Alix Knowles

Emma Serrano  
Acting Senior Coroner for Staffordshire  
HM Coroner’s Court & Chambers 
Stoke Town Hall 
Kingsway 
Stoke-on-Trent 
ST4 1HH 

By email: 

Dear Emma Serrano, 

Trust Headquarters 
St George's Hospital  
Corporation Street 
Stafford ST16 3SR 

www.mpft.nhs.uk 

29th November 2024 

Regulation 28 Report to Prevent Future Deaths regarding the death of Miss Alix Elizabeth Knowles.   

I am writing to you on behalf of Midlands Partnership University Foundation NHS Trust (“MPFT”) in response to your 
Prevention of Future Deaths report dated 2 October 2024, following the inquest touching the death of Miss Alix 
Elizabeth Knowles.   

At the outset I would like to express my sincere condolences on behalf of MPFT to Miss Knowle’s family and friends. 

This letter is MPFT’s formal response to your PFD report. 

1.  Bank Staff are not able to access patient notes before assessments; 

It is accepted that at the time of Miss Knowle’s death bank members of staff did not have access to University 
Hospitals of Derby and Burton NHS Foundation Trust’s (“UHDB”) Emergency Department notes, but if there was a 
bank member of staff on duty, they were always with a permanent member of the Mental Health Liaison  team 
who could facilitate access. MPFT Liaison staff would also routinely contact the patients local Mental Health team 
as part of their assessment to determine if there was any current or previous Mental Health involvement. 

Following this inquest, several meetings have taken place between MPFT and UHDB to consider the most efficient 
way for bank staff to obtain access to patient notes. As a result of these meetings, it has been agreed that a list of 
all liaison bank staff and Crisis Home Treatment staff have been provided to UHDB who will allow them access to 
their patient notes system V6. A joint Standard Operating Procedure for the ‘Referral Process to Liaison Psychiatry 
Team and Crisis Resolution and Home Treatment Team for patients 16 years old and over within the Emergency 
Department’ has also been developed to outline the referral process for all staff.  

2.  Different NHS Trusts are unable to access patient notes, because the computer systems used do not allow this. 
While MPFT recognises this as an ongoing issue, we work closely with other trusts to ensure we have processes 
and safeguards in place to allow staff to access patient notes when required. We are unable to comment on the 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 NHS Nationally but locally, we are actively working with other trusts to ensure staff have access to the records they 
need to deliver effective and safe patient care.  

We wish to assure you and Miss Knowle’s family that the actions described above are being taken forward with 
considerate attention.  

Yours sincerely 

Chief Executive 
Midlands Partnership University NHS Foundation Trust

Ms Emma Serrano 
Acting Senior Coroner  
Stoke-on-Trent and North Staffordshire  
Coroner’s Service 
Stoke Town Hall  
Kingsway  
Stone-on-Trent 
ST4 1HH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

3 March 2025  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Alix Elizabeth Knowles 
who died on 9 December 2023 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
October  2024  concerning  the  death  of  Alix  on  9  December  2023.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Alix’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner  that  the  concerns  raised  about  Alix’s  care  have  been 
listened to and reflected upon.   

The  first  concern  raised  in  your  Report  was  that  bank  staff  are  not  able  to  access 
patient  notes  before  assessments.  Individual  healthcare  providers  determine  the 
access levels that different members of staff have to different parts of their electronic 
patient records systems. This decision will be in line with each Trust’s access policy 
and  risk  assessment,  and  is  determined  solely  by  individual  healthcare  providers.  I 
note that you have also addressed your Report to Derby and Burton Hospital (Royal 
Derby Hospital) and Royal Stoke University Hospital and refer you to their responses 
on this matter.  

Your second concern raised that different NHS Trusts are unable to access patient 
notes because the different computer systems in use do not allow this.  

NHS Trusts are at differing levels of digital maturity regarding their Electronic Patient 
Records (EPR) system capabilities, with some having legacy systems that are not able 
to  transmit  information  between  systems  in  line  with  today's  standards  and 
expectations.  

As a response to this, NHS England set up the Frontline Digitisation Programme (FLD) 
in  2021  and  has  been  supporting  NHS  and  Foundation  Trusts  in  acquiring  modern 
EPR systems and helping them develop their system’s effectiveness once deployed. 
The FLD programme comes with substantial financial and specialist IT support to bring 
all Trusts to an optimum level of digital maturity.  

The  next  phase  of  optimising  digitisation  in  England  is  for  the  FLD  programme  to 
support  increased  EPR  convergence  across  Integrated  Care  Boards  (ICBs). 

                                                                                                                       
 
 
 
 
 
 
 
  
 
  
 Implementation of this will be subject to assurance by Trust Boards collectively, which 
are required to have the appropriate leadership, governance and capacity for their safe 
delivery.  

For  information,  local  healthcare  providers  make  the  decision  on  which  Electronic 
Patient Records (EPR) system to procure and deploy, and their decision may apply to 
either a single NHS organisation or across multiple NHS organisations within a single 
Integrated Care System (ICS) where convergence of EPR systems across an ICB or 
ICS is seen as the most beneficial model. These decisions are based on many factors 
including the required functionality, a system’s suitability for the service specialities on 
offer, user experience, cost, and ease of information sharing. Today, there are already 
many  examples  where  EPR  records  are  shared  seamlessly  between  provider 
organisations to enhance care provision.  

However,  there  remain  multiple  reasons  as  to  why  information  may  not  be  openly 
accessible or shared with other healthcare providers. For example, this could be due 
to incompatibility between the version of the systems being used thus not enabling full 
data sharing, permission not being granted between organisations to share data due 
to  concerns  about  data  security  or  sensitivity  of  the  material  or  not  having  patient 
permission to share data.   

Patient  handover  and  referral  are  two  processes  that  are  central  to  care  and  are 
expected to be effective regardless of the availability of digital records.  

I  would  also  like  to  provide  further  assurances  on  the  national  NHS  England  work 
taking  place around  the  Reports  to  Prevent Future  Deaths.  All  reports  received  are 
discussed  by  the  Regulation  28  Working  Group,  comprising  Regional  Medical 
Directors,  and  other  clinical  and  quality  colleagues  from  across  the  regions.  This 
ensures that key learnings and insights around events, such as the sad death of Alix, 
are shared across the NHS at both a national and regional level and helps us to pay 
close attention to any emerging trends that may require further review and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

National Medical Director

LEGAL DEPARTMENT 

PRIVATE & CONFIDENTIAL 
Miss Emma Serrano 
HM Coroner for Staffordshire & Stoke-
on-Trent 
Stoke Town Hall 
Date 
Kingsway 
Staffordshire 
ST4 1HH 

18 November 2024 

Dear Madam 

Alix Knowles: Regulation 28 Report Response 

I  am  writing  in  response  to  the  Regulation  28  Report  dated  2  October  2024,  following  the 
Inquest into Alix Knowles' death. The Regulation 28 report was addressed to NHS England, 
Midlands  Partnership  University  NHS  Foundation  Trust  (MPFT)  and  University  Hospitals  of 
Derby and Burton NHS Foundation Trust (UHDB).   

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.  

We  have  taken  these  concerns  seriously  and  have  considered  whether  there  are  any 
improvements we can make at UHDB. In order to support this, discussion has taken place 
between MPFT and UHDB.  

Scope 

Within your report, you identified the following concerns: 

1.  Bank Staff are not able to access patient notes before assessments; 

2.  Different  NHS  Trusts  are  unable  to  access  patient  notes,  because  the  computer 

systems used do not allow this. 

Trust Response 

["MPFT"] Bank Staff are not able to access patient notes before assessments 

Liaison Psychiatry is provided by MPFT and the team work in the Emergency Department of 
the  Queen's  Hospital  in  Burton  on  Trent.  Their  role  is  to  assess  and  plan  interventions 
needed for people in the Emergency Department who present with mental health problems.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 Access  to  Meditech  V6,  the  electronic  patient  record  that  is  used  at  Queen's  Hospital,  is 
provided  to  staff  within  the  Liaison  Psychiatry  team  at  MPFT,  allowing  them  to  review  our 
Emergency Department records and to make their own records onto the system. Access is 
granted at MPFT's request.  

As  was  confirmed  by  MPFT  in  court,  their  substantive  staff  in  Liaison  Psychiatry  do  have 
access to Meditech V6 records at UHDB, and they have subsequently confirmed that long-
term bank staff also have access to Meditech V6. The issue that arose in this case is that the 
individual  MPFT  bank  nurse  from  the  Liaison  Psychiatry  team  did  not  have  access  to  the 
Meditech V6 records as UHDB had not been notified of the need for access on this occasion 
and therefore UHDB were not aware of until after Miss Knowles' death. As we heard during 
the  inquest  hearing,  MPFT  explained  that  they  mitigate  the  risk  of  bank  staff  not  having 
access to Meditech V6 by always ensuring that they are on shift with a member of staff who 
does  have  access.  The  bank  nurse  confirmed  in  her  evidence  that  the  Meditech  V6  notes 
were accessed by a colleague from MPFT Liaison Psychiatry team on the night in question.  

If  it  had  been  communicated  to  UHDB  at  the  time  that  the  bank  staff  member  from  MPFT 
could  not  access  Meditech  V6,  Emergency  Department  staff  could  have  shown  the  bank 
staff  member  themselves,  printed  a  copy  out  on  request,  or  with  sufficient  notice,  have 
arranged emergency IT access for them using the same processes we have in place when 
using  agency  or  bank  staff  at  UHDB.  We  have  re-iterated  to  MPFT  that  these  are  options 
available  to  them  if  emergency  access  is  required,  and  to  formalise  this,  we  are  in  the 
process of developing a written standard operating procedure for both organisations.  

We are also working together with MPFT to arrange access to Meditech V6 for any of their 
current short term bank staff in the Liaison Psychiatry team who do not already have access.  

Different  NHS  Trusts  are  unable  to  access  patient  notes,  because  the  computer  systems 
used do not allow this. 

Across  the  NHS  in  England  there  are  health  and  care  services  using  different  clinical 
systems  that  do  not  interact  with  each  other,  and  it  is  accepted  that  there  is  a  need  for 
interoperability across the system. This is a national issue whose feasibility is being looked 
at as part of the long-term plan for the NHS. Given the broader context that applies and the 
complexities around digital infrastructure and transformation, we are unable to comment any 
further  on  this,  except  to  say  that  we  recognise  the  importance  of  effective  information 
sharing between organisations. It is for this reason that we arrange access where possible 
and  having  sharing  protocols  in  place  as  described  above.  The  focus  of  our  response  is 
therefore on the post death review processes that took place and access to Miss Knowles' 
medical  records  for these  purposes,  which  is the  context  for  which  the  Coroner's  concerns 
arose.  

UHDB  seeks  input  and  shares  outcomes  of  investigations  with  all  external  providers  that 
have  been  involved  or  contributed  to  an  investigation.  This  is  a  standard  practice  in  the 
Trust.  Conversely,  if  an  external  provider  is  conducting  an  investigation  that  requires  input 
from  UHDB,  it  is  our  standard  practice  to  actively  participate  and  share  information  where 
this  is  requested.  We  understand  from  our  recent  discussions  with  MPFT  that  their 
processes have now changed, so we hope that provides assurance that such information will 
be shared as standard practice in the future.   

Yours sincerely 

 
 
 
 
 
 
 Executive Chief Medical Officer 
University Hospitals of Derby and Burton