Glennis Connelly

Our ref: 

HM Coroner Andrew Barkley   
Coroners Chambers,  
Town Hall, Kingsway,  
Stoke-on-Trent,  
Staffordshire ST4 1HH  
By email: 

Dear Andrew,  

From Karin Smyth MP  
Minister of State for Health  

39 Victoria Street  
London  
SW1H 0EU 

25 July 2024 

Thank you for the Regulation 28 report of 31 May 2024 sent to the Department of Health 
and Social Care about the death of Ms. Glennis Connolly. I am replying as the Minister with 
responsibility for data in the NHS, on behalf of the Secretary of State for Health and Social 
Care.       

Firstly, I would like to say how saddened I was to read of the circumstances of Ms. Connolly’s 
death. I offer my sincere condolences to her family and loved ones. The circumstances your 
report describes are concerning and I am grateful to you for bringing these matters to the 
attention of myself and the Department. 

The report raises concerns over the fact that the Queens Hospital Burton Upon Trent and 
the  Royal  Derby  Hospital  have  different  electronic  patient  record  systems,  although 
governed by the same hospital trust. Entries made by the renal team at the Royal Derby 
Hospital  were  not  automatically  visible  to  medical  staff  at  the  Queens  Hospital,  and 
information on allergies did not automatically cross populate despite entries being made on 
the Lorenzo system and the GP records being updated.  

In preparing this response, Departmental officials have made enquiries with NHS England 
and the Care Quality Commission (CQC).  

As  you  may  be  aware,  NHS  England  has  been  supporting  NHS  Trusts  and  Foundation 
Trusts in acquiring and developing the effectiveness of their electronic patient records, with 
funding and support available to bring trusts to an optimum level of digital maturity.  

The Queens Hospital Burton Upon Trent and the Royal Derby Hospital had secured their 
own electronic patient records independently when they were governed by separate trusts. 
Following  their  organisational  merger,  University  Hospitals  of  Derby  and  Burton  NHS 
Foundation Trust undertook to connect data to ensure patients could be identified across 
the two systems and information appropriately shared to support effective care. The failure 
of information sharing in respect to Ms. Connelly’s treatment was clearly in part due to the 
challenge of still having two systems. The action needed to address this, which I am assured 
is  underway,  is  for  the  hospitals  to  move  to  convergence  and  the  Trust  to  have  a  single 

   
  
 
 
 
 
 
 
 
 
 
 
 
 
     
  
 
 
 
 electronic  patient  record  system  within  the  next  two  years.  A  provider  has  already  been 
identified. This is a clinically assured process, with NHS England clinicians scrutinising the 
plans and support provided, to ensure safe implementation, as required by the Information 
Standard DCB0160: Clinical Risk Management: its Application in the Deployment and Use 
of  Health  IT  Systems  (DCB0160:  Clinical  Risk  Management:  its  Application  in  the 
Deployment and Use of Health IT Systems - NHS England Digital).  

More  widely  within  the  NHS  the  One  Digital  Estate  programme  will  deliver  increasing 
electronic patient record convergence and connection between hospital provider systems, 
and its implementation will be subject to clinical quality assurance, both centrally, and in the 
local trusts which are required to have the appropriate leadership, governance and capacity 
to safely deliver.  

Where there is any death or serious injury at a provider or service registered by the CQC, 
the CQC will consider this in line with their specific incident guidance to identify if a patient 
has suffered avoidable harm or they were placed at significant risk of avoidable harm. This 
includes  when  there  are  issues  relating  to digital  systems,  and  a  specific  incident  review 
would consider the role of the system, as well as the registered providers involved.  

Since receiving this Regulation 28 Report, the CQC has followed its usual processes and 
has reached out to the Trust requesting information on this death, alongside any response 
the Trust issued to yourself as HM Coroner. This information will be used in the decision 
making when considering the matter as a specific incident and if any further actions need to 
be taken by the CQC. The CQC continue to monitor this Trust through its usual regulatory 
powers.   

I understand that the University Hospitals of Derby and Burton NHS Foundation Trust will 
be  separately  responding  to  the  report  and  commenting  on  specific  local  action  in  their 
response.  

I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely,    

KARIN SMYTH MP

LEGAL DEPARTMENT 

Our Ref:   
Your Ref: 

PRIVATE & CONFIDENTIAL 
Mr Andrew R Barkley 
HM Senior Coroner for Staffordshire 
& Stoke-on-Trent 
Date 
Stoke Town Hall 
Kingsway 
Staffordshire 
ST4 1HH 

26 July 2024 

Dear Sir 

Glennis Connelly: Regulation 28 Report Response 

I am writing in response to the Regulation 28 Report dated 31 May 2024, following 
the Inquest into Glennis Connelly's sad death.   

At the outset, and in the knowledge that her family will read this report, I want to first 
begin by reiterating the Trust's condolences and offering my own. I am deeply sorry 
for the errors made in the care we delivered.  

Scope 

Within your report, you identified the following concern: 

"Although the Queens Hospital Burton Upon Trent and the Royal Derby Hospital 
are  governed  by  the  same  hospital  trust,  they  have  different  electronic  patient 
records.  Entries  made  by  the  renal  team  at  the  Royal  Derby  Hospital  are  not 
automatically  visible  to  medical  staff  at  the  Queens  Hospital,  "allergies"  do  not 
automatically  cross  populate  despite  entries  being  made  on  the  Lorenzo  system 
and the GP records being updated on 6th & 12th February 2020." 

Event Summary 

The broad circumstances summarised were: 

• 
• 

In October 2016 Ms Connelly had Tazocin without noted issue.   
In  October  2019  Ms  Connelly  during  an  admission  for  pneumonia  it  was 
noted that she suffered a deterioration in kidney function with an impression 
of interstitial nephritis, but of uncertain cause. Tazocin was not identified as 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 • 

• 

the definitive cause at this stage and further investigations were initiated and 
her clinical condition improved.  
In  January  2020  Ms  Connelly  was  admitted  with  respiratory  problems, 
amongst  other  treatments,  received  Tazocin.  Due  to  her  renal  function 
deterioration she was escalated to the Trust's Derby site and with the benefit 
of  this  admission  and  the  repeat  association  with  Tazocin,  the  diagnosis  of 
Tubulo-Interstitial  Nephritis  (TIN)  due  to  an  underlying  Tazocin  allergy  was 
arrived  at.  The  GP  was  updated,  as  standard,  upon  discharge.  The  Derby 
site's electronic record system was also updated.  
In September 2022 Ms Connelly was admitted to the Trust's Burton site and, 
as  heard  at  inquest,  was  changed  to  a  prescription  of  Tazocin.  The  Burton 
system  did  not  have  the  recorded  Tazocin  allergy  and  the  Summary  Care 
Record (GP summary information) was not effectively interrogated.  

Trust Response 

At  the  time  of  the  incident  we  immediately  investigated  the  circumstances 
surrounding the death of Ms Connelly, culminating in a full patient safety review. This 
acknowledged that the Trust operates two electronic patient systems arising from the 
merger  of  the  two  organisations.  Our  actions  arising  from  this  and  our  wider 
considerations have included: 

1.  Electronic Patient Record systems ("EPR") 

Whilst  the  incident  was  multifactorial,  the  unification  of  the  EPR  systems  is 
something the Trust is working hard to remedy. As noted, the Trust currently has two 
enterprise  wide  systems  which  include  all  patient  administrative  and  clinical 
functionality, appointments,  waiting  lists,  test  results,  medications, emergency  care, 
maternity and clinical noting.  

Implementing an entirely new system is not a small undertaking. It is important to get 
this right for the five hospital sites now and into the future. These EPR systems are 
not created by the Trust, but rather bought under contracting arrangements with their 
associated contractual periods, support and shelf life. As was heard at inquest, it has 
not  been  possible  to  extend  one  of  the  existing  systems  to  the  whole  site  as  they 
need  to  function  effectively  across  all  specialisms.  In  the  case  of  one  system  it  is 
reaching  the  end  of  its  support  life.  Any  system  has  to  be  then  integrated  into  the 
wider Trust in a safe way, operating alongside our other systems. 

Pending implementation of a unified system, the Trust has created a Master Patient 
Index,  enabling  us  to  create  a  patient  context  link  from  each  EPR  to  the  other, 
meaning that staff would be able to click a link to be taken to a mobile version of the 
other  EPR/ eCasenote  systems  without  needing  to  log  in  or  search  for  the  patient 
again.  Similarly,  access  was  created  to  link  to  the  GP  surgery  held  Summary  Care 
Record (SCR). Patients have to agree to share their information on SCR in order for 
the information to be accessible. 

However,  acknowledging  the need  for  a  unified  system,  we  initiated  the  process  of 
identifying what the needs of the wider Trust would be now and into the future. This 
is  an  incredibly  large  and  complex  piece  of  work,  requiring  engagement  of  clinical 

 
 
 
 
 
 
 
 colleagues  from across  the  Trust.  Following initial  work  the  identify  needs,  the  plan 
was approved by the Trust Board and we went out to market.  

For  such  a  large  project,  this  required  significant  capital  investment  and  NHS 
England  were  also  at  the  time  embarking  on  a  programme  of  work  to  fund  EPR 
replacement systems nationally. Our competitive tender was published in April 2023, 
followed  by  supplier  demonstrations,  briefing  sessions,  engagement  sessions  and 
culminating in a decision in October 2023.  

This  whole  process  involved  130  clinicians  and  operational  staff  within  the 
procurement  process  and  then  also  required  secured  capital  investment  from  NHS 
England for £65million, granted on 27 March 2024. We signed the contract with our 
preferred provider on 16  April  2024  and now  have a  staged  implementation across 
the  Trust  over  the next  18  to  24 months,  which  has  already  commenced. We  have 
also liaised with other Trusts within the region as to their systems and the needs for 
the  future.  There  is  a  potential  additional  benefit  of  aligned  systems  aiding 
information sharing. 

Our  first  phase  of  the  rollout  is  planned  to  include  the  allergies,  sensitivities  and 
adverse reactions function.  

This  therefore  represents  a  Trust  wide  and  fundamental  change  in  the  way  our 
systems  operate.  It  requires  careful  implementation  to  ensure  the  safety  of  the 
immediate  changes  being  made,  allowing  people  to  learn  and  work  with  the  new 
system, but also provides us with an effective system for the future. It will enable us 
to  link  in  to  a  greater extent  with  regional health  sector  organisations and  will  drive 
forward wider system improvements for the future.  

2.  Pharmacy Reconciliation 

Acknowledging that a wholesale EPR change takes time to tender for, develop and 
implement,  we  have  sought  to  improve  our  interim  solutions.  We  already  have  a 
medicines  reconciliation  process,  but  arising  directly  from  Ms  Connelly's  case,  we 
implemented  a  specific  pharmacy  prompt  to  staff  to  compare  allergies,  sensitivities 
and adverse reactions with the GP SCR. Alongside our wider awareness raising, we 
hope  this  prompt  will  deliver  real  impact  arising  from  the  circumstances  of  this 
incident. 

We  also  plan to  audit against  the  wider  medicines  reconciliation  process  starting  in 
the next quarter and will be conducted every six months until such time that our new 
EPR  system  is  fully  implemented.  This  will  include  an  assessment  of  whether  the 
patient's  allergy  status  has  been  recorded  correctly.  The  medicines  reconciliation 
process includes checking both systems.  

3.  Trust wide shared learning 

The  Trust  is  large,  employing  over  14,000  people  through  a  variety  of  very  busy 
clinical  services.  However,  appreciating  that  incidents  can  occur  in  a  variety  of 
different  settings,  we  have  sought  to  drive  forward  wider  learning  across  the 
organisation. These steps included: 

 
 
 
 
 
 
 
 
 
 •  An article specific to Ms Connelly's case was written and posted on the Trust's 
intranet  page.  This  is  available  across  all  sites,  all  divisions  and  all 
specialities. 

•  We  published  the  learning  article  through  the  all-staff  bulletin  sent  out  Trust 

wide. 

•  Our Medical Director sent out a bulletin to the whole medical workforce. 
•  We developed a screen saver, shown on every computer screen in the Trust.  
•  We developed a desktop banner highlighting the importance of the Summary 
Care Record and confirming allergy status. This is shown on every computer 
screen in the Trust. 

•  Discussed  the  incident  at  the  Trust's  leadership  meeting,  highlighting  the 

importance of obtaining information directly from the GP systems.  

•  Case  discussion  at  the  Divisional  Day  agenda  with  a  presentation  on 

"discordant allergy recording on two electronic patient records" 

4.  Setting up an allergy working group 

An  allergy  working  group  was  set  up  which  is  made  up  of  clinical  and  non-clinical 
digital staff, alongside the Chief Nursing Informatics Officer, Pharmacy, and the Trust 
Improvement  Team.  Their  objective  is  to  ensure  robust  systems  are  in  place  to 
manage allergies and alerts.  

5.  Medical clerking changes 

Medical clerking is an important initial step on a patient journey through the hospital 
and  represents  a  key  opportunity  to  capture  relevant  clinical  history.  We  would 
always  ask  a  patient  about  relevant  history,  including  allergy  information  but 
analysing Ms Connelly's case we felt that this is a better opportunity to check allergy 
information,  rather  than  expecting  a  doctor  to  read  all  available  information  on  the 
system or external systems during a busy ward round. As such we added a prompt 
to both EPRs to each clerking forms to prompt the user to check the patient's SCR. 
All assessing clinicians are expected to check this regardless of the patient provided 
information.  

To support in the delivery of this we have reviewed and amended the training scripts 
for both EPRs, specifically referencing that the two systems do not automatically talk 
to one another.  

We have also implemented a new quick reference guide covering how the SCR can 
be accessed and includes a link to NHSE information and eLearning/Assessment via 
the new NCRS section on the Digital Services Hub.  

6.  Allergy card for TIN 

The Renal team have already developed alert cards to be given to patients who have 
Tubulointerstitial  Nephritis  (TIN)  because  of  a  known  allergy  to  a  medication.  The 
patient can carry this alert card to alert clinicians involved in their care of the adverse 
reaction they have experienced to certain medications. 

 
 
 
 
 
 
 
 
 
 We  acknowledge  that working  on  two  different  EPRs  is  not  how  we  wish  to  deliver 
our services. We have worked hard to deliver on an entirely new system, including a 
£65million investment covering all sites. This will take time to implement safely but in 
the  meantime  we  have  sought  to  mitigate  the  risk  with  the  efforts  above.  We  hope 
that this provides assurance that we are doing all we can pending implementation of 
the new EPR.  

Yours sincerely 

Executive Chief Medical Officer 
University Hospitals of Derby and Burton