IN THE SURREY CORONER'S COURT BEFORE HIS MAJESTY S ASSISTANT CORONER FOR SURREY THE INQUEST TOUCHING THE DEATH OF TAMMY DENISE MILWARD RESPONSE TO REGULATION 28 ESHER GREEN SURGERY HM. Assistant Coroner Ridge for the Coroner Area of Surrey has made a Regulation 28 Report Action to prevent deaths dated 15 January 2025 (the Regulation 28 Report") concerning the death of Tammy Denise Milward (the Deceased" ) This arises from the Inquest of 13 December 2024, adjourned concluded on 20 December 2024 (the Inquest" ) Esher Green Surgery ("the Practice") respond in accordance with Regulation 29 of the Coroners (Investigations) Regulations 2013 ( the Response")_ The numbering in the Regulation 28 Report is adopted. HM. Assistant Coroner Ridge s concerns are set in italics, with the Practice's Response below: "The MATTERS OF' CONCERN are: The Inquest heard evidence that Ms Milward $ case presented treatment challenges which several agencies sought t0 address but there was limited coordination, in particular that: The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS. As a result, neither the GP practice, nor GPimhs was aware that the other had received messages from or about Ms Milward on 28 December 2023. The coroner heard from SABP that there is ongoing work ongoing to create greater connectivity between the various electronic record systems, but this work is not yet 'complete. General Practice Integrated Mental Health Service (GPiMHS") is a Surrey wide system run by Surrey and Borders Partnership NHS Foundation Trust ("SABP") and commissioned by Surrey Heartlands Integrated Care Board (MICB ) The Practice is just one of over 100 GP practices for which SABP is the provider for GPiMHS services_ Therefore, the development of the ability for the electronic GP medical record systems such as SystmOne and EMIS to communicate with each other and allow sharing of clinical information, is not within the control ofany individual GP practice; including ours. This is a matter that falls and out

under the responsibility ofthe service commissioners at Surrey-wide level, specifically the ICB_ Individual practices, including ours, have no authority to determine the specifications of such services, nor" are they involved in the due diligence processes related to the Information Management and Technology (IM&T) aspects of these systems However; we would welcome better connectivity between systems and therefore easier sharing of clinical records, which would improve patient safety and clinical efficiency. As such in respect ofthis Concern & , we consider we cannot proactively do anything save bring this to the attention of the ICB as it is a commissioning issue, which we have done, and later react to requests from SABP, subject to approval from the ICB, to facilitate integration of the clinical IT systems which; of course we will do and would expect the other 100 plus practices to do likewise_ "The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs: The coroner waS told that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support) but that levels of interaction varied and was sometimes also undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices. The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death The majority of GPiMHS consultations for our Practice patients take place away from our surgery building, either at other NHS estates or via remote consultations _ We have consequently not had regular in-person interactions with SABP staff, as they are not frequently on-site with our clinicians. Communication is therefore usually via email andlor by telephone. Clinical space in GP practices is usually fully utilised by the practices themselves and this is the case at our Practice. We are currently working with the ICB on finding a solution to our own estate' $ challenges but are aware that there is pressure on GP space Surrey wide. As such, we consider that in-person interactions are unlikely to be effected Surrey-wide So email and telephone interactions should be prioritised in our view. This concern b. is not specific to the Practice but is Surrey-wide for all practices and any action taken by the Practice alone will not address the wider community unless SABP seek a uniform approach: Of course, in this specific case we note the Coroner did not raise a concern with the care actually provided by the Practice in general, Or in relation to the circumstances before the death, when the level of risk was evaluated and managed. We welcome the ongoing work by SABP to create greater connectivity between the electronic record systems. We are hopeful that this will significantly improve communication between

primary and secondary mental health care, in order to improve patient safety reduce the risk of future deaths_ Unfortunately, we as an individual practice have very limited power and no authority to improve communication in this manner across the whole Surrey GP population of over 100 practices that GPiMHS covers, Until effective software is provided by commissioners; and maybe beyond depending upon the nature ofany IT improvements, we propose the following: We have already contacted the ICB as above; Pending IT integration; which needs to be effected as soon as possible, we will implement any temporary measures recommended by the ICB, alongside the other 100 plus practices. We believe it is important that any changes are effected Surrey-wide and not on an ad hoc basis for an individual practice; and (iii) We will continue to have timely verbal communication with GPiMHS when concerns arise about & patient at risk and follow the same up by erail. The three above proposed measures are the result of a Significant Event Meeting at the Practice on 22 January 2025 (as attached) which we hope are constructive and useful These measures have already been discussed aS & practice with staff amongst whom wc have raised awareness, but this advice might benefit from disseminated by SABP Surrey-wide. We are copying this Response to SABP and also the CQC who have written to the Practice in respect of the Regulation 28 Report, We will implement changes as recommended by the ICB and SABP for all Surrey Practices Dated 4rdlay of fesn~ 2025 Signed: on behalf of Esher Green Surgery, Esher Green Drive, Esher; Surrey, KTLO 8BX and staff being this

Sharing of information between different services within the NHS has historically been very problematic as they have evolved in perfect silos. This is the driving force behind the setting up of the Surrey Care Record and whilst not fully complete, it is close to resolving the issues the Coroner’s report highlights.

Currently the Surrey Care Record does share a live feed of the GP medication, all GP held letters and also any letters sent from an acute trust to the GP (live feed again) By mid-April we will have been able to implement a live feed from the GP system which will show the entire consultation free text, including historic consultations. This will effectively give the meat (all clinically relevant) GP record to the health professional treating that patient. Patient/pharmacy messages are stored within the GP record as an administration consultation and as such any messages from the pharmacist to the GP will be fully visible to the GPimhs team. Of note, there is embedded link (single sign on) from within the SABP system so that it requires only one button push from the SABP System One record, in order to automatically open up the Surrey Care Record for that patient. Any data is only two mouse clicks away. This should fully resolve the issue of the GPimhs staff not being able to see the GP record to the degree that is required to mitigate this risk. In order for GPimhs staff to communicate with the practice, each practice has a specific email for their reception. This email address can be provided to SABP by each practice. It is monitored by the practice during opening hours and any urgent emails would be forwarded on to the duty doctor within the practice. This would allow urgent (but not emergency) communication between the GPimhs team and the practice. The GPs can reply to this using the AccuRx email solution which writes any sent emails back into the clinical system, so that they are again visible to the system (SECAMB,111,OOH, and acute trust A&E). As long as the GPimhs’ email address is available, the GP can also email directly to raise non-urgent concerns. Again, the sent email is written back into the GP system and will soon viewable via the Surrey Care Record. This should again mitigate this highlighted risk. Historically there has been little personal interaction between GPihms and the practice though there is no reason why they cannot speak via Microsoft Teams, which is provided for all NHS staff. This allows both phone and video calls to take place securely. In the real world there are often logistical problems (different working hours/days) doing this, though it is possible.

Surrey Heartlands ICB