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recurance

Rachelle Ross

17 Feb 2023 · Coroner Carly Henley · Newcastle upon Tyne and North Tyneside

The coroner's concerns

  1. 1. lack of automatic flag for non-responder smear test patients

    “During the course of the inquest I heard evidence from GP [name redacted] at the Collingwood Health Group who [REDACTED] informed me that GP practice records do not include an alert from EMIS or System 1 IT systems to provide an automatic flag on a patient's GP medical records if they are classed as a non-responder for a smear test by the National Screening Service.”
  2. 2. delayed detection of cervical cancer

    “The alert system is only triggered after a patient attends a smear test. For a non-responder, they go back into the three or five year waiting list for a National Screening invitation for a smear test.”
  3. 3. manual warning entry variability

    “An automatic flag or alert when a patient fails to attend for a smear test as part of the National Screening Service, would mean that a GP surgery would not have to manually add a warning as an entry onto an individual's GP records. It would standardise the approach across all GP surgeries and could increase patient safety.”

Responses

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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.

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