John Johnson

Parliamentary Under-Secretary of State for 
Health Innovation and Safety 

39 Victoria Street 
London 
SW1H 0EU 

HM Coroner James Thompson 
Gateshead and South Tyneside 

06 March 2026 

Dear Mr Johnson,  

Thank you for the Regulation 28 report of 06/05/2025 sent to the Department of Health and 
Social  Care  about  the  death  of  John  James  Johnson.  I  am  replying  as  the  Parliamentary 
Under-Secretary of State with responsibility for data and technology, and I apologise for the 
delay in doing so.       

Firstly, I would like to say how saddened I was to read of the circumstances of John Johnson’s 
death, and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. Please accept my sincere apologies for the delay in responding to this matter. 
Thank you for the additional time provided to the department to provide a response to the 
concerns raised in the report. 

The report raises concerns over multiple IT systems being used not just in one, but many 
NHS  Trusts  which  makes  it  a  matter  of  concern  on  a  national  scale  as  significant  patient 
information  may  be  overlooked  switching  between  different  clinical  systems  as  well  as 
slowing down clinical decision making which makes it more difficult to follow a patient’s overall 
care. 

In preparing this response, my officials have made enquiries with NHS England and the Care 
Quality Commission (CQC) to ensure we adequately address your concerns. 

NHS England Response: 

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6th May 2025 
concerning the death of John James Johnson on 22nd November 2023.  

 
 
 
 
 
 
 
 
 
 
  
  
  
 
 
 
 
 
 In advance of responding to the specific concerns raised in your report, I would like to express 
my deep condolences to John James Johnson family and loved ones. NHS England are keen 
to assure the family and yourself that the concerns raised have been listened to and reflected 
upon. Your concerns are as follows:  

1.  The hospital trust operates a variety of IT systems to document a patient's stay whilst 
in  hospital.  There  is  not  one  system  which  contained  all  the  information  generated 
during a patient’s stay. This requires clinical users to switch between systems to gather 
all the necessary information which raises the potential risk of significant findings being 
overlooked. This slows down clinical decision making and makes it more difficult to 
follow a patient's overall care.  

2.  The X Ray report was returned to a department not then involved in his care. The use 
of multiple systems can create a risk around safe transfers of care for discharge or 
handover.  

3.  This issue is not confined to one individual trust, and the use of multiple systems is 
widespread across the National Health Service. Their use is well known to the national 
NHS responsible bodies.  

4.  Your  concerns  are  not  confined  to  the  operations  of  one  NHS  Trust,  as  this  risk 

appears to present nationally.  

Queen  Elizabeth II  Hospital is managed by Gateshead  Health  NHS  Foundation  Trust and 
uses System C Medway EPR system (System C Healthcare Ltd) which was first deployed in 
2012 and was found to meet the core standards of the Frontline Digitisation (FD) Programme. 
Gateshead Health NHS Foundation Trust subsequently received further funding through the 
FD Programme to support greater optimisation of its Electronic Patient Record (EPR).  

Queen  Elizabeth  II  Gateshead  have  used  Philips  Picture  Archiving  and  Communication 
System  (PACS) a  Radiology  information  system  (RIS) since 2014  which  is integrated  into 
their  EPR  thus  any  flags/notes  applied  to  abnormal  result  in  RIS  are  visible  across 
departments using RIS and the EPR.  

The Frontline Digitisation (FD) Programme enables provider organisations to procure EPR 
systems  and  provides  guidance on  their  implementation  to  enhance  local digital capability 
and  interoperability,  including  the  ability  of  different  digital  systems  to  communicate  more 
effectively. However, these systems are typically configured and managed locally, in line with 
agreements  between  provider  organisations  and  their  technology  suppliers.  As  a  result, 
interoperability  often  varies  depending  on  local  infrastructure  and  information  governance 
arrangements.  

Where multiple digital systems, including EPR systems and RIS system are in use across a 
provider  organisation,  policies  and  procedures  should  be  in  place  to  outline  expectations, 
advice, clinical record management, and handover of abnormal results to relevant individuals. 
Responsibility and accountability for the sharing of information held within electronic records, 
including across different systems, rests with each organisation through its established digital 
governance processes.  

 
 
 
 
 
 
 
 
 
 
 NHS England (NHSE) recognises that delayed information-sharing within and between care 
settings  can  contribute  to  delays  in  discharge,  incomplete  handovers,  and  less  effective 
continuity of care. NHSE has developed and led the Frontline Digitisation (FD) Programme, 
which  has  supported  provider  organisations  to  adopt  Electronic  Patient  Record  (EPR) 
systems which support increased consistency in digital maturity but also improve information 
sharing within and between organisations.  

The FD Programme not only enables organisations to purchase EPRs but also advises on 
safe and effective deployment. However, whilst the FD Programme supports investment into 
local digital capabilities, interoperability i.e. how different digital systems communicate with 
one  another,  is  typically  configured  and  managed  at  a  local  level,  based  on  local 
arrangements between provider organisations (although regional centres will be cognisant of 
the wider catchment area) and their technology suppliers. As such, interoperability may vary 
depending  on  local  infrastructure  and  information  governance  arrangements.  Access  and 
information  contained  within  the  Gateshead  Health  NHS  FT  record  is  determined  by  local 
policy and procedures.  

All trusts have to use multiple systems which follow agreed technology standards for timely 
management  of  patient  data  and  have  mechanisms  to  manage  multiple  systems.  For 
example:  

Unified Integration Engines - Rather than connecting every system individually, trusts use 
a  Trust  Integration  Engine  (TIE).  This  acts  as  a  central  hub  that  translates  data  between 
different technologies (like blood test results and patient records) using messaging protocols 
such as HL7 and FHIR.  

Adoption  of  Interoperability  Standards  - To  ensure  systems  from  different  vendors can 
"speak the same language," the NHS mandates specific standards i.e.  
Data  Standards:  Use  SNOMED  CT  for  clinical  terminology  and  NHS  Numbers  as  the 
universal patient identifier.  

Communication Protocols: Rely on APIs (Application Programming Interfaces) to allow real-
time data sharing between separate platforms.  

Interoperability Toolkit (ITK): Are a set of national frameworks that provide developers with 
common specifications for system interaction.  

The newly published Fit for the future: 10 Year Plan for England, sets out the government’s 
plan for healthcare in England over the next 10 years, which includes a commitment to give 
patients  ‘a  single  patient  record  (SPR)  –  to  enable  more  coordinated,  personalised  and 
predictive care.’ However rather than build a SPR record from scratch, a likely solution may 
include even better interoperability between the many systems in operation as NHS England 
is  aware  of  the  challenge  in  sharing  medical  records  and  results  within  and  between  all 
organisations  (including  social  care  and  commissioned  organisations)  that  use  different 
technologies. 

 
 
 
 
 
 
 
 
 
 
 
 
 CQC Response: 

The Trust submitted Mr Johnson’s death at the time as an incident in StEIS. Unfortunately, 
due  to  organisational  and  personnel  changes  CQC  are  unable  to  confirm  whether  it  was 
discussed at the time with the Trust. 

In relation to the matters of concern: 

•  The Trust was using a variety of IT systems to document a patient’s stay in hospital. It 
required  clinical  users  to  switch  between  systems  to  gather  all  the  necessary 
information. 

CQC also understand that the use of multiple systems impacting safe transfers of care is a 
national issue. 

•  Mr Johnson’s X-Ray was returned to a department not then involved in his care. 

Following a fall, Mr Johnson presented to A&E in April 2022. The ED clinician requested a 
chest X-ray, where a suspicious mass in the lung was identified. This finding was flagged in 
the report comments, and with a red alert marker. The report was returned to the ED clinician; 
however Mr Johnson was by then under the care of the orthopaedic team. The ED clinician 
assumed the red alert was related to a fracture, and not suspected cancer. The orthopaedic 
department were not informed of the results, and Mr Johnson was not alerted or placed into 
the lung cancer pathway. The IT system did not allow the test result to be shared with multiple 
clinicians or different departments at the same time. 

The Trust identified the failure to follow up the X-ray outcome with Mr Johnson and his family 
as a significant incident and subsequently followed the patient safety incident review process. 

The Trust has undertaken work to make the multiple systems it uses as safe and effective as 
possible. 

As part of a QI rapid process improvement group, the Trust developed a Standard Operating 
Procedure  (SOP)  which  specifies  how  clinicians  should  handle  results,  for  example,  they 
should not be filed without recommended actions being completed. Additionally, the picture 
archiving  and  communication  system  has  been  upgraded,  removing  previous  risks  to  the 
system. The Trust also conducted wider digital and quality improvements between 2022 and 
2023. 

CQC will continue to monitor the Trust’s arrangements for ensuring diagnostic test results 
are  shared  with  the  right  departments,  and  to  prevent  red  flag  warnings  being  missed  in 
future. CQC will also share the learning internally with our National Professional Advisors for 
Urgent and Emergency Care to ensure that the UEC inspection methodology includes these 
arrangements.’ 

 
 
 
  
  
  
  
 
  
  
  
  
 
 
 
 Department of Health and Social Care: 

I agree that ensuring health and care professionals have access to a single source of digital 
information about the patients they are treating and caring for is vitally important to 
delivering the best care possible. The Department of Health and Social Care, and NHS 
England have programmes of work underway which should assist in preventing future 
deaths connected to this issue. 

The Single Patient Record (SPR) will unify patient data from multiple sources into one easy-
to-access platform for patients and clinicians. The SPR will bring together fragmented 
pieces of information, creating a single source of truth which improves care quality, reduces 
administrative burden, empowers patients and enables more effective use of health data for 
both care delivery and research. A single source of patient information will ensure that 
clinicians are able to view a patient’s test results and diagnostic activity among other patient 
alerts, which will prevent important patient information from being missed by clinicians. 

The SPR is designed to harmonise with existing data systems being used by healthcare 
professionals which will allow them to access the SPR through their existing clinical 
systems. Seamless data sharing through the SPR will significantly reduce administrative 
burden for clinicians. The Government’s 10 Year Health Plan specifically commits to saving 
NHS staff an estimated 140,000 hours annually. This will free up valuable clinical time for 
clinicians to focus on direct patient care. 

In addition to the SPR being a source for clinicians to access a patient’s medical information 
in one place, the Data (Use and Access) Act 2025 builds upon the changes made in the 
Health and Social Care Act 2022 to enable improved integration between different IT 
systems across the NHS. The interoperability enabled by the changes in the Act would 
make it easier for all healthcare professionals delivering care to access accurate and 
complete information when they need it. These information standards will help ensure that 
patient data recorded across multiple IT systems are easy to read for clinicians and that no 
vital patient information is missed. 

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

Yours sincerely, 

Parliamentary Under-Secretary of State  
for Health Innovation and Safety