Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Stephen Martin Rhodes who died on 11 March 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 6th February 2026 concerning the death of Stephen Martin Rhodes on 11th March 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Mr Rhode’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Mr Rhode’s care have been listened to and reflected upon.

Your Report raised concerns that laboratory reports don’t flag or highlight an abnormal blood result on the front page of the report. You advised that NHS England may wish to review any national guidance on how abnormal results are flagged by laboratories. The responsibility for the formatting, structure and presentation of pathology results sits primarily with:
• The laboratory information management system (LIMS) supplier, and
• The GP clinical system supplier, who determines how results are displayed once the results have been received NHS England’s role has been to set out a range of interoperability standards. The current standard that guides how the flow of information passes between the pathology report laboratory and the receiving GP practice is the called the ‘Pathology Messaging Implementation Project - Electronic Data Interchange for Administration, Commerce and Transport (PMIP EDIFACT) Standard. If a laboratory test result falls outside the normal range, the PMIP EDIFACT pathology report includes a marker in most cases to show this. GP records system providers can use this marker to alert the receiving GP that the result is abnormal or different from the expected range. This marker is called the ‘Deviating Results Indicator.’ It is the responsibility of the GP system provider to ensure this information is clearly displayed National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

9 April 2026

and thus properly received to the GP. We note that you have indicated the supplier in this case has already responded to the need for greater visibility of abnormal results. EDIFACT is a legacy product, and NHS England is currently promoting the adoption of a new nationally agreed Pathology Messaging Standards using Fast Healthcare Interoperability Resources (FHIR). The new system will:
• Allow results to be sent in a structured way to GPs so their computer systems can read them more easily which reduces the risk of mistakes and helps ensure nothing important is missed.
• Enable standard clinical coding system called SNOMED CT to be used, which helps ensure test names and results mean the same thing everywhere and to every practice. This improves communication between laboratories, hospitals, and GP practices.
• Ensure results are sent using a secure NHS messaging system which helps keep personal medical information safe.
• These changes will initially cover common tests such as blood counts, biochemistry (like kidney or liver tests), immunology, and microbiology (infection tests) but will widen its scope over time. NHS England’s Pathology FHIR Specification is one of the data products mandated for use in the DAPB4101: Pathology and Laboratory Medicine Reporting Information Standard. The Information Standards Notice (Amd 63/2023) that supports DAPB4101 was issued on 15th April 2024. The Pathology Transformation and Interoperability Programme in NHS England is currently undertaking the opportunity to promote:
• Wider standardisation of pathology result flagging conventions
• Strengthen digital clinical safety assurance across Laboratory Information Management System and primary care systems To help providers and system suppliers integrate the Pathology FHIR Specification and reach conformance with DAPB4101, four NHS England teams (Core Services, Digital Services for Integrated Care, Diagnostic Digital Capability, and Terminology Design) are working together to create a roadmap for national adoption. A pilot is underway to establish and prove how a DAPB4101 pathology report can be sent from labs and ingested by GP practices safely. This will involve working with the GP system supplier, and the three pathology middleware suppliers that enable national coverage for lab to GP reporting as well as with Berkshire & Surrey NHS Pathology Services. Once the pilot has completed, implementing DAPB4101will then go onto NHS England's GP system suppliers’ managed roadmap of development work, leading to national roll-out. GP Practice Systems and Result Handling Processes Your report notes that the practice handles ‘several hundred’ reports per day.

NHS England recognises the need for robust result review processes are needed at pace in busy practices and the ability to correctly assign and act on results. While operational arrangements are managed at individual practice level, NHS England has published several resources available to support safe systems of work, including:
• Clinical messaging and test results. This guidance is part of the Data sharing and interoperability section of the Good practice guidelines for GP electronic patient records.
• Use of clinical decision support NHS England » Supporting clinical decisions with health information technology
• Digital clinical safety standards (DCB0129/DCB0160) All of which support safer practice. Auto reviewing of pathology results Some GP practices employ third‑party software solutions that use Robotic Process Automation (RPA) to support or automate the handling of both normal and abnormal laboratory results. These RPA tools operate outside of the digital safety assurance work undertaken by NHS England. Some of the major GP records suppliers have introduced significant robotic automation capabilities for laboratory tests within their electronic patient record systems which have been specifically designed to reduce the administrative burden on GPs and improve patient safety. This system, often referred to as "auto-reviewing" or "Pathology Auto-review" automatically processes, files, and, in some cases, manages the follow-up of test results. Auto‑review and auto‑filing of pathology results in GP systems can only ever be safe if “normal” is interpreted in the context of the individual patient, not just the laboratory reference range, so these functions need stringent governance, testing, feedback, and monitoring. Other Guidance includes:
• GP mythbuster 46: Managing test results and clinical correspondence - Care Quality Commission which informs practices on how they should manage test results and clinical correspondence and
• The General Medical Council Good Medical Practice 2024 establishes the professional duties that underpin safe test result handling, including providing a good standard of care, ensuring continuity, and acting on info Patient safety is at the heart of NHS England’s role and the 2024 ‘Primary Care Patient Safety Strategy’ describes some of the work and approaches being promoted by NHSE. The Patient Safety Team (clinician’s) and technology teams work in step with one another to support patient safety related to digital systems and technology clinical assurance processes. NHS England’s Patient Safety teams and Digital Clinical Safety team have a programme of work that monitors reported clinical incidents via the Learning From

Patient Safety Events (LFPSE) portal which receives incidents reported by all clinical organisations funded by the NHS. This activity includes looking for any emerging trends and includes a review of all PFD reports to ensure that any lessons learned from incidents are discussed and fed into future national policy on patient safety. Learning may be shared via specific advice given, incorporated into training sessions or documented guidance or policy. Learning is shared with suppliers, technologists and Digital Clinical Safety Officers in line with DCB standards which help ensure digital health products are safe and help to reduce harm events and in line with the Patient Safety Strategy. 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 Mr Rhodes 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 Mr Siddique, We write in response to the Regulation 28 Report to Prevent Future Deaths sent to Quarry Bank Medical Centre (“the Practice”), dated 6 February 2026. We are pleased to confirm that this response is provided within the 56-day period required, by 6 April 2026. We have taken the circumstances surrounding the death of Mr Rhodes extremely seriously. A formal written response has been sent to Mrs Rhodes offering condolences, setting out the circumstances as understood by the Practice, and detailing the system-level changes implemented following review. The Practice has also offered to meet with Mrs Rhodes in person to discuss the matter further should she wish to do so. The Practice has engaged openly and transparently throughout the coroner’s investigation and will continue to do so. By way of context, laboratory blood test results are transmitted directly from ICE, the laboratory reporting system, into EMIS Web, the Practice’s clinical system. EMIS Web has an inbuilt results management filter function. When laboratory results are received, the ICE system assigns an abnormal alert flag to any result that falls outside the defined reference range. Within EMIS Web, each GP manually applies the results management filter by clicking within the system. This filter segregates incoming results into two distinct categories based on the presence or absence of a laboratory abnormal alert flag: those carrying an alert, which require clinical review and action, and those without an alert, which are filed as normal results. The purpose of applying this filter is twofold: to file normal results efficiently, and to identify and take prompt clinical action on abnormal results. This ensures that results requiring attention are not overlooked within the volume of daily pathology reports and that each GP can direct focused clinical review to those results that carry a laboratory abnormal alert. Each GP is expected to review and action their results within 24 hours of receipt. In respect of the late Mr Rhodes, blood tests including NT-proBNP were requested on 13 September 2024 following presentation with progressive shortness of breath. A chest X-ray was also requested. The blood test results were received on 17 September 2024. The requesting clinician did not review and file the results at the time they became available. The results were subsequently reviewed and filed by a different clinician. As the NT-proBNP result did not carry a laboratory alert flag at that time, it was not identified as requiring action during the manual filtering process and entered the normal results pathway, where it was processed and filed without the laboratory’s recommendation for urgent specialist referral being actioned.

We wish to address the chest X-ray result separately. The X-ray report indicated findings in keeping with suspected COPD, consistent with the clinical indication on the request form. This result was reviewed, acted upon, and followed up: spirometry was requested to confirm the diagnosis and reception staff were tasked with contacting Mr Rhodes to inform him of the results and arrange the necessary referral. The pathway failure in this case was therefore specific to the NT-proBNP result not carrying a laboratory alert flag, rather than reflecting a general failure of results management across the Practice. Please find enclosed a copy of the Significant Event Analysis (SEA) minutes for your records. Significant Event Analysis A formal Significant Event Analysis was initiated on 30 April 2025, led by the Practice Manager, The SEA was reviewed and updated on 18 February 2026 following the conclusion of the coroner’s inquest. The review involved clinical and administrative input and examined the systems and processes surrounding the ordering, receipt, filing, and actioning of the late Mr Rhodes’ blood test results. The primary cause was identified as failure to appropriately scrutinise and act upon a significantly abnormal NT- proBNP result, with contributory factors including the absence of a laboratory alert flag, the high daily volume of pathology reports, and the absence at that time of a structured escalation protocol for high-risk cardiac biomarkers. All agreed actions were completed by 18 February 2026. The SEA records the likelihood of reoccurrence as rare. Duty of Candour The Practice confirms that its Duty of Candour obligations under Regulation 20 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 have been discharged. This was completed on 18 February 2026, as recorded within the enclosed SEA. The Practice wishes to highlight that it was the Practice itself that first identified the issue following the death of the late Mr Rhodes, and proactively communicated with Mrs Rhodes following the conclusion of the coroner’s inquest on 29 January 2026. The written response sent to Mrs Rhodes acknowledges the findings of the inquest, offers condolences, and sets out the changes implemented by the Practice. An offer to meet in person has also been extended. Actions Taken The following changes have been implemented, all with effect from 18 February 2026 unless otherwise stated:
1. Laboratory Reporting (actioned 14 March 2025): On 14 March 2025, the Practice wrote to Russells Hall Hospital laboratory to notify them that their reports were not including an alert on raised NT-proBNP results. The laboratory conducted a review and their reports now include an alert when NT-proBNP results are raised. As these results now carry a laboratory red flag indicator, they are correctly identified during the Practice’s manual filtering process and routed into the action-required category for clinical review. The laboratory has also updated its report format so that all abnormal results are flagged on the first page of each report. This change will benefit all practices receiving reports from this laboratory and materially reduces the risk of a similar event occurring across the wider system.
2. MY Bot AI Triage System (implemented 18 February 2026): The Practice introduced the MY bot AI triage system on 18 February 2026 following a careful, phased assessment to ensure clinical accuracy and safety prior to full adoption. MY bot works by applying an intelligent filter to incoming blood test results, segregating them into two categories: results that require clinical action and results that do not require action. This enables each GP to focus their review directly on results requiring

attention, rather than manually scanning the full volume of daily pathology reports – which, as noted at inquest, can run to several hundred per day. The system underwent supervised validation to ensure that no clinically significant result was misclassified before it was relied upon as part of the Practice’s results management pathway. This directly addresses the concern raised at inquest regarding the risk of significant findings being overlooked within a high-volume routine workflow. MY bot additionally flags to the duty doctor, on the day of receipt, any urgent results electronically flagged as abnormal by the laboratory – including NT-proBNP, Gamma GT, CRP, and PSA – which must be actioned that day or tasked to the requesting GP. We note that, as the laboratory had not assigned an alert to NT-proBNP at the time of the late Mr Rhodes’ blood tests, MY bot would not have flagged his result at that point. However, following the laboratory’s reporting update (paragraph 1 above), any future raised NT-proBNP result will be electronically flagged and automatically segregated into the action-required category, bringing it to the duty doctor’s attention on the day of receipt. The laboratory alert change and MY bot together provide a combined safety net that did not exist at the time of the late Mr Rhodes’ presentation.
3. Revised Results Management SOP (18 February 2026): The Results Management Policy has been formally revised and reissued. The updated SOP explicitly mandates that the requesting clinician retains responsibility for the review, interpretation, actioning, and filing of all investigation results within 24 hours of availability. An automated alert is generated where results remain unfiled beyond this defined timeframe, with escalation to the clinical lead where defined backlog thresholds are exceeded.
4. Mandatory Same-Day Protocol for Raised NT-proBNP (18 February 2026): A mandatory same-day clinical review and documented action protocol has been introduced for all NT-proBNP values exceeding 400 – the threshold above which results are considered abnormal. The Practice has deliberately adopted this more conservative threshold rather than the NICE urgent referral threshold of >2000, to ensure that any raised NT-proBNP result, however early in its trajectory, receives prompt clinical attention on the day of receipt without exception.
5. High-Risk Biomarker Escalation Framework and Abnormal Alert System (18 February 2026): The “Abnormal Alert” system has been introduced within EMIS Web as an additional safety check. A defined list of critical biomarkers – including NT- proBNP, markedly abnormal potassium, CRP, and PSA – has been agreed, with results exceeding defined thresholds flagged for enhanced scrutiny. No result carrying a laboratory recommendation for onward referral may now be filed without documented clinician acknowledgement. Where a referral recommendation is not followed, a documented clinical reason must be recorded.
6. Cross-Filing Safeguard and Secondary Review (18 February 2026): Where results are reviewed and filed by a clinician other than the requesting GP, that clinician must send the requesting GP a task to review the results upon their return, ensuring a secondary review by the clinician with full knowledge of the clinical context. A secondary review safeguard has additionally been introduced for specified critical cardiac biomarkers to provide additional oversight where results exceed urgent referral criteria.
7. Clinical Documentation and Safety Netting (18 February 2026): The Practice has reiterated to all clinical staff the importance of recording the clinical reason for each investigation request in the patient’s record, so that any covering clinician reviewing results does so with full awareness of the clinical context. Safety netting now routinely includes advice to patients to contact the Practice to check their results.
8. Clinical Audit Programme (18 February 2026): The Practice has developed a programme of practice-level clinical audits targeting results of high clinical significance, designed to provide ongoing assurance that abnormal results are identified, actioned, and that time-bound referral recommendations are completed within the specified timeframe. The audit programme includes NT-proBNP and BNP,

PSA, and other clinically significant markers, to be expanded through ongoing clinical governance review. Audits are conducted on a fortnightly basis with outcomes reported to the monthly clinical governance meeting, at which results management is now a standing agenda item. A quarterly audit of NT-proBNP results and associated referral pathways will be conducted for a 12-month period to provide sustained assurance of compliance. The initial audit has confirmed that no other raised results have been missed.
9. Staff Training and Wider Sharing (18 February 2026): Refresher training has been provided to all clinical and administrative staff involved in the results management pathway. The findings of the SEA, the inquest, and the lessons learned have been shared with the wider practice team in a whole-practice learning session. The Practice is actively planning to share the audit framework and learning with all practices within the Dudley Primary Care Network. We note that the laboratory’s updated reporting format, which now flags all abnormal results prominently, will itself materially reduce the risk of a similar event across all practices using Russells Hall Hospital laboratory, further reducing the likelihood of recurrence beyond the Practice’s own boundaries. Personal Professional Reflection The clinician involved has reflected fully and openly on this case. The matter was brought to the GP’s responsible appraiser in February 2026 and has been formally documented within the annual appraisal and revalidation portfolio as a significant event. In addition, the clinician has enrolled on the Red Whale ‘Managing Blood Results’ course to support structured learning and reinforce safe practice in this area. The Practice considers this personal engagement with learning to be an important component of the overall response to this incident. Notification to Relevant Authorities The Practice confirms that the incident has been reported to and is known to Black Country Integrated Care Board. Upon identifying the issue, the Practice proactively notified Dudley Place, the ICB primary care team, and specifically raised the absence of an abnormal alert on NT-proBNP results within laboratory reports. The Practice requested that action be taken to ensure the laboratory implemented the alert, in order to protect not only patients of this Practice but patients across all practices receiving reports from Russells Hall Hospital laboratory. The Practice has maintained open communication with the ICB throughout this process and is pleased to confirm that the laboratory has since acted upon this. Russells Hall Hospital laboratory now reports NT-proBNP results with a clear abnormal alert flag, meaning any raised NT-proBNP result will be automatically identified during the results management filtering process and routed for clinical action. This change prevents any future instance of a raised NT-proBNP result being missed in the manner that occurred in this case. Response to NHS England’s Involvement The Practice notes that a copy of the Regulation 28 Report has been sent to NHS England and fully supports the Coroner’s suggestion that NHS England may wish to review national guidance for laboratories regarding the flagging of abnormal results. The Practice’s direct experience in this case demonstrates that a laboratory’s failure to flag an abnormal result at source can silently circumvent even well-designed electronic filtering systems at practice level. National standardisation of laboratory alert protocols would represent a meaningful and systemic patient safety improvement. The Practice would welcome any such guidance. Ongoing Monitoring

Ongoing compliance with the revised protocols will be monitored jointly by the Practice Manager and GP Partner through monthly clinical governance meetings, at which results management is a standing agenda item. The effectiveness of all changes will be formally reviewed at three and six months from the date of this response, with outcomes documented. Any further corrective action identified will be implemented promptly. We hope this response, together with the enclosed SEA, demonstrates the comprehensiveness and seriousness with which Quarry Bank Medical Centre has responded to this incident. The Practice has implemented substantive, system-level changes that address each of the contributory factors identified, and is committed to ensuring that the circumstances that led to Mr Rhodes’ death are not repeated. We remain committed to the highest standards of patient safety.