Rt Hon Alistair Burt MP Minister of State for Community and Social Care Department of Health Richmond House 79 Whitehall London SW1A ZNS Ms M Mulrennan; Tel: 020 7210 4850 Office and Main Court; The Council House, Old Market Square, Nottingham NG] 2DT Hez ( M-(rmn Thank you for your letter of 22 October 2015,following the inquest into the death of Harry Mellor: was SOTTy to hear of Harry's death and wish to extend my condolences to his family. Your concerns in this case focus on the system of registration and de-registration of patients with General Practitioners You are worried that the practice of de- registering a patient, particularly a child patient as in this case; could lead to children put at risk and ask that we consider the following: There is no legal requirement to register or re-register a child with a General Practitioner: There is no reliable system in place to identify when a child has been de- registered from a General Practice. There are potential safeguarding concerns if a General Practitioner can de-register child, particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration. The paediatric team and physiotherapy services were not directly informed that Harry was going to be de-registered or had been de-registered [was extremely concerned on reading your report that a vulnerable child could lose touch with services so quickly and without anyone apparently becoming aware ofit: While the GP de-registration is relevant; the failure by King's Mill Hospital to follow up the complete loss of contact is, in my view, more serious. There is perhaps an assumption that the patient or the patient'$ parents will always maintain contact with services: Harry'$ case however demonstrates clearly that this cannot be taken being

for granted. Harry'$ mother retained her parental authority to make decisions about his care, and legal proceedings would have been needed to change that position. It seems however that the NHS lost contact with Harry, but was unaware of the loss of contact and therefore no action followed: I intend to ask the Department of Health and NHS England to look at current processes in the NHS to ensure that the possibility of anything like this reoccurring is reduced as far aS possible and preferably eliminated: It would however be useful to describe the current system. There is no legal requirement for any person (adult or child) to be registered with a GP, and there are no plans to make registration compulsory. There is also no legal power to require any individual with capacity to receive medical treatment The NHS Constitution allows patients and the public to register with a GP practice. In addition, patients and the public have inherent rights under the same constitution: to choose GP practice, and to be accepted by that practice unless there are reasonable grounds to refuse in which case you will be informed of those reasons. Reasonable grounds for refusal include; amongst other things, a patient not in the GP practice area. These are also grounds for a patient (whether adult o child) to be removed from a GP practice list; with the necessary notice being provided to the patient or guardian. When a patient is to be de-registered from a GP practice list; the practice and NHS England should notify the patient that will be removed from the practice'$ list and advise them to register with another practice. Although the information we have on the case is limited, it seems reasonable for the GP to have de-registered Harry once his family moved out of the practice area There was nothing to prevent Harry'$ mother registering him with another GP although there was no legal obligation on her to do s0. Had Harry been re-registered with a GP the break in contact with paediatric services should have been picked up. There are other opportunities for ensuring a child receives basic health care. For example, when a child starts school, as Harry did, the school is required to hold certain pupil records which include details of the relevant GP and whether the child has specific health problems Or needs. School nursing services visit schools to administer vaccines and offer health advice, and therefore have an opportunity to ascertain whether & child has any unmet health needs: your living they:

Whilst the above information explains the current of patient GP registration and the opportunities available for protecting a child's health needs, no-one in this case, even the physiotherapist who had remained in contact with Harry throughout; was aware of the loss of contact with the paediatric service at Kings Mill Hospital. As indicated above, Iam concerned that King's Mill hospital failed to realise that Harry had not had a further paediatric review, and that no action was taken in the intervening period by the paediatric service at the hospital to re-establish contact with Information regarding missed appointments and the break in contact should have come to light via Harry' s case records. From the information you have sent; it appears that the hospital relied on each successful appointment triggering the next: The use of an appropriate IT system by the Sherwood Forest Hospitals NHS Foundation Trust to regularly collate and review Harry' s case records and ensure automatic follow-up letters ought to have indicated his missed appointments. It would also have enabled the sharing of this information with all those involved in his care. Iam grateful to you for bringing the circumstances of Harry'$ death to my attention and hope that you find this reply helpful. edsluc^ 6 Kerrs" 04i5 K <'9eny Ai QQ. ALISTAIR BURT system Harry.

Dear Ms Mulrennan Harry George Mellor Thank you for your letter of 22 October reporting your concerns about the unfortunate circumstances surrounding the death of this 8 year-old boy: PHE does not have a direct role in determining the process for the registration of patients in General Practice. NHS England, as commissioners of primary care services, will be able to comment further on the regulation and procedure for GP registration and where there are concerns about loss of continuity of care, will be able to take action to address them: PHE has alerted the relevant NHS England team in North Midlands and the Director of Public Hezlth for Nottinghamshire and we have subsequently received confirmation the Nottinghamshire Safeguarding Board that the child's death is known to them and is considered for review. expect the issue of GP registration will form part of this review: With best wishes

Dear Ms Mulrennan Our ref: SR1-1280119182 Thank you for your letter dated 22 October 2015 which recommended we review procedures for the registration of children with general practitioners, following your investigation into the death of Harry Mellor. We are sorry to hear of Harry's death and understand your concern to consider whether organisations that have a role in healthcare delivery might be able to take some form of preventative action: In your letter, you set out four matters of specific concern and recommended we review procedures around the registration of children with general practitioners (GPs): In responding to the recommendations, it may be helpful to set out our role and functions: We are an independent organisation that helps to protect patients and improve medical education and practice across the UK: We decide which doctors are qualified to work here and we oversee UK medical education and training: We set the standards that doctors need to follow, and make sure that continue to meet these standards throughout their careers: We take action when we believe a doctor may be putting the safety of patients, or the public's confidence in doctors, at risk: We publish guidance setting out the professional values and standards of practice expected of all doctors working in the UK core guidance is Good medical practice which is supported by a range of explanatory guidance on topics such as patient confidentiality consent to_treatment; child_protection and other issues in healthcare practice: We do not have a direct role in the design and operation of healthcare services and the systems for managing patients' clinical care, although the standards in our guidance will touch on doctors responsibilities for ensuring The GMC is charity registered in Workingwith doctors Working for patients England and Wales (1089278) and Scotland (SC037750) they our

that organisational systems and services operate in a way that provides safe and effective standards of care as explained below: Responsibility for registration of a child with a GP Our guidance sets out a number of duties on doctors which are relevant to Harry's case, as they concern responsibilities for managing or participating in organisational systems set up to prevent ad reduce harm to patients, and responsibilities to work with child patients and their parents or guardians in ways that ensure the health needs of children are met and action is taken on child protection concerns. We do not have any powers to create obligations for parents or guardians such as requiring them to register their children with a GP or to notify their GP when leaving the practice area. Doctors' responsibilities for ensuring continuity of care for child patients Good Medical Practice (GMP) provides guidance on doctors' roles in ensuring continuity of care and this makes clear that doctors are expected to provide all relevant information about a patient to those taking over a patients care (see paragraphs 44-45). It alerts doctors to the need to: check, where practical, that a named clinician or team has taken over responsibility when your role in providing a patient's care has ended. This may be particularly important for patients with impaired capacity or who are vulnerable for other reasons: However, this is in the context of situations where, for example, a doctor is going off duty, or delegates care to another practitioner, or knows that a patient's care has been transferred to another practitioner . Doctors have a number of responsibilities in relation to patient support and protection from harm, set out in GMP and related explanatory guidance which, taken together, require them to: contribute to the safe handover of care between different providers (in Good medical practice 44 and Ending your professional relationship with a patient
6.d) support vulnerable patients, contribute to their protection and help them if their rights have been denied (in Good medical practice 27 , and Protecting children and young people &, and Confidentiality paragraph 63) support patients and families to ensure their health needs are met (in Good medical practice 49 and 51 and Protecting Children and young people paragraphs 1b and 8) participate in systems to share information about children at risk of serious harm (in 0-18 years: guidance for alldoctors paragraphs 61 and 63 Protecting Children and young people paragraphs 5 and 25) The GMC is charity registered in Working with doctors Working for patients England and Wales (1089278) and Scotland (SC037750)

to act on concerns where suspect that a child may be at risk of neglect or abuse (Child protection paragraphs 6-8, 32). We believe it's clear from our guidance that; if a GP suspects that a child may be at risk of neglect or abuse, s/he would responsibility to act to protect the interests of the child: And more broadly, GPs have responsibility to work with parents in ways that support them to provide a good standard of care to their children for example by sign-posting or referring parents to local advice ad support services: Other organisations provide more detailed guidance on how GPs can meet their obligations, for example the Royal College of General Practitioners (RCGP) and NSPCC provide clinical guidance in the form of a safeguarding toolkit to assist GPs to make decisions about what assessments to offer and when to raise concerns, including when children who are the subject of safeguarding concerns leave the GP practice: Responsibility for systems and processes around the transfer of care We understand that, the NHS doesn't impose requirement on patients to notify their GP that are leaving the practice, nor is there an obligation to be registered with a GP. So a GP may be unaware that a patient has left a practice area for a long time after the patient has moved on. may also be unaware of the patient's new location. Requests to transfer a patient's records are triggered when a patient registers with a new GP, and it may be months or years before this takes place: We also understand that it is standard practice for GPs to remove patients from their lists should become aware that they have left the practice area, which is described as 'administrative removal' . GPs in England are expected to notify their Primary Care Organisation of administrative removals. Bearing this in mind, it seems that a GPs ability to make a judgement about whether a deregistration notification or a decision about administrative removal should trigger child protection action, may be constrained by having no or limited knowledge of a patients circumstances at that point in time The design and management of national systems of clinical monitoring and quality in England are the responsibility of NHS England: NHS England is also the primary care organisation responsible for receiving administrative removals from GP practices and the recipient of any requests for records to be transferred once a patient has registered with a new practice: NHS England is currently developing a system to improve the protection of children who have previously been identified as vulnerable by social services, the Child Protection Information Sharing (CP-IS) project: More information about NHS systems, including the CP-IS project are available from NHS England, and information about how these services work at the local level can be obtained from the GP contracting team at NHS England. We have discussed the issues raised by your correspondence with the RCGP as the body responsible for setting clinical standards for primary care and advised that: The GMC is charity registered in Working with doctors Working for patients England and Wales (1089278) and Scotland (SC037750) they have they They they they

There are potential safeguarding concerns if a General Practitioner can administratively de-register a child with chronic health needs, before a new General Practitioner has been identified as taking over the care of that child, Work is ongoing to improve the clinical guidance available to doctors to support decision making in relation to children with long term conditions. The Royal College of Paediatrics and Child Health is working to produce standards for the care of children with long term health conditions (with input from the RCGP): Publication is due for 2017. In cases of child deaths where abuse or neglect is thought to be factor, the national system for carrying out a serious case review offers an effective way of engaging local and national organisations in a process to evaluate existing systems and identify any need for change. Conclusions While our standards make it clear that doctors need to take steps to ensure the care of their patient is transferred safely, clearly their ability to do so is bound up with the systems they work within, so you may wish to pursue your concerns with the NHSE, RCGP and RCPCH who are better placed to advise on whether and how systems and processes within the NHS in England can be changed to address your concerns Finally, from your correspondence, you have not indicated that any individual doctor has failed in their duty of care or has been criticised by your inquiry. However, if your investigation has identified concerns about individual doctors including any concerns that they have failed to follow our guidance on good practice, we would appreciate your providing us with any relevant information so we can consider whether action is needed through our fitness to_practise procedures I hope you find this response helpful to the process:

Dear Ms Mulrennan,

Re Regulation 28: Report to Prevent Future Deaths request dated 22.10.15 Subject: - Harry George Mellor - inquest conclusion 5th October 2015

Thank you for drawing our attention to the issues arising from the above inquest into the circumstances of the tragic death of Harry Mellor who had resided in the Mansfield and Ashfield Clinical Commissioning Group (CCG) area.

The CCG is aware of this case through representation on the Nottinghamshire Safeguarding Children Board (NSCB) Serious Incident Review Panel which is currently considering this case as part of a multi- agency serious case review. As commissioners of health services we will be appointing an independent author to undertake a review into the GP involvement in the case to ensure that any resulting lessons learned for health organisations arising from this review are implemented.

With regard to the specific requests raised in the report I would like to inform you of the following: -

1. There is no legal requirement to register or re-register a child with a General Practitioner The legislative framework is outside the remit of the CCG but we support your request to the Secretary of State regarding this matter. The principle of Parental Responsibility requires parents to make decisions in the best interests of children. In this case, this principle did not result in the best outcome for the child. We will request that this aspect is considered as part of the terms of reference for the NSCB serious case review

2. There is no reliable system in place to identify when a child has been de-registered from a General Practice The CCG recognises that this is a risk for children with health needs, whose parents do not access appropriate primary care services. The circumstances around GP de-registration in this case will be examined in detail by the CCG Independent Review into GP Contracted Services as part of the NSCB Serious Case Review. This review will be complete by 31.03.16 and any recommendations relating to GP contracted Services will be implemented by the CCG as part of the resulting action plan.

Your Ref: Our Ref: EM/FB/HGM

Direct dial: 01623 673481

Email: elaine.moss@newarkandsherwoodccg.nhs.uk

Date: 8 December 2015

In the meantime this risk is mitigated locally by the following arrangements: -

Current arrangements require specialist services and urgent healthcare settings to ask parents at each attendance the GP registration status. Paediatric pathways revised in 2015 promote multi-disciplinary communication and care planning (the paediatric pathway requires an Early Help Assessment Framework (EHAF) “team around the child” approach to children referred to specialist services.)

This should promote communication between professionals including the GP.

3. There are potential safeguarding concerns if a General Practitioner can de-register a child, particularly a child with chronic health needs, before a new General Practitioner has been identified and notified of the proposed de-registration a) Parental responsibility places the responsibility of GP registration on parents. If families do not inform GPs of changes of address and telephone numbers GPs face significant challenges in tracing mobile families. The circumstances around GP de- registration in this case will be examined in detail by the CCG Independent Review into GP Contracted Services as part of the NSCB Serious Case Review. b) To mitigate this problem, specialist paediatric services should have robust “Did not attend” (DNA) procedures which ensure primary health services communicate with GPs when patients do not attend specialist appointments. As a result of this case the CCG has requested assurance from specialist paediatric services that the (DNA) procedures are being effectively implemented. c) If children with complex needs are found not to be receiving appropriate specialist services, then safeguarding children procedures apply. These procedures were not mobilised in this case and this issue will be further scrutinised as part of the serious case review.

I hope this response gives you some assurance that the CCGs and NHS England are taking the issues identified around the circumstances of this Childs death very seriously. However solutions to the issues you have highlighted are complex and require detailed investigation. We will ensure these issues are considered as part of the Terms of Reference for the Multi-agency Serious Case Review which is due for completion by 31st March 2016.

We will be pleased to share the CCG GP IMR and subsequent action plan by the 31st March 2016 with you, to give assurance that the CCG has fully reviewed the circumstances of this case and is undertaking all appropriate actions to meet any recommendations made.