Dear Professor Marks, Re: Regulation 28 Report to Prevent Future Deaths – John Michael Kirkman who died on 27 December 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 July 2025 concerning the death of John Michael Kirkman on 27 December 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to John’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about John’s care have been listened to and reflected upon.

Your Report raised the concern that the use of different IT systems across different healthcare institutions means that the results of a mental health screening assessment carried out in one part of the country may not be available in another part of the country, and that this could adversely influence subsequent assessments. This is not unique to mental health records and fragmentation of IT systems remains a risk to patient safety.

The NHS in England has made significant strides in improving the sharing of clinical information across systems, with the National Care Records Service (NCRS) playing a central role. This includes access to the Summary Care Record (SCR) - which provides vital information such as current medications, allergies, and adverse reactions - and the National Record Locator (NRL) - which helps to locate care plans and other key documents. These tools are designed to support clinicians in delivering safe and informed care, particularly in unscheduled or urgent scenarios. The SCR is a national database derived from GP records and is updated automatically whenever a GP record changes. It is accessible to authorised staff across the health and care system who are involved in a patient’s direct care, offering a concise summary without exposing the full record. This is especially valuable during emergency or out-of-hours care. The NRL complements this by indexing the location of digital and paper records across the NHS, allowing health and social care professionals to securely retrieve information from the source. It reduces duplication and ensures access to the most up-to-date data. Importantly, it also provides visibility into which organisations are National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

22nd September 2025

currently involved in a patient’s care, enabling timely coordination - particularly in crisis situations. In the context of mental health, the NRL is especially impactful. It does not store sensitive data, but instead points users to where documents such as Mental Health Crisis Plans can be found. This allows professionals, such as Care Coordinators, to gain a longitudinal view of a patient’s treatment history at the point of need. NRL data can be accessed via the NCRS, and users can sort multiple document pointers by creation date to find the most relevant information. The NRL functionality allows any previous health assessment to be both located and seen, however only 17 out of 54 mental health trusts can currently share data via the NRL, mainly due to the need for system suppliers to implement technical pointers, but also as there is currently limited funding for this development work. Some suppliers have not participated in using the NRL due to their preferences for structured data formats. NHS England cannot currently mandate that suppliers undertake this work, but significant progress is being made with the Shared Care Records services across the country in adopting the NRL, which will increase accessibility substantially over the next few months. Beyond these national services, NHS England is committed to supporting broader clinical record sharing across organisational boundaries. Since 2021, all primary and secondary care organisations have been able to share a subset of patient information within Integrated Care Board footprints via their local Shared Care Record. The Core Information Standard defines the typical content of these records and provides a consistent framework for data sharing. Recognising the clinical need for greater interoperability, NHS England has launched a national initiative to connect Shared Care Records across England. This investment aims to ensure that authorised professionals can access safe, reliable, and accurate records, regardless of where care is delivered. Local organisations, including participating NHS Trusts, determine what additional information beyond the core standard is shared, and individual Trusts are responsible for negotiating data-sharing protocols to support enhanced local collaboration. We acknowledge the ongoing challenges posed by disparate IT systems, particularly in mental health services, where timely access to information can significantly affect assessment and referral decisions. This is a recognised patient safety and clinical quality issue. NHS England continues to develop solutions to address these challenges, including the proposed creation of a Single Patient Record as part of the NHS 10 Year Health Plan. It is intended that this record will bring a patient’s medical records into once place and will build on existing foundations to support clinicians and patients in accessing the information needed to aid clinical decision-making, subject to appropriate permissions and privacy safeguards. We remain committed to working collaboratively with partners across the health and social care system to improve data sharing, enhance interoperability, and ensure that patient care is supported by the best possible access to information.

Whilst NHS England does not have many details of this case, we have sought to obtain further information to support a further review of John’s case. We hope the information in this response clarifies the existing systems, and confirms our intention to deliver improvements in this area to support clinical outcomes for patients such as John. NHS England is also developing a specific framework for delivering personalised care and support to adults and older adults with severe mental health problems. The framework will set out the core aspects of care for people who require help from secondary or integrated primary, voluntary, community and social enterprise (VCSE) and secondary care mental health services. The framework outlines that all required information relating to a person’s mental health assessment and their care and support plan should be available to all staff who need it. This includes where people move between different services across different geographical areas.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of John, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.