“During the inquest I heard evidence from the Senior Quality Manager for Coroner Services…”

The coroner’s concerns

– During the inquest I heard evidence from the Senior Quality Manager for Coroner Services at the East Midlands Ambulance Service NHS Trust (“EMAS”). She explained that some Integrated Care Boards had introduced a scheme whereby a mental health nurse would accompany a paramedic in a car and in appropriate cases would be dispatched to a patient for the purposes of meeting both their physical and mental health needs. The NHS Northamptonshire Integrated Care Board (“the Northamptonshire ICB”) did not adopt this scheme. Instead, the Northamptonshire ICB have introduced a mental health nurse located within the Emergency Operations Centres (“the EOC”) for the purpose of providing advice and, in appropriate cases, despatch from the EOC. I was told that members of EMAS have access to General Practitioner records held on SystmOne. EMAS does not have access to mental health records. In respect of Leicestershire, Lincolnshire and Nottinghamshire those records are held on a system called RiO. In respect of Northamptonshire and Derbyshire those records are held on SystmOne. I was told that there was no technical reason why EMAS staff (especially the mental health nurse located in the EOS) could not access a patient’s mental health records if held on SystmOne. There are such technical reasons why EMAS staff do not have access to RiO (an entirely different database). A data sharing agreement is likely to be needed as may a particular patient’s consent. I am concerned that notwithstanding the recognition of the desirability for specialist mental health input, those mental health professionals within the EOC do not presently have access to records which may have been produced by the community mental health team. That is notwithstanding that the principal database used by the provider of community mental health treatment in Northamptonshire (the Northamptonshire Healthcare NHS Foundation Trust) is one to which EMAS does presently have access. Such information may be relevant to, for example, whether the patient has a history of suicidal ideation or attempts. That information may in turn be material to the triage and dispatch of ambulance resources.

An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.

Source

judiciary.uk, Prevention of Future Deaths reports, 2024-0337

Added to Minute Book

8 Oct 2026

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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0