Internal Reference Number: FOI_9463
Date Request Received: 16/06/2026 00:00:00
Date Request Replied To: 02/07/2026 00:00:00
This response was sent via: By Email
Request Summary: Governance and oversight of information tools used within clinical or operational services maintaine
Request Category: Private Individuals
| Question Number 1: I am conducting independent research into the governance of information tools used within clinical or operational services across NHS provider Trusts. "For the purposes of this request, 'locally developed or maintained information tools used within clinical or operational services' means any spreadsheet, database, document, shared drive folder, whiteboard, paper-based tracker, printed patient list, or other digital or non-digital tool that contains patient-identifiable or service-level information and is created or maintained by clinical or operational staff outside the Trust's formally managed IT systems and record-keeping processes (such as the EPR, PAS, or other centrally supported applications). It does not need to contain patient identifiable data to be included, it just needs to be in use within clinical or operational services. Has the Trust completed an audit or survey of locally developed or maintained information tools used within clinical or operational services in the last three years? If so, please provide the date of the most recent audit and a summary of its scope and principal findings. If no such audit has been completed, please confirm this. | |
| Answer To Question 1: The Trust holds an Information Asset Register that covers, systems, databases, spreadsheets etc. Audits are conducted annually if considered a critical system and every 2nd year if non critical. Any actions or findings are dealt with on an asset by asset basis. | |
| Question Number 2: Does the Trust's Board Assurance Framework or Corporate Risk Register currently include a risk entry relating to the use of clinical or operational information held outside the Trust's formally managed IT systems? If so, please provide the risk detail in full. If no such risk entry exists, please confirm this. | |
| Answer To Question 2: The BAF does not have this risk but when specific risks arise they are dealt with on a case by case basis. | |
| Question Number 3: How many incidents (e.g. Serious Incidents, Patient Safety Incidents, data breaches, or formal complaints) in the last three years had a root cause or contributing factor related to the accuracy, availability, security, or governance of information held outside the Trust's formally managed IT systems? If the Trust does not categorise or record incidents in a way that would allow this question to be answered without a manual review of individual records, just confirm this rather than attempting the search. | |
| Answer To Question 3: Datix does not categorise or recorded incidents in a way that would allow this question to be answered without a manual review of individual records as we don鈥檛 have a separate field that is this specific | |
| Question Number 4: Which role(s) within the Trust has designated responsibility for the oversight and governance of information tools used within clinical or operational services that sit outside the Trust's formally managed IT systems? Please provide the job title and directorate. If no role has designated responsibility, please confirm this. If disclosing the job title would identify a specific individual, please provide the directorate and pay band instead. | |
| Answer To Question 4: SIRO - Senior Information Risk Officer holds the responsibility. They sit across the BSW under Informatics | |
| Question Number 5: Has the Trust issued a current policy or guidance to staff regarding the creation, use, and governance of locally developed information tools used within clinical or operational services as defined above? If so, please provide a copy or a link to the published version. If no such policy exists, please confirm this | |
| Answer To Question 5: There is no specific single policy that covers this. | |
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