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What investigators keep finding
The Health Services Safety Investigations Body (HSSIB) has looked at this pattern from several angles. Its thematic review of electronic patient record systems identified a recurring scenario behind patient harm: someone needed information to deliver care, and either the system did not make it available to them, or they could not find it.
A July 2025 HSSIB investigation into hospital discharge reached a related conclusion. Systems that do not connect within and across providers make it more likely that information is lost, delayed or missed.
HSSIB's September 2026 report on mental health crisis care in emergency departments went further. Poor information sharing between IT systems meant that emergency department and liaison psychiatry staff could not always access or share risk history, crisis plans, safeguarding information and recent assessments.
Those settings are NHS emergency departments, not independent hospitals. The mechanism applies wherever a patient moves between teams: the information sits in one place, the decision happens in another.
Why independent providers sit close to this risk
Independent providers work at the junction of several care pathways. Many care for patients commissioned by the NHS or by local authorities, so patients arrive from, and return to, teams that run other systems. A provider with more than one site may also hold records in more than one way.
Each handover between those systems is a point where a risk assessment, an allergy or a change to a care plan can fail to travel with the patient.
The case for the way things are
Healthcare teams cope, and many cope well. A phone call to the community team, a handwritten handover sheet and a spreadsheet of review dates all exist because clinicians care about getting it right. The sector's record reflects that care. The Independent Healthcare Providers Network (IHPN) reports that 94% of its member locations in England that the CQC has rated are good or outstanding.
The weakness lies in what those workarounds depend on: someone has to remember to ring, the sheet has to be current, the experienced nurse has to be on shift. Safety that rests on individual effort holds until the night with two agency staff and three admissions.
A smaller provider may not need a large platform. The test still applies to every provider, whatever its size: can the right person see the right information at the moment of decision?
Five questions, and what good looks like
Take these five questions to your next governance meeting. Each question has a standard to aim for and a check you can run this month with patients and staff.
| Number | Question | What good looks like | How to check |
| 1 | At two in the morning, can the nurse in charge see a patient's risk assessment, current medication and crisis plan without leaving the screen or making a call? | One screen shows all three. Nobody needs to phone another team or find a paper copy. | Pick a current patient. Ask a night-shift nurse to find all three items and time them. Run it at night, not on a weekday morning. |
| 2 | When a patient transfers in, which parts of their record arrive as structured information, and which arrive as a PDF or a phone conversation? | Risk, medication, allergies and care plan arrive as structured information in the record. Nobody retypes them from a document. | Take your last five admissions. For each, mark every item that someone entered by hand from a letter, PDF or call. |
| 3 | After an incident, how long does it take to build the full timeline, and how many systems does it draw on? | One source produces the timeline in minutes. The reviewer does not chase other teams for entries. | Take a recent incident. Count the systems used and the hours the timeline took. |
| 4 | When a care plan changes, how many places need updating, and who checks that they all match? | One update is visible wherever the care plan is used. Nobody keeps a second copy in step. | Change a test care plan entry. Count the places that show it, and how long until they match. |
| 5 | Can you show an inspector or commissioner, from the record itself, how a risk was identified, escalated and reviewed? | The record shows each step, with who acted and when. The quality team does not rebuild the story from emails and notes. | Pick one risk from last quarter. Ask someone outside the team to follow the trail from the record alone. |
If your team answers any of these with "it depends who is on", the record is relying on people to do the work a system should do.
Three ways to close the gap
A gap in one or two of those checks does not mean you need a new system. Providers usually take one of three routes.
1. Tighten the handover process
Standardise the admission checklist, name one person responsible for collecting information before the patient arrives, and use a fixed handover template across shifts.
Enough when: you run a single site, take few transfers, and receive patients from only one or two source teams. A better process often fixes checks 1 and 2 at that scale.
Where it strains: the process still depends on people remembering. It’s enough for a normal shift but slips on the night with agency staff. Information stays in separate places, so checks 3 and 4 do not improve.
2. Connect the systems you already have
Add interfaces or shared-record links between the systems you run today, so key items such as medication and allergies move between them without retyping.
Enough when: your current systems work well, and the gaps sit in a few specific data items that you can name.
Where it strains: an interface moves only the data it was built to move. Each link needs maintaining, and a supplier update can break it. The more systems you run, the more links you carry, and the more places an incident timeline has to draw from.
3. Move to a single record solution
Hold risk assessments, care plans, medication and observations in one record. A clinician updates information once and every colleague sees it. The night nurse reads the same risk history as the consultant who wrote it. After an incident, the timeline comes from one source instead of four.
Enough when: you fail most of the five checks, run several sites, or work across many commissioner pathways, so the gap sits in the record itself.
Where it strains: a move takes real work. Data has to migrate, clinicians have to learn a new way of working, and the team loses time during the change. If only one check fails, this route is usually more than you need.
How to choose
Run the five checks first. One failure usually points to a process fix. Failures across most of the five suggest the problem sits in how the record is held, and that is where a single record solution earns its place.
No route guarantees an inspection outcome, and the provider remains responsible for regulatory compliance. What each route can do is give clinicians the information they need at the bedside and give quality teams the evidence to meet that responsibility.
Every admission, transfer and discharge asks your systems the same question: does the record follow the patient? At The Access Group, we stand on that principle. Access Rio EPR gives independent healthcare organisations a complete patient record that supports safer, more compliant care, on an EPR trusted across the healthcare sector.
