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recurance

Lack of electronic medical records sharing across trusts

Closely relatedConfidence 0.90 · high5 reports · 2021–2025No published response to an earlier report One-page brief (print or PDF)

NHS England received 5 coroners' reports about this hazard between 26 Nov 2021 and 22 Oct 2025.

They came from 5 different coroners in 5 coroner areas. A similar concern was raised again 4 times after the first warning.

A published response was found for 4 of the 4 earlier reports, stating 2 specific actions.

5
reports
5
different coroners
2021–2025
years
0.90
lowest link confidence

The story, report by report

Spacing grows with the time between reports.

  1. First warning

    Felicity Clough↗

    26 Nov 2021 · Rachael Griffin · Dorset

    “There are different systems used by healthcare trusts across England and Wales for holding patients records and information.”
    Original on judiciary.uk ↗

    NHS England responded.Response (PDF) ↗

  2. 1 year 10 months later

    Raised again · 1st time

    Jack Farrington↗

    14 Sept 2023 · Robert Simpson · Hampshire, Portsmouth and Southampton

    “there is no systems or arrangements for the sharing of access to electronic medical records (such as SystmOne and RIO) outside of local areas”
    Original on judiciary.uk ↗
  3. 10 months later

    Raised again · 2nd time

    Judith Obholzer↗

    12 Jul 2024 · Ellie Oakley · Inner West London

    “ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.”
    Original on judiciary.uk ↗

    NHS England responded, stating 2 specific actions.Response (PDF) ↗Response (PDF) ↗

    “The National Care Records Service (NCRS) is the successor to the Summary Care Record application (SCRa) and by design removes a large amount of the reported barriers to adoption within many care settings including the private sector.”

    Web search (Tavily): No evidence found either way

    National Care Records Service ↗
    “we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment”

    Web search (Tavily): Evidence found that the action was carried out

    'Government must now set a more ambitious goal': We ... ↗
  4. 3 months later

    Raised again · 3rd time

    Alix Knowles↗

    2 Oct 2024 · Emma Serrano · Staffordshire

    Identical hazardConfidence 0.95 · higha different coroner
    “Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
    Original on judiciary.uk ↗

    Repeated from the earlier report:DifferentTrustssystemsused

  5. 1 year 1 month later

    Raised again · 4th time

    Amy Cross↗

    22 Oct 2025 · Peter Harrowing · Avon

    Closely relatedConfidence 0.92 · higha different coroner
    “There is no standard medical records system which can be accessed by each healthcare organisation to ensure the efficient and effective transfer of medical information.”
    Original on judiciary.uk ↗

    NHS England responded.Response (PDF) ↗

  6. All reports to NHS England

Next

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.

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Source: Prevention of Future Deaths reports and responses published by the Courts and Tribunals Judiciary at judiciary.uk. Crown copyright, used under the Open Government Licence v3.0. Data updated 26 Oct 2026.

A link shows that a similar concern was raised again, not why. It is not a finding about any organisation or person. Methodology and responsible use · Report an error