Dear Ms Serrano

Re: Regulation 28 Report to Prevent Future Deaths – Eirwen Rebecca Hollister who died on 10 May 2022

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 October 2022, concerning the death of Eirwen Rebecca Hollister on 10 May 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ms Hollister’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Ms Hollister’s care have been listened to and reflected upon.

We also would like to take this opportunity to thank you for your continued support in allowing an extension of the deadline date for our response. This has been a very complex case and the extra time was essential in enabling a full and robust response.

Following the inquest, you raised a Matter of Concern that:

NHS registration could not explain why a patient, with a history of prescription drug abuse, had managed to, and continued to be, registered at two GP practices. Thus, allowing this patient to obtain two prescriptions of each medication at a time.

This response has been prepared following investigations supported by key stakeholders including NHS England, Staffordshire and Stoke-on-Trent Integrated Care System, Birmingham and Solihull Integrated Care System and NHS patient registrations.

Dual GP registration is not supported by NHS England, given the unacceptable patient safety risks arising from duplicate offers of care including, for example, in the prescribing of medicines or the delivery of other treatments such as vaccinations. Only one GP practice can access and add to and amend medical records at one time.

Patients can be deducted from practice lists due to:
• the patient moving out of area and the practice not wishing to treat the patient under the Out of Area Scheme National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

31 January 2023

• mail returned as “undelivered”
• the patient’s whereabouts are unknown NHS England directs that all deductions are processed via Primary Care Support England (PCSE). When GP practices update patient registration information on clinical systems, PCSE uses that information to update National Health Application and Infrastructure Services (NHAIS). NHAIS is the IT system that holds the National Patient Register, which is used to call/recall patients for national screening programmes. When NHAIS is updated, changes are fed through and made to patient demographic data held on the Personal Demographics Service (PDS) on the NHS Spine.

Following local investigations, it has been identified that Ms Hollister was not dual registered at both practices at the same time. However, it appears that she was “dual consulting” with clinicians at both practices between September 2021 and February
2022. At the time of her death, Ms Hollister was only registered at Heathview Practice in Tamworth (February 2022 – May 2022) and was not registered or receiving care from the Sutton Coldfield Group Practice.

Ms Hollister was previously a permanent registered patient at the Sutton Coldfield Group Practice between September 2021 and February 2022, during a time when she moved to the Sutton Coldfield area. A review of audit records has confirmed that Ms Hollister’s medical records were transferred between Heathview Medical Practice and the Sutton Coldfield Group Practice within a few days of the new registration via GP Link, and all secondary care admission/discharge letters were received by the Sutton Coldfield Group Practice. However, during this time, Ms Hollister also consulted at Heathview Medical Practice nine times.

We are aware that SystmOne has features such as alerts when accessing patient records for patients who are no longer registered at the practice, and it provides details of all consultations / contacts and prescriptions given at other healthcare facilities outside of that GP practice. Despite this and a detailed investigation, it has not been possible to answer how Ms Hollister was able to consult with both practices at the same time, without this flagging on either system. Possible hypotheses have been investigated and ongoing work is being completed to identify if any digital or system improvements are needed or possible.

Locally, in response to the incident, Heathview Medical Practice have undertaken a significant event audit which has resulted in an update to the practice’s local policy on management of hospital letters. A teaching event has also taken place with all practice staff on the importance of read coding, which is the standard vocabulary for clinicians to record patient findings and procedures in health and social care IT systems, and ensuring urgent reviews of patients who self-harm or overdose.

Heathview Medical Practice have also produced a new policy/procedure on patient registrations and deductions and have introduced a new dedicated team to manage patient registrations within the practice. EMIS training on registrations is also planned for March 2023.

In addition, the Integrated Care System (ICS) hosting the Heathview Medical Practice (Staffordshire and Stoke-on-Trent ICS) working with system partners to look at wider learning, including areas such as pharmacy dispensing.

Regionally, where applicable, learning will be shared across the region and nationally from this case using established communication channels within NHSE.

I would also like to provide further assurances on the national NHSE 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 Ms Hollister, 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.

Dear Sirs, RE; REFERENCE ARB/EAS 12533072 Further to your recent correspondence regarding the above please find the enclosed:- !. Report following the inquest to prevent future deaths
2. Significant Event Analysis
3. Overdose Policy