Dear Coroner,

Re: Regulation 28 Report to Prevent Future Deaths – Meghan Irene Chrismas who died on 20 October 2021.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 29 December 2023 concerning the death of Meghan Irene Christmas on 20 October
2021. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Meghan’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Meghan’s care have been listened to and reflected upon.

This response focusses on the NHS England national and regional policy, programmes, and commitments relevant to the matters of concern identified in your Report, namely your concern that the passage of information between NHS and private healthcare providers is hindered due to the absence of an adequate structure to share important clinical information about patients in a timely and effective manner.

Meghan’s case highlights the importance of effective information sharing to support providing the best care possible where individuals are transferred between different care settings. When sharing information between clinicians looking after patients, the concept of ‘Direct Care’ is relied on as the legal basis of the sharing and explicit consent for this sharing is not required from the patient. However, the patient can object to information being shared, at which point a clinical decision will need to be made as to whether the patient is at risk and the information needs to be shared despite their objections. NHS England is currently working to enhance the sharing of patient information to and from Voluntary, Charity and Social Enterprise (VCSE) and other independent/private sector providers who are commissioned by NHS organisations.

The Summary Care Record (SCR) was originally designed and communicated as a means to support patients when they receive emergency care. Over time, the significant value of access to SCR to wider healthcare services has been recognised and, as a result, the SCR Team have worked with the Expert Advisory Committee to extend its use into multiple other care settings through a governance framework into which patients and professionals contribute. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

21st January 2024

The SCR Team at NHS England have done significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services as part of Proof of Concepts (PoCs), into settings where SCRs have previously been unavailable. e.g. private GP Services. This work will continue throughout 2024. Clearly, it is difficult to define precisely what is included within “private hospitals and privately funded healthcare services”. However, all “private hospitals and independent healthcare services” that have approached NHS England to date seeking access to SCR have either been onboarded into the existing proof of concepts or there have been discussions with the requesters regarding initial setup and their use for access to SCR. Learnings from these PoCs will be reported back to the Expert Advisory Committee to better understand any benefits realised but also any potential unintended consequences. The SCR Team will work with the Expert Advisory Committee to seek full rollout approval in this sector and consider the scope of this approval and any specific exclusions, constraints, or caveats. It is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base and the private sector PoCs. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work has accelerated during 2023 and is projected to conclude during Q2 2024. NCRS is the successor to SCRa and by design removes a large amount of the reported barriers to adoption within many care settings including the private sector. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, it is free to use and includes additional features and services beyond the legacy SCRa product. Further information on NCRS can be found here:

The NCRS complements Shared Care Records, which is a way of bringing separate records from different health and care organisations together digitally in one place and joining up information based on an individual rather than one organisation. Shared Care Records will include prescribed medications and will typically hold more information about an individual than a Summary Care Record. Responsibility for delivering shared care records sits with local Integrated Care Boards (ICB). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England. Regarding the duplicate prescriptions administered to Meghan, the General Medical Council (GMC) have produced clear professional standards guidance for doctors on the prescribing and managing of medicines and addressed where a prescribing clinician may not be the patient’s regular prescriber. Sections to note are referenced below:

• Section 20: You should only prescribe medicines if you have adequate knowledge of the patient’s health and you are satisfied that the medicines serve the patient’s needs. You must consider … whether you have sufficient information to prescribe safely, for example if you have access to the patient’s medical records and can verify relevant information.
• Section 27:
a. It’s not safe to prescribe if you don’t have sufficient information about the patient’s health or if the mode of consultation is unsuitable to meet their needs.
b. It may be unsafe if relevant information is not shared with other healthcare providers involved in the patient’s care – for example because the patient refuses consent.
• Section 28: Before prescribing, you must consider whether the information you have is sufficient and reliable enough to enable you to prescribe safely. For example, whether … you have access to the patient’s medical records or other reliable information about their health and other treatments they are receiving.
• Section 29: If you are not the patient’s regular prescriber, you should ask for the patient’s consent to:
a. contact their GP or other treating doctors if you need more information or confirmation of the information you have before prescribing,
b. share information with their GP when the episode of care is completed.
• Section 30: If the patient objects to information being shared with you, or does not have a regular prescriber, you must be able to justify a decision to prescribe without that information.
• Section 31: If the patient refuses to consent to you sharing information with their GP, or does not have a GP, you should explain to the patient the risks of not sharing this information. This should be documented in their medical records.
• Section 32: If failing to share information could pose a risk to patient safety, you should explain to the patient that you cannot prescribe. You should outline their options and signpost them to appropriate alternative services. You should clearly document your reasons for any decisions made. I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.

Hampshire & Isle of Wight Constabulary

and Thames Valley Police

Strategic Police & Fire Headquarters Leigh Road Eastleigh SO50 9SJ

RE; Regulation 28 Report to Prevent Future Deaths- Meghan Irene Christmas who died on 20th October 2021

Thank you for your report to Prevent Future Deaths (hereafter the report dated 29th December 2023 concerning the death of Meghan Irene Christmas on 20th October
2021. In advance of responding to the specific concerns raised in your report I would like to express my deep condolences to Megan’s Family and loved ones.

The Coroner has previously been provided with statements and live evidence from a Superintendent. This dealt with topics including the national position on transfer or enquiries/incidents, the National Police Directory, learning within the Constabulary and control room supervision. This evidence included the updated manner in which risk assessments are conducted following a system upgrade and the focus that on supervisory review of high risk incidents awaiting deployment, as well as being their availability to advise staff. Those matters are not set out again in this document. The following information is provided in order to update the Coroner with further detail and recent developments in relation to training and organisational updates.

Training Staff in the police control room receive five dedicated CPD training days each year. The CPD training which was provided in 2023 to both supervisors and operators included THRIVE Risk Assessment and Re-assessment of Risk training as a training topic. Further details of these assessments are provided below.

In addition, control room supervisors attend two additional CPD briefing days each year, the most recent training day in November 2023. The Coroner has previously received evidence in relation to the Professional Development Portfolio (PDP) which is completed by newly appointed supervisors. This is a comprehensive portfolio dealing with incident management, handovers, briefings, and team

welfare/supervision. All supervisors are expected to complete the portfolio prior to being ‘independent.’ There is a distinct section on incident management, and it requires competence to be shown in an operational environment. This includes competency of incidents of the following type: “High Risk Missing Person – Early identification of a High Risk missing person incident and ensuring appropriate initial lines of enquiry. Assisting FIM with initial command and handing over to duty R&P inspector when appropriate.” It also includes a unit on supervisor handovers and requires competency in relation to the handovers which includes, quick response to new incidents, handovers of incidents of note, and reviewing current, outstanding, and deployed incidents to get an overview and understanding of current work, with specific reference to priority incidents for deployment and offering guidance and support to controllers. It also requires competency in checking Control Room dispatch group (CWUN) for outstanding No apparent Risk grading (NAR) and other incidents of note, monitoring the OOC (Out of County)box, ensuring reviews of NAR missing persons are completed and onward tasked if required. The competency requires that all tasks are acknowledged and completed in a timely manner.

In December 2023, the PCR Operations Manager set out clear guidance in terms of the expectations on supervisors, specifically in terms of their responsibilities to regularly review and reassess risk. Adherence and compliance against this is tracked by our Quality Assurance and Development Team which is referred to in further detail below.

The December 2023 guidance document was circulated to provide guidance to PCR supervisors in terms of Contact Management’s expectation of supervisory reviews, for incidents being managed through the PCR in CMP, and what should be included within them, and to provide supervisors with a framework to help in the timely completion of their reviews.

The document set out that performance Management is a key accountability of PCR supervisors clearly outlined within their Role Profile. Relevant considerations from the Performance Management section of the role include but are not limited to the following: -
• Monitor and review incidents to ensure an effective and efficient response in accordance with performance guidelines utilising THRIVE principals and the NDM.
• Monitor demand from all routes into the Control Room and where necessary take proactive action to manage any apparent shortfalls in resourcing.
• Liaise with staff across the organisation but in particular with DPT Sergeants and Inspectors to optimise service delivery.
• Monitor and respond to service delivery demands using appropriate IT systems, primarily CMP.

• Support the management of major, critical or significant incidents including conducting dynamic risk assessments to ensure the safety of relevant persons.
• Complete Quality Assurance processes.
• Room Management – including set up of staff, staff roles and incident response.
• Ensure that Force Policies and working practices are adhered to, providing advice when necessary.

The December 2023 guidance also set out that although every incident is different and therefore supervisory input will vary significantly between incidents, the following points are required for consideration and inclusion on CMP as part of a supervisory review, unless there is good reason for any of the points not to be covered.

• Is the incident type correct.
• Is the grading appropriate.
• Is the incident appropriate for deployment through the PCR, would it be better suited for allocation via the Triage Hub or other specialist team.
• Is the THRIVE assessment appropriate, have any relevant points / considerations been missed.
• Has any re-THRIVE been completed, is one required.
• If relevant, have action plans been identified and followed.
• Have appropriate attempts to resource the incident been made.
• Are likely breaches of SLA identified in good time to allow for remedial action to prevent any breach.
• Has the escalation process been followed.
• If deployed, are the actions of attending officers appropriate (in line with the recently shared terms of reference).

A template was provided to assist supervisors completing each of these reviews and provided guidance on each of the steps above to ensure that each of the steps are properly considered.

Introduction of THRIVE Risk Assessments

In order to improve the quality of initial risk assessments as well as reassessment of risk in PCR, Contact Management adopted the THRIVE risk assessment model (October 2023). HMICFRS define THRIVE as ‘a model used to assess the right initial police response to a call for service. It allows a judgement to be made of the relative risk posed by the call and places the individual needs of the victim at the centre of that decision’. THRIVE refers to Threat, Harm, Risk, Investigation, Vulnerability and

Engagement. THRIVE is used both as an initial risk assessment tool but also by staff and supervisors in the PCR to reassess risk.

All staff were trained in THRIVE between October and December 2023.

Quality Assurance and Development Team (QuAD)

In 2021 Contact Management set up the QuAD team to provide continual audit and inspection of our call handling. This is a team of four staff, seconded from the department who are trained to conduct the audits. Results from the audits drive both individual, department and organisational learning.

In December 2023 the remit of the QuAD team was expanded so that we could audit incidents managed in the PCR as well as call handling. Importantly we now audit the quality of supervisory reviews and re-assessment of risk, providing immediate feedback to individuals. Audit results are also subject to scrutiny during a monthly Senior Leadership Team Performance Meeting.

‘Your Call’ Learning Publication

In January 2024, Contact Management launched its first ‘Your Call’ publication. ‘Your Call’ features a series of anonymised case studies where there has been learning for our staff. This provides another opportunity to upskill our staff, learn from mistakes and improve our service to the public.