Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Neil Michael Yates who died on 25 April 2023

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 4 November 2024 concerning the death of Neil Michael Yates on 25 April 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Neil’s family and loved ones. NHS England are keen to assure the family and the Coroner that the concerns raised about Neil’s care have been listened to and reflected upon.

Your Report raises concerns over delays to prescribing information for patients being sent to GP surgeries by voluntary and NHS organisations.

There is a National Care Records Service (NCRS), also referred to as the Summary Care Record (SCR), which is often used by care providers as a source of information for a patient’s current medication. The medications displayed on this record are driven by the patient’s GP record as opposed to other sources. This means that there remains a need for medications supplied from sources other than the patient’s GP to be recorded on the GP record before the information can then be made available on the National Care Records Service.

The limitation of medication information within patient clinical records is a known one, and a series of initiatives and work are being undertaken to address this across NHS England, local systems and IT vendors. These include the following:

• A core set of fully “interoperable medicine standards” (IMS) have been defined and tested by early adopters and are available to IT system suppliers.
• An Information Standards Notice (ISN) for Trusts is supporting wider adoption of IMS which have been incorporated into national digital medicines programmes.
• National adoption of IMS to underpin the transfer of medication information at the time of hospital admission and discharge is underway.
• The first NHS Trust has used the IMS as part of the local shared care record. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

9 January 2025

• GP IT suppliers are now required to deliver the requirements set out in the IMS by June 2025.
• The GP Connect interface, where prescription only medication supplies made from specific settings (e.g. community pharmacies) without being prescribed directly by the GP, can now be electronically recorded into the GP record by the supplying professional.
• Guidance on consolidated patient medication records has been published by the Faculty of Clinical Informatics, as follows: professional-consolidated- medication-record-rendering-guidance-v20-sep-23.pdf
• The Professional Record Standards Body (PRSB) have updated their discharge summary standards:

• Work is currently underway to update the medicines specification of the Transfer of Care initiative, i.e. the mechanism to send information from secondary care to primary care.
• NHS England have worked with local Integrated Care Boards (ICBs) to support the development of “local shared care records.” This provides the opportunity for local systems to present medication information across multiple providers.
• This programme of work is seen as a priority by NHS England, and timelines are currently being reviewed but implementation must be managed in line with the differing levels of digital maturity within ICBs.

The full national adoption and implementation of these pieces of work would allow permitted clinicians to have an up-to-date record available along with medicines supply information to aid safe clinical decision making.

Work is underway on all these projects, but adoption is required by multiple vendors which makes it difficult to give a specific completion end date. These projects will likely be rolled out over the coming two to five years.

Regarding prison screening processes specifically, the reception screening process for those arriving at prison asks the patient about their current medicines, in line with the National Institute for Health and Care Excellence (NICE) guideline NG57: Recommendations | Physical health of people in prison | Guidance | NICE. This is the basis by which the current medicines are initially recorded and reviewed. A patient receiving treatment in the community under the Substance Misuse Service (SMS) would be referred to the prison’s SMS team for review and a care plan.

It should be noted that morphine sulphate tablets (MST) are not used for substance misuse treatment but are used as an opioid for pain.

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 Neil, 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.