Mark Simpson

Dear Mr Wilson

Regulation 28 Report to Prevent Future Deaths - regarding the death of Mr Mark Simpson

We are grateful for this Regulation 28 report and write to respond formally within the required timeframe. We offer our sincere condolences to Mr Simpson's family. The circumstances of his death, and the systemic failures identified at the inquest, are of the utmost concern to the Royal College of General Practitioners (RCGP), and we take our responsibility to respond constructively very seriously.

About the RCGP By way of brief background, the RCGP sets professional standards and the curriculum for GP training and supports the career-long development of GPs. Its core purpose is to encourage, foster and maintain the highest possible standards in general medical practice. While the commissioning and regulation of individual GP practices sits with NHS England through Integrated Care Boards and the Care Quality Commission respectively, the RCGP has a significant role in shaping professional norms, guidance and education across general practice.

Responding to the two areas of concern

Concern 1: Triage of clinical correspondence by non-clinical staff The RCGP agrees that clinical correspondence, including reports received from NHS 111, must be reviewed by a clinician before any decision is made about whether it requires further action. The responsibility of GPs to respond to letters, test results and clinical correspondence in a timely manner, to maintain safe patient pathways, is reflected in our curriculum under ‘Being a General Practitioner and Continuity of Care’ , and in the Clinical Topic Guides on Cardiovascular Health and Urgent and Unscheduled Care. This principle is further supported by CQC guidance through GP Myth Buster 46 on managing test results and clinical correspondence, which makes clear that where non-clinical staff are involved in

workflow tasks, there must be appropriate safeguards, supervision, training and audit in place and that the responsible clinician must take action when appropriate.

We recognise, however, that the existence of curriculum content and regulatory guidance does not in itself ensure safe practice at the level of individual practices. It is clear from the evidence at the inquest that the systems in this practice failed to route the ‘111 report’ to the responsible GP at the appropriate time. The RCGP takes seriously its role in reinforcing professional standards through guidance and communication to its membership.

Concern 2: 111 consultation reports not added to the patient record The RCGP agrees that any report received by a GP practice following an NHS 111 consultation must be added to the patient's medical record. This is fundamental to continuity of care and patient safety. A GP reviewing a patient's record must be able to see the full clinical picture, including any recent contact with 111, in order to make appropriate clinical decisions.

General practice currently holds some of the most advanced electronic health record systems in the NHS. Information received at a practice is ordinarily filed and coded to ensure it remains clinically accessible. The failure identified in this case, where a 111 report was neither routed to the responsible clinician nor added to Mr Simpson's record, represents a breakdown in what should be a routine and mandatory process.

Action being taken In taking action, I shall bring these concerns around systems of workflow, coding of information, and the timely availability of correspondence within the clinical record as an agenda item to the Health Informatics Group within the next three months. The RCGP will ask the Group to examine why 111 consultation reports are not consistently recorded in the patient record, and to determine whether action is required to take this forward to the Joint GP IT Committee, to communicate with the wider membership, or both.

The Joint GP IT Committee is a contractually mandated committee jointly constituted by the RCGP and the General Practitioners Committee of the BMA. It represents the views of GPs from all four nations, working with NHS England on the use and management of GP systems and data. Bringing these concerns through this route represents a meaningful and appropriate escalation with the potential to achieve systemic improvement.

We also recognise that General Practice is currently bearing significant risk for many patients due to unsatisfactory and timely pathways to specialist care, and that policy changes such as ‘Advice and Guidance’ and increasing numbers of rejected referrals by secondary care providers may add further pressure. The RCGP has published its policy position on the interface between primary and secondary care and on Advice and Guidance, and we remain committed to advocating for safer patient pathways.

We are committed to learning from Mr Simpson's death. The RCGP will ensure this case informs our guidance, our communications to members, and our engagement with system partners on the safe handling of clinical correspondence. We would welcome the opportunity to update the Coroner on the outcomes of these actions in due course.

Dear Mr Wilson,

Thank you for the Regulation 28 report of 11 March sent to the Secretary of State about the death of Mark Simpson. I am replying as the Minister with responsibility for Primary Care.

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Simpons’s death and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are very concerning and I am grateful to you for bringing these matters to my attention.

The report raises concerns over the failure of information relating to an NHS 111 consultation to be relayed to a clinician or added to Mr Simpson’s medical record at his GP surgery. The information was considered by a member of staff who was not medically qualified.

In preparing this response, my officials have made enquiries with NHS England to ensure we adequately address your concerns. NHS England in turn made enquiries with Lancashire and South Cumbria ICB. The ICB has reported that following an in-house investigation in the completion of a Significant Event Analysis, the GP practice has made changes to how clinical information is reviewed from external providers. The practice has revised its workflow so that all clinical documents received from providers, including NHS 111 and out-of-hours services, are now reviewed by a clinician rather than administrative staff. Under the new process, all incoming 111 and out-of-hours documents are attached to the patient record and sent as a clear task directly to a clinician as part of their daily workflow to ensure that all relevant clinical information is reviewed by a member of staff with appropriate medical knowledge. The GP practice now ensures that all consultation notes and reports are added to the patient’s medical record. Relevant information will be coded and free-texted into the record by the clinician, ensuring it is easily accessible for review during future contacts without the need to open attached documents. The practice will undertake an audit within three to six months to assess the effectiveness of this new process and learning from this work will be shared across GP practices within Lancashire and South Cumbria.

The practice has also decided to review the process of practice nurses requesting ECGs for patients and consider whether the patient could have been asked to book a GP appointment for a further review, assessment and consideration of an ECG. The ICB has been advised that the practice will also implement a system to inform all patients by text about their referral. Two-week wait, urgent and routine referrals will all receive an appropriate electronic message to confirm their referral with additional information. The NHSE GP Contracts Team has outlined several relevant points on GMC Good Medical Practice on record keeping, as well as the GP contract and underpinning regulations on record keeping, referrals, ongoing care requires and handling clinical information.

In summary: (1) GMC Good Medical Practice requires clear, accurate and contemporaneous records and emphasises continuity of care and information sharing before referral; (2) regulation 67 specifically requires GP contractors to keep adequate records and include clinical reports from other services/professionals; (3) the GP contract makes referral part of essential services and includes explicit requirements to review NHS 111 “Post Event Messages” and out-of-hours clinical details within specified timescales. These standards and contractual requirements are directly relevant to the handling and incorporation of NHS 111/out-of-hours information into the patient record and to the responsibilities that continue while a patient is awaiting specialist care. We expect ICBs, as commissioners of GP contracts, to monitor GP practice compliance with, and performance against, the contract. ICBs will take appropriate action if a GP practice is in breach of its contract.

I hope this response is helpful. Thank you for bringing these concerns to my attention.