Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Samuel Thomas Jordan who died on 26 March 2020.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 2 February 2024 concerning the death of Samuel Thomas Jordan on 26 March 2020. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Samuel’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Samuel’s care have been listened to and reflected upon. 

I am grateful for the further time granted to respond to your Report and I apologise for any anguish this delay may have caused to Samuel’s family or friends. I realise that responses to Coroner Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones and appreciate this will have been an incredibly difficult time for them.

Your Report raised the concern that NHS Spine only operates to transmit records from a GP Practice where a patient is registered as permanent, and not a GP Practice consulted on a temporary basis. In Samuel’s case, this meant that Exeter Prison Healthcare were not aware of Samuel’s mental health issues or current prescription. Your Report raised the point that prisoners were frequently nomadic and may be registered with GP practices on a temporary basis.

NHS England has been working to improve the processes around information sharing between the detained estate and the wider NHS. This includes enabling access to a range of Spine connected services including Personal Demographics Service (PDS), Electronic Referral Service (eRS) and GP2GP Transfer. As a result of these changes, some patients transferring into the detained estate will have a GP2GP transfer whereby the patient’s electronic GP record is sent from their previously registered GP Practice to the new GP Practice that they register with within the detained estate. Further details are available via the links below:

• Detained estate overview: https://pcse.england.nhs.uk/services/medical- records/detained-estates
• GP2GP Transfer: https://pcse.england.nhs.uk/services/medical- records/gp2gp-transfer National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

9th April

• Primary Care Support England (PCSE) web guidance regarding registering patients with the detained estate: https://pcse.england.nhs.uk/help/patient- registrations/patient-registrations

Patients within the adult male and children and young people’s secure estate (adult male prisons, young offender institutions and secure training centres) have the opportunity to register with healthcare at their place of detention. This means a GP2GP transfer can now take place, electronically transferring the patient’s community GP record into the clinical system in place across the secure estate, and then back out to the community when the patient registers with a GP on release. The ability for a GP2GP transfer of a community GP record into the prison healthcare system was rolled out to the male prison estate between February and July 2022, so this option was not available at the time of Samuel’s death, but I hope provides assurance around current practice.

Regarding management of temporary resident patients and information flow, the relevant NHS England guidance to GP practices can be found here:

registrations. Specifically, within the ‘Managing temporary registrations’ section, this guidance includes the following points:

• ‘A temporary registration (GMSE) can be in place for three months. A GMSE form will need to be completed by the patient.’
• ‘GP practices can apply discretion in judging when it is appropriate to permanently register the patient with their GP Practice’. We note that in this matter, Samuel was a temporary resident at the GP Practice in Cornwall for four months.
• Information sharing back to the patient’s permanent registered GP Practice is currently managed via a PCSE process:

forms-gms3
• Once a GMSE form is received by the patient’s registered GP Practice, the information should be transferred into the patient’s GP record and made available via the Summary Care Record.

The Summary Care Record has been enabled for viewing in the detained estate for a number of years. In 2020, when Samuel died, SCRs were accessed using the Summary Care Record application. However, currently users across the detained estate will access the SCR via the National Care Records Service NCRS (see further information below). In summary, there are existing processes around the management of temporary resident patients. These support GP Practices to take over the management of patients by registering them permanently at the new practice where this is appropriate. Where care continues to be provided on a temporary basis, there are existing information flows to send information about the care episode back to the patients’ registered GP Practice via the GMS3 form, where the patient has consented, and for this information to then be integrated into the patients’ registered GP record so that

the information can be made available in SCR and other GP extracts. Separate work over the last few years has also enabled patients’ healthcare information to flow into and out of the detained estate via the GP2GP process with GP Practices within the detained estate being able to receive and manage the patient’s longitudinal GP record. If a patient has not consented to a GP2GP transfer via the GMS3 form, the GP2GP transfer cannot take place and the registered GP should instead be contacted directly for a summary. For further background information, the NCRS is the improved successor to the Summary Care Record application (SCRa). SCRa has provided access to Spine services for clinical users for a number of years. NCRS has been developed gradually over the last four to five years, and as the NCRS product has matured, we have been migrating users across from SCRa to NCRS throughout 2023. As a minimum, the SCR contains important information about:
• current medication
• allergies and details of any previous reactions to medicines
• the name, address, date of birth and NHS number of the patient

In addition, details of long-term conditions, significant medical history, or specific communications needs, is now included by default for patients with an SCR, unless they have previously told the NHS that they did not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR Additional Information in the SCR includes the active problems and many significant past problems for a patient as recorded by their registered GP practice. In reference to Samuel’s case, this could include mental health conditions (e.g. bipolar disorder) or previous psychotic episodes. In addition, a history of deliberate self-harm, suicide attempts or suicidal ideation where these have been recorded as problems in the patient’s GP record. However, apart from the date, the SCR would not include further details of the episodes of deliberate self-harm, suicide attempts or suicidal ideation. Therefore, the SCR does not contain any documents (e.g. a mental health care plan or mental health crisis plan) but the SCR can act as a signpost to unscheduled care clinicians to seek further information from other teams involved in the care of the patient. I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.