Skip to content
recurance

Alix Knowles

2 Oct 2024 · Coroner Emma Serrano · Staffordshire

This report repeats 2 earlier warnings. See the linked reports.

The coroner's concerns

  1. 1. lack of access to patient notes before assessments

    “Bank Staff are not able to access patient notes before assessments”
  2. 2. lack of inter‑trust patient note access

    “Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this”

Linked reports

Repeats an earlier warningFelicity Clough26 Nov 2021 · 2 years 10 months earlier
Identical hazardConfidence 0.95 · high

Earlier report

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

This report

“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
Full chain: Lack of electronic medical records sharing across trusts
Repeats an earlier warningJack Farrington14 Sept 2023 · 1 year 1 month earlier
Closely relatedConfidence 0.90 · high

Earlier report

“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 ↗

This report

“Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this.”
Full chain: Lack of electronic medical records sharing across trusts

Responses

  • Built with
  • NVIDIA Nemotron Nano, Super and Ultra
  • Nebius Token Factory inference
  • Qwen3 Embedding 8B on Token Factory
  • Tavily follow-up web search
  • Postgres and pgvector search
  • Next.js site

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