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recurance

Judith Obholzer

12 Jul 2024 · Coroner Ellie Oakley · Inner West London

This report repeats 1 earlier warning, and was raised again 1 time later. See the linked reports.

The coroner's concerns

  1. 1. insufficient NHS mental health capacity

    “significant pressure on NHS mental health services”
  2. 2. fragmented medical information prevents coordinated care

    “no sharing of medical notes between private practitioners and NHS providers”

Linked reports

Repeats an earlier warningShannon Quinn6 Sept 2019 · 4 years 10 months earlier
Identical hazardConfidence 0.90 · high

Earlier report

“Evidence emerged during the inquest that there was inconsistent sharing of documentation and case notes between the statutory agencies and private sector.”
Original on judiciary.uk ↗

This report

“In the course of the evidence it was confirmed that there is no sharing of medical notes between private practitioners and NHS providers.”
Full chain: Inconsistent sharing of medical notes between agencies
Raised again laterAmy Cross22 Oct 2025 · 1 year 3 months later
Closely relatedConfidence 0.92 · high

This report

“ensuring a process that allows private practitioners to arrange crisis support through the NHS directly.”

Later report

“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 ↗
Full chain: Lack of electronic medical records sharing across trusts

Responses

2024-0377-Response-from-DHSC.pdf ↗· Department of Health and Social Care

Stated action

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

2024-0377-Response-from-NHS-England.pdf ↗· NHS England

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.”

2024-0377-Response-from-SW-London-Mental-Health-Trust.pdf ↗· South West London and St George's Mental Health NHS Trust

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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