Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Ellen Victoria Floyd Taylor who died on 1st July 2025.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 9th February 2026 concerning the death of Ms Ellen Victoria Floyd Taylor on 1st July 2025. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Ms Floyd Taylor’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Ms Floyd Taylor’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 Ms Floyd Taylor’s family or friends. I realise that responses to Coroners’ Reports can form part of the important process of family and friends coming to terms with what has happened to their loved ones, and I appreciate this will have been an incredibly difficult time for them. Your Report raises concerns that previous surgery, and possible altered anatomy was unclear in the medical notes and thus in investigations. Additionally, previous surgery was not a routine consideration when inserting a nasogastric tube and is not included in the nasogastric tube guidelines. Whilst local guidelines have changed as a result of Ms Floyd Taylor’s death, you were concerned that this is a risk nationally without a national guideline. The responsibility for clinical guidance sits with the National Institute for Health and Care Excellence (NICE). We would advise the Coroner to contact NICE directly to address concerns regarding the guidance. NHS England were not in attendance at the inquest and it is not clear from the Report if the clinical team completed a pH check after insertion of the nasogastric tube. Checking the pH of liquid aspirated out of the nasogastric tube before using the tube is normally done to show this is acidic, as would be expected in the stomach. Usually, the pH in the stomach is less than around 5.5 although can be higher if patients are National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

28 April 2026

on acid suppressing medication. The pH in the small bowel is normally around 6 to 8. If this patient wasn't on acid suppressing medication and the pH was higher than expected, that may have alerted the team sooner that the tip of the tube was not in the stomach. Past medical history in patient records We note your concern centres around the fact that Ms Floyd Taylors’ previous surgery was not obvious from her notes, and you note that ‘this was not known’ to clinicians caring for her. NHS England recognises that limited information-sharing within and between care settings can contribute to delays in discharge, cause handovers to be incomplete and create less effective continuity of care. NHS England has developed and led for the last 5 years a Frontline Digitisation (FD) Programme, which has supported provider organisations across England to adopt Electronic Patient Record (EPR) systems which support increased consistency in digital maturity but also improve information sharing within and between organisations. The FD Programme enables provider organisations to procure EPR systems and provides guidance on their implementation to enhance local digital capability and interoperability, including the ability of different digital systems to communicate more effectively. However, these systems are typically configured and managed locally, in line with agreements between provider organisations and their technology suppliers. As a result, interoperability often varies depending on local infrastructure and information governance arrangements. Where multiple digital systems, including EPR systems and Radiology Information Systems (RIS), are in use across a provider organisation, policies and procedures should be in place to outline expectations, advice, and guidance regarding clinical record management. Responsibility and accountability for the sharing of information held within electronic records, including across different systems, rests with each organisation through its established digital governance processes. Information sharing across digital records is governed through established Information Governance. In practice, organisations do not generally share the entire patient record as a single dataset. Information sharing is purpose-led and governed through a combination of information governance, clinical governance and clinical safety processes (information sharing agreements, role- based access, audit trails and clinical safety assurance), ensuring disclosures are necessary, proportionate and safe for the stated purpose. The disclosing organisation determines what information is necessary and proportionate for the intended care purpose, applies patient confidentiality requirements and local/national choice mechanisms where relevant and uses role-based access controls (RBAC) and audit trails to ensure ‘need-to-know’ access. Shared information is therefore typically a defined subset of information such as clinical summary, which would usually contain information regarding medications, allergies, key problems, recent results/encounters and relevant documents appropriate to the clinical context. Northumbria Specialist Emergency Care Hospital is a hospital specialising in emergency care for sick and injured patients (managed by Northumbria Healthcare NHS Foundation Trust). It had previously used a ‘Best of Breed’ approach towards achieving digital maturity. As this did not meet the FD Programme core standards it

received funding in 2023/24 as part of the FD Programme to support optimisation of their EPR through the development of a clinical noting tool for clinical teams to record details of patient care/treatment that would have previously been a paper process. The FD Programme not only enables organisations to purchase EPRs but also advises on safe and effective deployment. However, whilst the FD Programme supports investment into local digital capabilities, interoperability i.e. how different digital systems communicate with one another, is typically configured and managed at a local level, based on local arrangements between provider organisations (although regional centres will be cognisant of the wider catchment area) and their technology suppliers. As such, interoperability may vary depending on local infrastructure and information governance arrangements. Access and information contained within the Northumberland Care record is determined by local policy and procedures. Developing this further NHS England and the Department of Health and Social Care published the Fit for the future: 10 Year Plan for England, which sets out the government’s plan for healthcare in England over the next 10 years. It also sets out a commitment to give patients ‘a single, secure and authoritative account of their data – a single patient record – to enable more coordinated, personalised and predictive care.’ NHS England is aware of the challenge in sharing medical records and results within organisations and recognises the variability between areas using different technologies. The FD programme continues to work across the health and care system to support greater integration and awareness of record sharing between providers. NHS England is also working with the Shared Care Records Programme which supports wider access to relevant patient information. When new EPR systems are deployed the management of historical records is one of the critical features of deployment and this would have been locally agreed between the trust and the EPR supplier. Visibility of key events of a person’s clinical history is a critical component.

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 Ms Floyd Taylor, 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.