A coroner has warned NHS bosses that delays to the availability of mental health assessments between different teams due to outdated IT systems could lead to future deaths.
Prof Paul Marks, senior coroner for Hull and East Riding, issued a prevention of future deaths report following an inquest into the death of John Kirkman, who took his own life.
Prof Marks said healthcare teams could encounter problems accessing "vital" information about patients as a result of incompatible computer programmes and this could lead to delays in care.
A spokesperson for NHS England expressed their "deepest sympathies" to Mr Kirkman's family and said the organisation would "carefully consider" the report.
The report, sent to the chief executive of NHS England, said the organisation should take action, "possibly by reviewing the compatibility of IT systems".
The document said Mr Kirkman, who was 36, had a long history of paranoid schizophrenia and took his own life on 27 December 2023.
During the inquest, the coroner said the evidence revealed matters that caused him concern.
Prof Marks said that if a mental health screening assessment was carried out in one part of the country, the results and conclusions may not be immediately available elsewhere when a further assessment is carried out, due to the use of different IT systems.
"Absence of vital background information could result in an incorrect prioritisation for onward referral, as it did in this case," he said.
The lack of availability of clinical information and data may "adversely influence subsequent assessments", he said.
Source: BBC News, 19 July 2025
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