Dear Dr Shaw Coroners Regulation 28 Report Patient: TM DOB: 05/03/1945 Date of Death: 23/11/2024 I am responding to the Regulation 28 Report to prevent future deaths as outlined in your letter of the 30/6/25 The Regulation 28 relates to the case of the late Thomas Mallinson who died on the 23/11/24. The summary of matters of concern as documented is below: To Cumbria Health (CH) - Thomas's case was sent electronically to the service, marked for 2- hour attention. I appreciate why this did not take place as it was impossible for clinicians on night duty to triage a large number of calls waiting while actually visiting and treating their caseload. I note a new "OPEL” system has since been instituted to try to escalate and get extra help as the number of calls waiting increases, but where will these extra resources come from overnight? I am also concerned that the referral from NWAS came as a result of a 999- emergency phone call but there seemed to be no way of telling NWAS that the call had not been dealt with and (presumably) passing responsibility back to them. As referred to above where does responsibility lie? I have responded taking each concern separately
1. At inquest and in my statement, I outlined a new updated escalation policy (attached) Within this policy there are steps to be taken to request extra clinical triage assistance The Control Room will send a text out to Clinicians but there is no requirement for any of the receiving Clinicians to respond to the request There are no financial constraints (within reason) to this part of the escalation policy Getting Clinicians to work extra over night shifts is understandably challenging, but we do find that some evening Clinicians are able to extend their shifts into the early hours We therefore do our best to add extra resources where we can at times such as those in November 2024 where we know there was pressure on all system partners (particularly NWAS and the Emergency Departments) due to the high number of respiratory cases in the community It is also important to note that at that time there was no winter pressure 4 Waveil 0r f RosehiU Indusinal Estate Carlisle CAI 2SE 0 1 228 S 1 4830 ch.off ics@>cumbrianealth.nhs.uk a-jfnirn' ifl f A wnisi C ?■ y o "v N■■■ '

CH CumbriaHealth funding available to support the system which in previous years has come in the form of funding for additional Out of Hours staffing and/or the setting up of community Respiratory Infection hubs to reduce pressure in the daytime for North Cumbria practices and ourselves. These were commenced but not in the period in question. In terms of the updated policy, we have put in place a clear process for managing calls that we cannot deal with overnight to reduce the risk of simply handing them all back to the daytime GP practices (page 13 in Clinical Operational Policy). We now provide a welfare call to patients in the overnight period in whom we have breached their response times. If there are concerns of deterioration then the case is escalated to a Clinician as priority. As discussed at inquest we will be adopting an automated text system to do the welfare checks with Adastra (our patient record software provider) when it becomes available which we understand will be by the end of the year.
2. The responsibility for the case of TM lay with CH after it had been passed to our organisation We held a joint case review with NWAS, and they stated that they can get over 200 such calls daily across their area (999 triage that come directly to CH with no allocation of an ambulance) and policing such calls would not be possible Once the case comes into the CH system it sits with us as responsible organisations. As documented in my statement and at inquest I acknowledged that the triage volume made it challenging to manage ail the cases that came into CH that period. CH has no cap on its capacity and if the demand outstrips the capacity our actions are focussed on risk mitigation which the updated policy addresses. In other case types we receive from NWAS (those cases that have been allocated a Category 3 or 4 ambulance that requires revalidating to see if the case can be dealt with by primary care and not need an ambulance) there is a robust system for safety netting. The case remains visible to NWAS. If the time response from CH breaches (a Category 3 response from CH is 30 minutes and a Category 4 is 60 mins), then the CH Control Supervisor will automatically hand these cases back to NWAS. There is an additional safety net which involves NWAS checking that the case has also been addressed within those timelines and they will see if CH has not managed the case (which may include handing back to them). NWAS would in such cases contact CH to get an update on the situation. Other actions taken so far
1. CQC have been informed of the receipt of the Regulation 28 and discussions have taken place
2. The ICB have been informed of the receipt of the Regulation 28. I have had meetings with their quality team looking at how we manage the “shoulder time" at the daytime practice/Out of Hours interface These discussions are ongoing as currently there is no formal agreement on how cases are managed and I have raised the possibility with the ICB about an MOU with all practices that would 4 W&vell Dr, RoseMl industrial Estate. CerirsleCAI 2SE 01228 514830 on rofl ice@cumtjneheanh.nhs.uk n H lanti A VJji,? t Cp/no.u'iy Ni> 0 J12 11 1 '

CumbriaHealth enable both parties to manage the risk of handing over cases to each other. Part of this was a meeting with the Chair of the LMC on the 13/8/25 3 The ICB have arranged a SUI meeting with the daytime practice in question leading This has not happened as yet but is planned for September 2025. In summary, the systems involved in dunng the period of time for TM did function in that the case was sent correctly to CH, but our workload outstripped our capacity to deal with the case in the response time required. We did attempt to contact the patient's wife at approximately 6 am but the Clinician was called way to what was deemed a more urgent case Our actions have centred on mitigating this risk to prevent such events happening again and we continue to work collaboratively with the ICS on managing the challenges of the winter’s clinical pressures. I would be happy to provide any clarification if needed.

Dear Dr Shaw l write further to your Prevention of Future Deaths Report dated 30 June 2025, which was issued to North West Ambulance Service ("NWAS") following the conclusion of the inquest touching the death of Mr Mallinson. I am aware that you will share my response with Mr Mallinson's family, and I firstly wish to express my sincere condolences to them. NWAS' core purpose is to save lives, prevent harm and provide services which optimise the likelihood of positive patient outcomes. Through the Regulation 28 report, you have requested that NWAS considers your matters of concern and have suggested that action is taken to prevent future deaths occurring in the future By this letter I will address those concerns as far as I am able.
1. There were multiple calls to 111 and 999 in this case. I was told that there was no alert to a call handler to Indicate recent contacts for the same patient with the same condition which might highlight a need for more decisive action. When a call handler receives a call from someone who has been attended by NWAS, either face to face or over the telephone, within the previous 24 hours, an alert is automatically generated on our Computer Aided Dispatch (CAD) system. Once the patient's location is confiimed, a 'pop-up box' appears to inform the call handler that a previous call has been made to that address. If the earlier call remains open in the CAD system, a banner is also displayed to allow the call handler to view the details of that previous call Where a call is no longer active, for example following cancellation, attendance, or onward referral (such as in Mallinson's case), the Emergency Medical Advisors (EMAs) can view the associated records for that location in the 'previous call' tab on their screen. The EMAs are empowered to escalate any concerns regarding a patient to a supervisor and/or a clinician if they have any concerns I understand this process was described in oral evidence by the NWAS witness, (Clinical Delivery Manager) at the inquest hearing, who explained how the system functions in practice. I can further confirm Delivering the at the in the every time.

clinicians also have the ability to review such incidents and can access patient details when this is necessary to support decision making It would not, however, be expected that call handlers review all previous calls while managing a new emergency call. The call details remain accessible in the system but, given the time-critical nature of emergency calls and the structured algorithm that must be followed, 999 call handlers would not have the capacity to explore historic records during live calls. With regards to the 111 service, I can confirm whilst there is no automated alert, our experience is that that the caller will inform the Health Advisor (HA) that they have previously called, and at this point the HA is able to review the previous calls and consider escalation, just as their 999 call handler colleagues are empowered to do i can provide assurance that our call handling process follows the nationally recognised algorithm of questions within NHS Pathways, which is a highly regarded safe and reliable system Where symptoms indicate a greater level of need, this will be appropriately flagged, ensuring that the patient is assessed and managed according to their presenting risk, so any changes in the patient's condition can be captured by the repeated triage that would take place on subsequent calls.
2. I am also concerned that there is no system that alerts your control to the fact that a 999 (emergency) case you have passed to another agency has not in fact been dealt with. In Mr Mallinson's case NWAS handed over the episode of care to Cumbria Health on Call (CHOC) in line with the established clinical pathway. It is not possible for NWAS to follow up on every call once care has been transferred, and the service relies on the contractual arrangements that are in place with partner organisations to ensure appropriate continuity of care. In this case, Mr Mallinson was referred to community-based care and CHOC accepted responsibility for the referral. I understand this was confirmed by CHOC during the inquest, and there was no dispute regarding the transfer of care. Once a referral has been accepted, the duty of care then rests with the receiving provider, and NWAS' responsibility appropriately ends at that point There was no subsequent pass back to NWAS in Mr Mallinson's case, but if there had been NWAS also have established pathways for these circumstances
3. A further concern refers specifically to the 111 service. At inquest it was questioned whether for out of hours GP services Cumbria had been better served when calls went to a local control room in Carlisle. NWAS 111 operates as an advice service, providing guidance and signposting patients to the most appropriate point of care based on their symptoms and needs. Any calls that are received into the NWAS 111 service, regardless of which of our four contacts centres it is received into, would be managed in the same manner Therefore, a contact centre in Carlisle would process the calls in the same way we do now and there would be no notable difference. All calls are handled in the same structured manner, and the outcomes for patients are unaffected by the location of the control centre. Each call is dealt with equitably, ensuring that all patients receive the same standard of assessment and advice. I am grateful to you for bringing this matter to my attention and I am sorry that you felt it necessary to issue a Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not hesitate to contact me or the Trust's Deputy Director of Corporate Affairs, Emma Shiner.

Dear Dr Shaw, Thank you for the Regulation 28 report of 30 June sent to the Secretary of State for Health and Social Care regarding the death of Thomas Raymond Mallinson. I am replying as the Minister with responsibility for urgent and emergency care Firstly, I would like to say how saddened I was to read of the circumstances of Mr Mallinson death, and I offer my sincere condolences to his family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention, Your report raises concerns of initial GP handling of the incident, high demand and communication issues between GP and 999 services, and information transfers between NHS111 and 999 in the North West. I understand that the SSP Health, Cumbria Health, and North West Ambulance Service should be responding to these respective concerns in due course. You also notified this case to the Secretary State in the context of an ’overcomplex system’ and the development of the 10-Year Health Plan. This response provides you an update in relation to this Plan and our work to improve urgent and emergency care (UEC) services The Government is clear that patients should expect and receive the highest standard of service and care from the NHS. The Government also accepts that the NHS's urgent and emergency care performance has been below the high standards that patients should expect in recent years. We have been honest about the challenges facing the NHS and we are serious about tackling the issues; however, we must be clear that there are no quick fixes. Building an NHS fit for the future is one of the Government’s five missions. I would like to assure you we are committed to continuing to improve NHS performance, to ensure all patients can access the right care first time, and in a timely manner. In June 2025, we published our 10-Year Health Plan which sets out how we will reform the system, including UEC care services, with a key focus on shifting urgent care into the community through new Neighbourhood Health Services. The 10-Year Health Plan

focusses on ensuring three big reform shifts in the way our health services deliver care. First, from hospital to community' to bring care closer to where people live. Second, from 'analogue to digital’ with new technologies and digital approaches to modernise the NHS, and third, from ‘sickness to prevention’ so people spend less time with ill-health by preventing illnesses before they happen. The plan also commits to a whole-system reform by creating a new NHS operating model, ouicomebased funding, integrated digital records, and personalised care plans, ensuring services work together rather than in isolation. It aims to reduce overcomplexity through system-wide working and joined-up pathways. With respect to clinical neglect, the plan outlines a commitment to a new era of transparency, improved quality of care for all, and stronger inclusion of patient and staff voices. This effort aims to address and prevent unnecessary suffering caused by healthcare failures and broader issues within the NHS. Regarding UEC services, we published our ]■ ■ ■ ■ >:•' , .< to on 6 June 2025 which sets out a fundamental shift in delivery, driving collaboration across the system to deliver improvements that will see the biggest impact on UEC performance. The Plan will:
• Commit to implement the recommendations from the NHS 111 review to make the service quicker and simpler to navigate.
• Undertake and implement the findings of an evidence -based clinical review of categorisation, with the aim of improving the clinical triage of 999 calls, by expanding overnight support for 999 call handlers and clinicians to provide urgent in-home care for clinically assessed patients with follow-up services available the next day. > Provide almost £450 million of capital investment for Same Day Emergency Care, Mental Health Crisis Assessment Centres and new ambulances, avoiding unnecessary admissions to hospital and supporting the diagnosis, treatment and discharge on the same day for patients.
• Reduce ambulance handovers to a maximum of 45 minutes, helping get ambulances back on the road quicker for patients, and reduce Category 2 ambulance response time to 30 minutes on average.
• Improve patient flow through hospitals, ensuring at least 78% of patients in A&E departments are seen within 4 hours and reduce the number of patients waiting over 1 2 hours for admission or discharge from an emergency department. The reforms will support putting the NHS on a sustainable footing so it can tackle the problems of today and the future. I hope this response is helpful. Thank you once again for bringing these concerns to my attention.

Dear Dr Shaw, Please find below our response to the Regulation 28 report dated 20 June 2025 following the inquest into the death of Mr Thomas Raymond Mallinson. Firstly, on behalf of Carlisle Central Practice, I would like to extend our sincere condolences to Mr Mallinson’s family. We recognise the concerns raised as we are fully committed to delivering high-quality, safe, and compassionate care to all our patients. As discussed during the inquest, while this tragic case involved multiple services including 111, 999 and the Out-of-Hours, we would like to assure you that our systems and staff are operating to the highest standards and clearly demonstrate below that they effective. As part of the inquest, we conducted a full investigation detailed as follows:
• Monday 18 November 2024: Mr Mallinson's wife called the surgery in the afternoon requesting an appointment for diarrhoea. This started the previous day (Sunday 17 November 2024). Reception advised that we had no available appointments and to call 111 should the symptoms worsen.

Providing NHS services
• Monday 18 November 2023: According to EMIS records, Mr Mallinson’s wife called 111 in the evening Mr Mallinson was eventually seen by the paramedics who deduced he was not clinically dehydrated His observations including his blood pressure, pulse, temperature and oxygen saturations were all normal. Mr Mallmson 's wife was advised to contact the GP if he was no better.
• Tuesday 19 November 2024: Mr Mattison’s wife called the GP surgery and was put through to the doctor on the same day. She spoke to (GP). At this point Mr Mallinson had been suffering with a two-day history of diarrhoea, and the GP was advised by Mr Madison’s wife that his vomiting and abdominal pain were settling. During the inquest it was suggested that should have carried out a home visit It would not be conventional to perform a home visit on a patient with such a short history of and improving symptoms. This is unless there were major concerns about sepsis or hydration, which there were not. Considering the information to hand, I believe followed the correct protocol.
• Wednesday 20 November 2024: Call to 111 was made by Mr Mallinson’s wife, this was booked on the self-booking system for a GP call back. 111 booked this into a 17:45 telephone slot at 17:42. The incoming 111 callback requests are manually monitored by the GP practice throughout the day. Due to the short timeframe of three minutes between booking and slot time the practice actioned the query as quickly as practically possible. Unfortunately, no follow up call was received from 111 to alert the practice to the short notice booking and, from a practice perspective, 111 should have not booked a slot on such short notice
• Thursday 21 November 2024: Reception staff arranged an outbound triage call with the GP as per 111*s request. The GP spoke to Mr Mallinson's wife at 15:36 and was advised that he had been admitted to hospital.
• Saturday 23 November 2024: Mr Mallinson sadly passed away on the Intensive Care Unit at Cumberland Infirmary Carlisle. Actions taken by me:
• I reviewed the care navigation process of this case. Considering the symptoms and their duration, the call handler and GP acted appropriately.
• I conducted an audit of all cases of diarrhoea, vomiting and gastroenteritis in the months of May and June 2025. It was ascertained that no missed opportunities were identified, and every case concluded with the best possible outcome.

Providing NHS services The GP practice have taken the following actions as part of our continuous training:
• Continue to reinforce training for reception and call navigation teams.
• Continue to do monthly significant event analysis review meetings to team reflection and learning. Additionally, as is usual, their formal training is recorded as part of our ongoing competence framework, with refresher sessions delivered regularly. Our regular telephone audit confirms our staff handle calls in an appropriate manner and direct patients to alternative services where necessary. For example, the telephone audit was carried out on calls taken between 1 May 2025 and 1 July 2025. The results show that 96% of calls taken were appropriately triaged with only 1 call failing to refer to other services. For further support, a structured mentorship system exists within the team to help less experienced reception staff. Doctors are accessible for same-day clinical triage where concerns are raised by reception. (GP) spoke to Mr Mallinson’s wife on the third day of his illness. At the time he was reported to be eating and drinking, with settled abdominal symptoms. You felt that there may be an element of wellness bias and that a face-to- face appointment or a home visit would have been more appropriate. has reflected in detail on the case, participated in a formal Significant Event Analysis, engaged in one-to-one clinical supervision with me and undertaken additional learning in the assessment for gastroenteritis, dehydration and frailty. Considering the indication from Mr Madison’s wife that they symptoms were improving and the number of patients that would present with similar symptoms, respectfully, our views differ from yours and we feel that acted appropriately in this case. To evaluate current standards of care, I conducted a focused audit on patients with Gastroenteritis, diarrhoea and vomiting at Carlisle Central Practice between 1 May 2025 and 1 July 2025. Fifty-five patients were reviewed to see whether appropriate clinical decisions, safety-netting, and escalation pathways were followed. Of the patients reviewed, 73% were seen face-to-face, with the remainder assessed remotely based on clinical appropriateness. Notably, high risk patients including those aged over 75, immunocompromised individuals and children under 5 were managed safely in every case. The audit clearly demonstrates that the practice has robust and safe systems in place for managing patients presenting with gastroenteritis. The tragic circumstances of Mr Matlinson's case are not due to any actions or in-actions of the surgery and there is no evidence of a wider pattern of unsafe care at the surgery. We have committed to repeating this audit annually to ensure continued assurance.

NHS Providing NHS services We also recognise your wider concerns about fragmented care across the NHS services. During the inquest, we noted that Mr Mallinson's case involved repeated transfers between 111, 999, Out-of-Hours and the GP surgery. In our view, this case exemplifies the complexity and lack of clarity that can occur when multiple providers share responsibility without a single clear point of accountability. We therefore support your decision to address this Regulation 28 to national stakeholders and would welcome further national guidance and structural changes to reduce these risks for vulnerable patients in future. In summary, when Mr Mallinson’s wife spoke to , he had diarrhoea for two days, his vomiting and abdominal pain had settled and he was eating and drinking. Considering his symptoms, it would be common practice to manage this case as did. My Mallinson’s family asked for medical help from the Northwest Ambulance Service who did not arrive, they re-directed the call to 111 instead. The call then sat in the third party Out-of-Hours GP system for seven hours without any action. At this point if an ambulance had gone out to Mr Mallinson, it would have significantly increased his chances of survival. We are deeply saddened by Mr Mallinson’s death and take this case as a serious opportunity for reflection and improvement where necessary. Should you require any additional documentation or evidence please let us know.