Out of sight: why patchy NHS data sharing is now a policing problem

When three Metropolitan Police officers walked into a supported living facility in August 2023 to check on a man in mental health crisis, the information that mattered most — that a warrant already existed to take him to hospital — wasn’t visible to them.

It wasn’t visible to the ambulance crew that followed them, either, or to the NHS 111 doctor who later authorised leaving him on site for the night. Edward Muwanga died under a Central line tube train hours later.

A coroner’s Prevention of Future Deaths report names this gap — the inability of frontline responders to see a complete picture of a patient’s mental health record — as a standalone risk to life, distinct from the policing failures examined elsewhere in the companion article to this piece, Nobody asked about the warrant.

The PFD report draws on evidence from London Ambulance Service NHS Trust and South London and Maudsley NHS Foundation Trust (SLAM), Muwanga’s treating trust. An LAS representative told the coroner that “there remain challenges with the visibility of information from healthcare settings across London,” adding that progress depends on “the coordination of a complex healthcare system.”

Shared platforms

The trust’s Chief Medical Officer went further, telling the coroner there is “no single, comprehensive system that provides universal access to all patient records across NHS organisations” — with access shaped by information governance rules, system interoperability, commissioning arrangements, and how willing individual partner organisations are to upload data to shared platforms.

The coroner sent the report to NHS England, the OneLondon Board, London Ambulance Service NHS Trust and SLAM, finding each has a role in delivering integrated, accessible care records.

The interoperability gap matters to forces because national policy is moving in a direction that makes it matter more, not less. Right Care, Right Person — the model adopted by police forces across England to reduce inappropriate police involvement in mental health crisis response — depends on officers being able to make a fast, accurate read of whether a situation requires a police presence at all.

That judgement is harder, not easier, when the underlying clinical and legal information about a person is scattered across systems an officer has no way to query in real time.

Some forces have already formalised the expectation that officers should be checking this information before deciding how to act. Kent Police’s standard operating procedure for section 136 detentions instructs officers to establish, where possible, whether they can access medical records or a care plan to determine a person’s history and the right strategy for managing their crisis — before deciding whether use of section 136 powers is even appropriate.

The Muwanga case shows what happens when that step doesn’t happen and the officer doesn’t know how to make it happen: nobody asked, and nobody could point to where the answer was held.

New system

NHS England’s response to the interoperability problem at scale is the Single Patient Record programme, still in development, which it describes as built to be “interoperable by design” so that systems “work seamlessly together.”

The Health Foundation’s most recent review of electronic patient records across the NHS found that mismatched systems were the most commonly reported barrier to staff working effectively across organisational boundaries, and called for the Department of Health and Social Care and NHS England to treat interoperability as urgent groundwork for exactly this kind of programme.

None of that was in place for Muwanga in August 2023, and none of it is confirmed to be in place now. For police forces operating under Right Care, Right Person and similar models, the practical question raised by the coroner’s report is not abstract: when an officer is standing in a room deciding whether someone needs detaining, what can they actually find out, and how fast?

This article is a companion piece to our feature: Nobody asked about the warrant