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Recommendations Better explanation of why ethnicity data is being collected. Develop better knowledge of links between ethnicity and health. Ensure ethnic categories reflect the current communities. Develop consistency in approach for recording ethnicity. A role for communities to contribute to how ethnicity is defined and categorised.

The investigation found that misidentification of the patient, and limited access to critical information about the patient at the bedside delayed his treatment. The investigation identified factors that contributed to the event. These included: access to computer systems the display of information around the bed the sharing of information among staff to support familiarity with their patients. Findings Clinical staff are not always able to access accurate, critical patient information at bedsides to support decision making in emergencies. Patient identity wristbands are not consistently checked by staff during the undertaking of clinical tasks. The expectations of how staff should identify patients in an emergency and access critical information in relation to their care cannot always be met in practice because of limitations of technology and the work environment. Concerns around confidentiality can prevent the display of critical patient information at bedsides that may be needed to support safe care, particularly in emergencies. What and how critical patient information is displayed at the bedside varies across hospitals, with differences in positioning, visibility, readability and legibility. There is no national guidance to support consistency and visibility of critical patient information on low-technology displays (whiteboards/posters) or high-technology displays (via digital systems). Lighting on hospital wards can make it difficult for staff to see critical patient information, either through too little light, or too much light causing glare. Clinical staff consistently report difficulties accessing digital systems because of limited or poorly functioning hardware. This can result in the use of less reliable, paper-based systems for accessing critical patient information. Limited interoperability of multiple digital systems means critical patient information may not be accessible or consistent across all systems used in the care of a patient. Staff need to know which systems contain the information they need. Limited ability at a national level to influence the functionality of digital systems and their procurement means healthcare organisations are implementing systems with varying design and functionality. At the hospital level, the configuration of electronic patient record systems can introduce further safety risks where the infrastructure and staff training needs necessary for successful implementation have not been fully considered, and the needs of the clinical users have not been fully established. There is variation in the words and symbols used to indicate CPR recommendations, and in the level of understanding of CPR recommendations across hospitals, that may influence responses to cardiac arrests. Nursing handovers (where information about patients is passed between nursing staff at shift changes) may not provide the information staff need to care for their patients because of where and how they are undertaken. There is no national guidance on how best to undertake handovers of care. The implementation of electronic handover systems in clinical workplaces is limited by digital infrastructure, and systems that do not meet the needs of their users. Safety recommendations HSIB makes the following safety recommendations. Office of the National Data Guardian HSIB recommends that the Office of the National Data Guardian supports local interpretation of the Caldicott Principles to give organisations and staff the confidence to display full patient names at the bedside to support correct patient identification for safer care. NHS England HSIB recommends that NHS England develops guidance to providers, via any digital maturity assessments that are developed, to help ensure critical patient information (such as patient identifiers and cardiopulmonary resuscitation status) is available to clinical staff when accessing electronic patient record systems. HSIB recommends that NHS England provides guidance to healthcare organisations to support local design and configuration of electronic patient records to enable end users to access critical patient information (such as patient identifiers and cardiopulmonary resuscitation status). HSIB recommends that NHS England, during review of relevant Health Building Notes and Technical Memoranda, includes, as a consideration, that bedside patient information should be consistently visible. HSIB recommends that NHS England assesses the priority, feasibility, and impact of future research into what and how critical information pertaining to the emergency care of patients in the acute hospital setting can be readily and reliably accessed at a patient’s bedside. Resuscitation Council (UK) HSIB recommends that the Resuscitation Council UK clarifies and promotes expectations around the sharing, presentation, and language of cardiopulmonary resuscitation recommendations in hospital ward environments in line with the findings of this investigation. British Standards Institution (BSI) HSIB recommends that the British Standards Institution, with support from relevant stakeholders, provides symbology to standardise how information relating to a patient’s resuscitation status can be displayed in digital systems. Royal College of Nursing HSIB recommends that the Royal College of Nursing develops guidance for ward-based nursing handovers with consideration of the following: how handovers are organised, their content, the environment in which they take place and the technology needed to support them. Safety observations HSIB notes the following safety observations. It may be beneficial for healthcare organisations to provide guidance to support decisions in clinical areas that balance confidentiality and the visibility of critical patient information for patient safety. It may be beneficial for healthcare organisations to assess their information technology infrastructure needs, such as equipment availability and network coverage, to enable staff to consistently access critical patient information. It may be beneficial if the language used to refer to cardiopulmonary resuscitation recommendations is standardised and clarified through the implementation of the Recommended Summary Plan for Emergency Care and Treatment.

Key recommendations Positively engaging DSCR providers not currently on the assured provider list A standard to ensure the inclusion and consultation of end-users at every stage of the design, production, and implementation process of any new technology A new forum for social care providers, end users, and technology providers to discuss digital solutions for the sector A call for financial support for digital inclusion among people in receipt of adult social care services Mandatory digital training for staff

Brooke was admitted to Chadwick Lodge on 15 April 2019 and had been diagnosed with Emotionally Unstable Personality Disorder and Autism Spectrum Disorder; she initially failed to engage and was violent to staff and self-harming. By the middle of May 2019 she had made progress. On 5th June 2019 she was found with a ligature around her neck, which was suspended from the door of her room. Following this incident consideration should have been given to a formal risk assessment to include consideration of her level of observation. The details of the incident should have been fully disclosed to the MDT meeting on 6 June and consideration given to increasing the level of observation. The incident should also have been discussed and disclosed to all members of staff caring for her. On 10 June 2019 Brooke Martin was found secretly fiddling with a bedsheet on two occasions by two different members of staff.. The bedsheet should have been removed and examined, that would have shown that a section of the sheet had been torn off. This would and should have resulted in a full risk assessment and search of her room, that would have resulted in an increase in her level of observations to 1:1 observations. Brooke Martin, if constantly observed or other safety measures put in place would not have been able to tie the ligature that caused her death and would not therefore have died on 11t June 2019. Coroner's concerns During the course of the evidence it was explained to the coroner that it had not been possible to access the notes and records from an out of area hospital because not all the health providers were using “System One”. It is a major concern that the various systems used throughout the NHS are not compatible with each other and it is not always possible for each healthcare provider to access the notes and records of the patient. This situation should be reviewed to see how access across the NHS can be gained to patient records when required. The coroner was told by one senior clinician that when a patient is referred to his specialist mental health unit it is often the case, that is 9 times out of 10, he does not receive all the information of the patient’s history. This would not be the case if he had direct access to the records.

Key take home messages A patient's drug allergy status should be checked and updated at all patient contacts with healthcare professionals. Recording suspected drug allergy in the patient record requires a minimum degree of detail including the reaction, the drug given, the time-frame of the reaction from initiation of the drug, and what drugs or drug groups to avoid. Both adverse drug reactions and drug allergies should be documented in the electronic patient record, separately if possible but together if not, and should not be removed from the record without consideration of and the involvement from the patient in the decision to remove it. Drug allergy status should be recorded on all written communication regarding the patient between health care professionals.

This blog explains the benefits of enabling people to access their health records within primary care.

What will I learn? How to access your GP record How to access your summary care record How to access someone else's care record How to get your records changed

This booklet is for patients to download and use. It includes: My basic information Things you must know about me Things that are important to me My likes and dislikes This passport can be taken into any healthcare setting.