Dear Madam

I write in response to your Regulation 28 report and your covering letter dated 09.02.2024, setting out your concerns after hearing evidence at the Inquest touching on the death of Susan Mary Young.

I would like to begin by extending my sincere condolences to Mrs Young’s family. This must have been an extremely difficult time for them, and I hope that my response provides them and you with some assurances that NHS Sussex has taken some action to address the issues set out in your Regulation 28 report.

Your matters of concern below have been reviewed and NHS Sussex response is also outlined below.

HM Coroner’s concerns The possible toxicity from the Co-codamol tablets was not considered by the ambulance crew who attended to Mrs Young following a 999 call. The ambulance service was not aware that Mrs Young had recently been prescribed Co-codamol as the ambulance service does not currently have access to GP records. There was a short period of time in which Naloxone antidote could have been given and evidence was heard from the expert at the inquest that if the toxicity had been recognised earlier and if Naloxone was administered there was a good chance that Mrs Young would have survived. As the ambulance service did not have the GP records readily available to them this meant that there was a missed opportunity to treat Mrs Young appropriately. The response We have investigated the concerns raised by HM Coroner with the GP practice concerned (the Practice). As we are commissioners of primary care in Sussex, we can only intervene in this case in respect of issues that affect patient safety as a consequence of concerns about the GP practice.

The NHS Sussex Digital team reviewed information for the GP practice where Mrs Young was registered as a patient in order to find out what technology and what systems they use for sharing their records with other healthcare providers. They advised that the two programmes used by the Practice for sharing GP records are SCR (the summary care record) and GP connect. SCRs are an electronic record of important patient information, created from GP medical records. They can be accessed by authorised staff in other areas of the health and care systems. GP connect is a system that allows the GP patient record to be viewed and shared between IT systems. In addition, the SCR and GP connect are both connected to the spine (safe programmable and integrated network environment which filters and forwards information securely across a network). Both SCR and GP connect are live systems and both are accessible to a variety of healthcare providers so that if a healthcare professional has a smartcard and an appropriate clinical system connected to the spine, the healthcare professional concerned will be able to view live information from the GP records from Mrs Young’s GP practice. The review also provided the following information: The summary care record, as a minimum, allows those with the appropriate access to view:
• The patient’s current medications
• Whether the patient has any allergies
• Whether the patient has any sensitivities
• Personal Demographic information about the patient. The summary care record with additional information allows those with the appropriate access to view the above information plus the following:
• Any significant medical history past and present
• The reason for the prescription of any medication
• Anticipatory care information
• End of life care information
• Immunisations. GP connect allows those with the appropriate access to view the entirety of the GP records. We are assured that the Practice are set up correctly to share their records with other healthcare providers, including SECAmb using the two systems described above. In relation to the question of whether and what exceptions there are that might prevent their records being shared with other healthcare providers, the Practice confirmed the following:
• An exception to the Practice being able to share any individual patient’s GP records would exist if the patient had refused to agree to their records being shared with other healthcare providers and may also exist if no preference either agreeing or disagreeing is recorded in the patient’s GP records. At Mrs Young’s GP surgery, their records show that 87.6% of their patients have agreed to share their records with other healthcare providers. The Practice has confirmed in this case that Mrs Young had consented to sharing her records, so they would have been available to SECAmb.

• Upon checking the Practice’s systems, our review found that SECAmb do not appear to access record reviews from the Practice as often as other providers do with no reviews being recorded for SECAmb by the Practice in December 2022. The Practice does have a record of successful reviews by other healthcare providers in December 2022 and we can therefore confirm that as far as we are able to determine, there were no problems with the Practice’s technology sharing the records at that time. NHS Sussex ICB does not know how SECAmb crews access GP records at the scene of a 999 call, and do not know what systems SECAmb use or what their understanding is of what is available to them from the Practice. Surrey Heartlands ICB who are the commissioners for SECAmb may have that information. Further enquiries of SECAmb may be needed to understand their systems, processes and their understanding of what is available to them in order to fully address HM Coroners concerns. Our investigations with the GP practice have found that they have the appropriate systems in place to enable other healthcare professionals to remotely access the GP records that are held by them. The Practice agreed with the findings of the NHS Sussex Digital Team that forms part of this response. I hope that we have provided you with some assurance that NHS Sussex ICB has taken steps to address the concerns outlined in your report and that we are continuing to take action to prioritise patient safety. Thank you for raising this matter with me. If I can be of any further assistance, please let me know.