Recurance · prevention of future deaths reports
Pre-inquest brief
The earlier warning
Robert Wrinch · 25 Jul 2018 · Alison Mutch, Manchester (South)
“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.”
judiciary.uk/prevention-of-future-death-reports/robert-wrinch
What was promised
Stated action 1 · response to Brooke Martin (2 Jul 2021) · stated 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.”
judiciary.uk/…/2021-0299-Response-from-Department-of-Health-and…
Stated action 2 · response to Brooke Martin (2 Jul 2021) · stated timescale: March 2023
“The aim is to have this largely in place by March 2023.”
judiciary.uk/…/2021-0299-Response-from-Department-of-Health-and…
Stated action 3 · response to Brooke Martin (2 Jul 2021) · stated timescale: none stated
“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.”
judiciary.uk/…/2021-0299-Response-from-Department-of-Health-and…
8 further stated actions are listed on the full chain page.
What recurred
- 19 Jun 2019 · Mason Logue · Alison Mutch · Identical hazard · confidence 0.90 (high)
- 2 Jul 2021 · Brooke Martin · Tom Osborne
- 17 Aug 2022 · Philip Jones · Alison Mutch · Closely related · confidence 0.96 (high)
- 18 Apr 2023 · Patrick Soames · Edmund Gritt · Closely related · confidence 0.90 (high)
- 19 Sept 2023 · Lauren Bridges (1) · Andrew Bridgman · Closely related · confidence 0.90 (high)
- 24 Jan 2025 · Andrew Heys · John Pollard · Identical hazard · confidence 0.96 (high)
The clearest link, quoted from both reports:
Earlier · Brooke Martin · 2 Jul 2021
“it is not always possible for each healthcare provider to access the notes and records of the patient.”
Later · Andrew Heys · 24 Jan 2025
“the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other".”
What happened next
A source suggests the action was not carried out as stated · stated action 1
“This draft strategy has been replaced by the final version, [Data saves lives: reshaping health and social care with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).”
[Withdrawn] [Withdrawn] Data saves lives: reshaping health and social care with data (draft) - GOV.UK · gov.uk/…/data-saves-lives-reshaping-health-and-social-care-with…
“NHSX has revealed that 37 of 42 integrated care systems (ICSs) now have basic shared care records in place, meaning that five missed the”
NHSX confirms 37 of 42 ICSs have shared care records · healthcareitnews.com/…/nhsx-confirms-37-42-icss-have-shared-car…
No evidence found either way · stated action 2
“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.”
Shared Care Records And Digital Health Interoperability · theaccessgroup.com/…/hsc-shared-care-records-and-digital-health…
“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”
CMS announces new interoperability initiative | AHA News · aha.org/…/2025-07-30-cms-announces-new-interoperability-initiat…
“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.”
TEFCA™, America’s National Interoperability Network, Reaches Nearly 500 Million Health Records Exchanged as HHS Leverages Technology and AI to Lower Costs and Reduce Burden | HHS.gov · hhs.gov/…/tefca-americas-national-interoperability-network-reac…
No evidence found does not mean the action did not happen.
No evidence found either way · stated action 3
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.
No evidence found either way · stated action: “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.”
“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”
[PDF] Strategies to reduce waiting times for elective care - The King's Fund · assets.kingsfund.org.uk/…/strategies_reduce_waiting_times_2022.…
No evidence found does not mean the action did not happen.
No evidence found either way · 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).”
“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.”
Neuro must be prioritised in elective recovery as NHS waiting times remain high – The Neurological Alliance · neural.org.uk/…/neuro-must-be-prioritised-in-elective-recovery-…
No evidence found does not mean the action did not happen.