Coroners in England and Wales have issued 36 warnings this year over inadequate sharing of NHS patient information, with some patients dying because clinicians couldn’t access important details about their needs.
Problems caused by conflicting IT systems, restricted access to medical records and obstacles to sharing information outside the NHS mean staff often struggle to access details about the patients they are treating.
In one case, a three-year-old boy died of streptococcal infection after contracting chicken pox. An NHS 111 adviser was unaware of the child’s Down’s Syndrome, which greatly increased his clinical vulnerability. As a result, the adviser did not tell the child’s mother to take him to hospital immediately. The boy became unresponsive and died the next day.
In a Prevention of Future Deaths report, the coroner wrote that “had the health adviser been aware of the diagnosis, [the child] would have been assessed by a clinician during the evening of the 30 May 2023. Had this happened, [his] death would have been avoided”.
In another case, an 11-year-old died because key information wasn’t communicated when he was handed over by under-pressure staff from ambulance to A&E. The IT systems used by the ambulance and hospital trusts were not directly compatible, so clinical information had to be transferred verbally and some details were missed out.
In a third case, mental health staff did not know why a patient had been taken to A&E, as her digital patient information was unavailable. They discharged her instead of detaining her under the Mental Health Act. She killed herself the next morning.
The warnings reinforce the need for better information-sharing in the NHS. Labour has announced plans to store each NHS patient’s health data in one place, and for patient records to be made readily available via standardised information systems across the NHS. The plans apply to England, with health mostly devolved in the rest of the UK.
Health secretary Wes Streeting said: “No patient should lose their life in 2024 because different parts of the NHS can’t share information. This is why we desperately need to modernise our health service.
“The budget provided an extra £2bn to arm NHS staff with modern technology, including digital patient records. Through our 10-year plan we will deliver a single patient record on the NHS app, so clinicians have the full picture of the patient they are treating. I am determined that we drag our analogue health service into the digital age, which will be better for patients and make the health service more efficient.”
A Welsh government spokesperson said: “We have provided over £300m to support digital change in NHS Wales over the last five years.”
But privacy campaigners are concerned that Labour’s plans threaten patient confidentiality. “The new central care record will have all the written notes from your GP accessible wherever the NHS logo is seen,” said Sam Smith, coordinator at medConfidential, which campaigns to protect medical confidentiality. “That’s necessary for A&E to work to save lives, but also risks a stalkers’ paradise.”
He pointed to two recent cases where doctors accessed the medical records of their ex-boyfriends’ new partners, and called for patients to be able to see in the NHS app “when and where records were snooped on”.
Aside from the cases where inadequate sharing of information led to patients dying, there have been 38 cases this year where coroners have flagged concerns about incomplete or incorrect information being inputted into patient records systems.
