months after Sarah Reed · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports highlight that the SystmOne computer system does not make critical patient information readily available to staff who need it. This lack of accessible information contributed to missed risk assessments and potential harm.
Sarah Reed · 28 Jul 2017
“The jury also found the system of some members of the multi-disciplinary team recording observations which were not accessible to all other members of the team to be 'detrimental'.”
Original on judiciary.uk ↗ Andrew Goldstraw · 21 Feb 2020
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
Original on judiciary.uk ↗ 2014 → 2020Andrew Goldstraw6 years after Simon McAndrew · different coronerClosely relatedConfidence 0.85 · high
Closely relatedConfidence 0.85 · highBoth reports highlight problems with the Trust's computer systems preventing effective retrieval and sharing of critical patient information. The earlier report cites poor communication across different databases, while the later report describes difficulties accessing relevant mental health history within SystmOne.
Simon McAndrew · 19 Feb 2014
“There are issues of poor communication which need to be addressed. I acknowledge that even the most detailed communication in this instance may not have averted Mr McAndrews' actions and subsequent death.”
Original on judiciary.uk ↗ Andrew Goldstraw · 21 Feb 2020
“SystmOne makes it difficult for a doctor or mental health nurse to ascertain the key information needed to undertake a risk assessment and to decide whether or not to open an ACCT.”
Original on judiciary.uk ↗
No published response from Central and North West London NHS Foundation Trust was found for this report.
Stated action · timescale: July 2017
“psychiatric reports. Work to review the procedures for obtaining and providing psychiatric reports is already underway, recognising the particular gap in relation to provision of reports for the purposes of fitness to plead. Following your letter to , Chief Executive HMCTS, I can confirm that in July 2017 HMCTS and the Judicial Office re- issued existing guidance from 2010 on this process, with the caveat that it is recognised that some information may be out of date. The Senior Presiding Judge has”
Stated action · timescale: early 2018
“The ACCT document is currently being redesigned with a view to its nationwide re- introduction in early 2018. As part of this redesign, we will consider your suggestion that a summary sheet of ACCT observations and conversations be included”
Stated action · timescale: July 2017
“learning bulletin (ACCT - Case Reviews, CAREMAPs and Levels of Conversations and Observations) was issued to all prisons in July this year. The bulletin reminded staff that ACCT review meetings must be multidisciplinary and must take place within the specified timescales. It further stated that that where any individual involved in the prisoner's management cannot attend the review, they must submit written contributions”
Stated action · timescale: summer 2018
“The PSI also states that unconvicted prisoners, such as [the deceased], must be allowed more frequent visits, and that establishments with a large number of unconvicted prisoners will require a more flexible system to enable rebooking of cancelled visits.”
Stated action
“Our service specification 'Manage the Custodial and Post Release Periods' is clear that all individuals in custody must have a resettlement plan and that the offender manager must ensure that external agencies are notified of a prisoner's release. All prisons are expected to adhere to this specification, but I know that it is not fully in place across the estate, and we are currently implementing a new model of offender management in custody.”
Stated action
“We have had a discussion with HMPPS who have agreed to provide a response regarding the procedure for cancelling visits.”
Stated action
“Procedures that any requests for reports are communicated to the Consultant as soon as they are received; this includes instructions from the Court, defence solicitors, Crown Prosecution Service and/or any other relevant external agencies including Probation Services.”
Stated action
“CNWL Offender Care has developed its own bespoke training for the management of harm and suicide in prison environments. This training forms part of our mandatory training list and is retaken annually by all staff. Across Offender Care, we are currently 94% compliant with this requirement.”
Stated action · timescale: 1 October 2017
“CNWL Offender Care has produced prison specific guidance highlighting these requirements which has been disseminated to all prison sites regarding expectations around CPA management, for comment. We expect this to be formally ratified as a new policy by 1 October 2017.”
Stated action · timescale: 1 October 2017
“A new discharge policy -”
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 Central and North West London NHS Foundation 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 |
|---|---|---|---|---|
| 2014 → 2017 | 0.72 | 0.04 | Closely related · 0.80 | different |
| 2017 → 2020 | 0.69 | 0.05 | Identical · 0.90 | different |
| 2014 → 2020 | 0.65 | 0.06 | Closely related · 0.85 | 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.