Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Amy Grace Pugh who died on 11th April 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12th January 2026 concerning the death of Amy Grace Pugh on 11th April 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Amy’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Amy’s care have been listened to and reflected upon.

Your Report raised concerns that clinical staff at the Avondale Unit in Hull (falling under the Humber Teaching NHS Foundation Trust) were unable to access important records pertaining to Amy’s mental health from partner NHS mental health institutions, which compromised her assessment and subsequent management.

NHS England is committed to improving the maturity and quality of Electronic Patient Records (EPRs) across all NHS Trusts. NHS England has provided funding to ensure all NHS Trusts have an EPR implemented. It is, however, up to individual NHS Trusts to effectively procure and implement their chosen EPR system, and to agree and progress any convergence of EPR systems within their local systems.

NHS England is also committed to supporting the sharing of critical clinical information across NHS organisations. Historically, different care settings have adopted different clinical systems to maintain a clinical record; some areas have adopted the same electronic patient record (other areas have adopted shared care records which can provide access to records from different care settings).

I have been advised by NHS England’s Frontline Digitisation Team that the Humber Teaching NHS Foundation Trust (formerly Humber NHS Mental Health Trust) reported that it had completed procurement to implement TPP SystmOne as a single, integrated EPR solution across both physical and mental health services within the Trust. The implementation was reported as successfully completed in 2025; prior to this the Trust had been using a different EPR system known as Lorenzo since 2012.

National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2nd March 2026

I am also advised that the Humber Teaching NHS Foundation Trust are connected to the Yorkshire and Humber Shared Care Record (YHCR) which should enable the sharing of patient information across the region. All staff at the Trust have access to the YHCR. GP Connect, which is accessible via the YHCR, provides information from Primary Care providers.

In addition, the National Care Records Service (NCRS) enables access to the patient’s Summary Care Record (SCR), which was accessible by the Trust through Lorenzo in 2024 and through TPP SystmOne since 2025. In the event that the patient is not able to provide ‘Permission to View’ their SCR, an emergency access option is available to clinicians. Additional information is also available on the SCR which may include further medical information.

The newly published Fit for the future: 10 Year Health Plan for England sets out the government’s plan for healthcare in England over the next 10 years. The plan 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 between providers and the variability between areas using different technologies. We are also aware that use of the SCR is variable across different care settings. We are therefore working across the health system to support greater integration and awareness of record sharing between providers. We are also working with the SCR Programme to support wider access to relevant patient information.

NHS England recognises the critical importance of improving data sharing between NHS organisations to support coordinated patient care. The 10 Year Plan commits to harnessing the digital revolution to enable more coordinated, personalised and predictive care. The Medium-Term Planning Framework (2026/27 to 2028/29) reinforces this ambition, with services becoming digital by default and integrated neighbourhood teams having access to digital tools and shared care records. This shift towards interoperable technology will support better communication and information sharing between NHS providers, helping to ensure safer, more joined up care for patients.

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 Amy, 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.