Dear Sir, I am writing in response to your Report to Prevent Future Deaths issued 25 April 2025 in relation to the inquest hearing for the late Richard James Moss. You expressed concern that when a GP completes a “Rapid Access Chest Pain Clinic” referral form, that there is no automatic alert to colleagues to complete the referral process. When the referral was done for Mr Moss, the GP was required to manually trigger an alert to the secretarial team, and in Mr Moss’s case this was not done. It is important to note that the Rapid Access Chest Pain referral form and the clinical IT system in which it sits are not owned or controlled by the GP surgery. The cardiology department at Airedale hospital, together with the IT department are responsible for the form content and referral process. We held a significant event meeting 23.07.24 for the GPs and Practice Manager. The purpose of the meeting was to determine whether anything had gone wrong with our referral process, and if so, could we prevent a recurrence. We determined that the Rapid Access Chest Pain referral form sits within an IT software system called “GP Assist.” GP Assist is used by all local GP surgeries to generate referrals to secondary care. In this case “GP Assist” gives the referring GP the option to either 1) Open the document and send a task (to secretaries) at the same time, or 2) Open the document only (no task generated unless done so manually). Dr Kerry used option 2) and once the referral form had been completed there was no automatic reminder to alert the secretarial team. Following the significant event meeting we approached GP Assist to ask that they remove option 2) from the clinical system. We felt this would be safer, as it would force

GPs to consider sending an alert. At the time GP Assist said this was not possible. Their reason was that some GP practices prefer a system without automatic alerts. We have had to develop our own internal safety system. This consists of a reporting system that searches all our patients for any unsent Rapid Access Chest Pain Referral. We run the report every two weeks. We have been using this since last year. So far, we have not detected any other missed referrals. We have raised this matter at a meeting held between the practice and representatives from NHS West Yorkshire Integrated Care Board on 06 June 2025. The outcome from this meeting is that we are escalating the matter to ICB level in the hope that other practices are made aware of the potential problem, but also that the referral process can be made safer by the IT team. I enclose a copy of the letter that I have sent the ICB.

Subject:    FW: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss Sent:     14/07/2025, 10:44:20 From:     Coroners Admin

From: Coroners Admin Sent: 14 July 2025 10:39 To: ' (TOWNHEAD SURGERY)' Subject: RE: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss

Good Morning

Thank you for the update received on the 1st July, which the Coroner has acknowledged.

Kind Regards Support Officer to Senior Coroner

From: (TOWNHEAD SURGERY) Sent: 01 July 2025 09:58 To: Coroners Admin < > Subject: Re: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss

Please can I provide a further update regards preventing future deaths. We raised the IT issue with our ICB, and they have confirmed that changes have been made to the chest pain referral pathway for all GPs in the area. It is now no longer possible to complete a referral without simultaneously sending a message to secretaries to ensure the referral is completed.

GP Partner Townhead Surgery Settle North Yorkshire BD24 9JA