Lack of electronic medical records sharing across trusts
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.
The story, report by report
Spacing grows with the time between reports.
“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) ↗
- 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 ↗ NHS England responded.Response (PDF) ↗Response (PDF) ↗
- 10 months later
“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 ... ↗ - 3 months laterIdentical 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
NHS England responded.Response (PDF) ↗Response (PDF) ↗Response (PDF) ↗
- 1 year 1 month laterClosely 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) ↗
- 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.
2021 → 2024Alix Knowles2 years 10 months after Felicity Clough · different coronerIdentical hazardConfidence 0.95 · high
Identical hazardConfidence 0.95 · highBoth reports highlight that separate NHS Trust computer systems prevent sharing of patient records, risking inadequate care.
Felicity Clough · 26 Nov 2021
“There are different systems used by healthcare trusts across England and Wales for holding patients records and information.”
Original on judiciary.uk ↗ Alix Knowles · 2 Oct 2024
“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
Original on judiciary.uk ↗ 2023 → 2024Alix Knowles1 year 1 month after Jack Farrington · different coronerClosely relatedConfidence 0.90 · high
Closely relatedConfidence 0.90 · highBoth reports describe that clinicians cannot obtain patient records because existing systems do not support sharing across trusts or regions. The earlier report cites missing national sharing arrangements and limited CHIE data, while the later report notes that differing computer systems block note access between NHS Trusts.
Jack Farrington · 14 Sept 2023
“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 ↗ Alix Knowles · 2 Oct 2024
“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
Original on judiciary.uk ↗ 2024 → 2025Amy Cross1 year 3 months after Judith Obholzer · different coronerClosely relatedConfidence 0.92 · high
Closely relatedConfidence 0.92 · highBoth reports highlight the absence of a system that enables medical information to be shared between different healthcare providers. The earlier report focuses on private‑NHS note sharing, while the later report calls for a universal standard system for transferring medical data across organisations.
Judith Obholzer · 12 Jul 2024
“ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.”
Original on judiciary.uk ↗ Amy Cross · 22 Oct 2025
“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 ↗ 2023 → 2025Amy Cross2 years 1 month after Jack Farrington · different coronerIdentical hazardConfidence 0.90 · high
Identical hazardConfidence 0.90 · highBoth reports describe the lack of a unified system that allows healthcare organisations to access patient records across different settings. This gap prevents timely sharing of vital clinical information.
Jack Farrington · 14 Sept 2023
“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 ↗ Amy Cross · 22 Oct 2025
“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 ↗
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.
Stated action
“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.”
What happened next: No evidence found either way
The National Care Records Service is described as a successor to the Summary Care Record and aims to improve communication across services.
“Improve communication across services. Use shared information to support multidisciplinary working and escalation between teams. How to access this service.”
No evidence found does not mean the action did not happen.
Stated action
“we will recruit an additional 8,500 mental health workers to reduce delays and provide faster treatment”
What happened next: Evidence found that the action was carried out
The organisation announced it has recruited 8,500 additional mental health workers, meeting its target ahead of schedule.
“The government has announced it has [recruited 8,500 additional mental health workers”
“We've hit our target of recruiting 8,500 more mental health workers in the NHS, three years ahead of schedule”
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.
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 |
|---|---|---|---|---|
| 2021 → 2024 | 0.86 | 0.18 | Identical · 0.95 | different |
| 2023 → 2024 | 0.77 | 0.13 | Closely related · 0.90 | different |
| 2024 → 2025 | 0.77 | 0.13 | Closely related · 0.92 | different |
| 2023 → 2025 | 0.79 | 0.16 | Identical · 0.90 | different |
Judge model: nvidia/nemotron-3-super-120b-a12b. How Nemotron did the work · Full methodology.
Drafted by Nemotron 3 Ultra and reviewed by a person before publication.
Between 2021 and 2025, five Prevention of Future Deaths reports raised the hazard of inaccessible patient records across NHS trusts and care settings. The 2021 report warned that different trusts use incompatible systems, making vital information unavailable to other trusts, and recommended national record access. No published NHS England response was found. A similar concern was raised again in 2023, where evidence showed no arrangements for sharing electronic records outside local areas, the National Record Locator only flagged record holders without granting clinician access, and out-of-hours access was impossible. No published NHS England response was found. In 2024, a coroner confirmed no sharing of notes between private practitioners and NHS providers and no access to GP details for private clinicians. No published NHS England response was found. Later in 2024, a coroner reported bank staff and different NHS trusts could not access notes due to incompatible computer systems. No published NHS England response was found.
Questions a coroner might ask
- What national infrastructure has been implemented since 2021 to enable clinicians to view patient records held by other trusts in real time?
- How does the National Record Locator currently function, and what steps are being taken to move it from a record-flagging tool to a record-access tool?
- What technical and governance barriers prevent the interoperability of systems such as SystmOne and RIO across trust boundaries?
- How is urgent out-of-hours access to records from other trusts or private providers guaranteed when local administrative staff are unavailable?
- What standards now require private practitioners and NHS providers to share notes and GP contact details, and how is compliance monitored?
- What mechanism ensures that healthcare information follows a patient moving between police, court, and prison healthcare providers?
Next
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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.