Oscar Keenan

Dear Mrs Leach,

I am writing to you in response to the concerns that you highlighted to the Trust following the inquest hearing into the very sad death of baby Oscar Michael Thomas Keenan that concluded on 3rd May 2025. Thank you for allowing us the time to review and respond to your concerns.

At the outset I would like to offer my personal condolences to baby Oscar’s parents.

To confirm, your Regulation 28 report relates to concerns regarding the adequacy of the algorithm built into the NHS Pathways clinical decision software support system when assessing ill newborns or infants. Your report was also issued to NHS England because they design and manage the NHS Pathways system and will be able to consider whether a change to the algorithm itself is required.

It is disappointing that the Trust were not provided with the opportunity to participate in the inquest hearing. I understand that the court were aware of concerns that had been raised by baby Oscar’s parents regarding the outcome of the 111 call in advance of the hearing. It is regretful that evidence was not requested from the Trust in response to these concerns as would usually be the case.

Actions taken by the Trust shortly after baby Oscar’s death.

At the Joint Agency Response meeting held on 28th June 2024, the Chair of the meeting, D , questioned whether the response reached at the end of the 111 call was appropriate. This prompted the Trust to review the call to see whether it was managed appropriately. The call was audited on the same day and regrettably it was identified that there were missed opportunities for a higher disposition (call outcome) to have been reached. The audit identified that the Health Advisor should have probed further using supportive information contained within the NHS Pathways system in relation to Oscar’s breathing. The auditor determined that if after probing a clear answer had not been received, the Health Advisor should have requested advice from a clinician.

Due to the comments made on the call by Oscar’s parents and their description of his breathing, it was determined that a Category 2 ambulance response disposition should have been reached at the end of the 111 call. On behalf of the Trust, I am very sorry that a lower outcome was reached.

On 1st July 2024, the case was discussed at the Trust’s Daily Critical Review meeting. This meeting is led by our Patient Safety Team who determine whether any wider review is required

2 under the Patient Safety Incident Response Framework when a concern is identified. The outcome of this meeting was that the Patient Safety Team were satisfied a wider review by the Trust was not required.

A meeting was held with the Health Advisor on 2nd July 2024 to feedback the results of the call audit and a call review plan was initiated to ensure that individual learning took place, and any support required was implemented. A call review plan details any specific support / learning / development actions required to address the area(s) of development highlighted within the non-compliant audit. The plan is accompanied by any relevant support materials, for example, NHS Pathways Hot Topics, extracts from NHS Pathways training materials, shared learning documents, local policies / procedures. At the audit feedback meeting, the call recording was played to the Health Advisor and the issues highlighted within the non- compliant audit were discussed with him in detail. The Health Advisor has continued to have regular random audits performed in line with the requirements of the NHS Pathways licence and their performance is in line with expected standards.

Review undertaken after receipt of the Regulation 29 report.

Following receipt of your report, the case was reviewed at the Trust’s Safety Review Panel which comprises of Assistant Directors from the clinical and medical teams, our Consultant Pre Hospital Care Practitioner, clinical governance leads, members of our safeguarding and quality improvement teams and our Patient Safety Specialist. The panel noted the speed at which the Trust ensured that feedback was provided to the Health Advisor following the call taking place and determined that the error made is not an issue that is occurring Trust wide, so a learning response was not required under the Patient Safety Incident Response Framework.

In addition to the above, our Clinical Coordination Centre (CCC) Quality Improvement Team have considered points 2 and 3 of the concerns raised and they are satisfied that there is not an inherent or recurrent issue of staff not seeking clinical advice when appropriate to do so within our call centres.

As indicated at the beginning of this letter, the Trust is a user of the NHS Pathways system, and we are consequently not able to alter the algorithms contained within it, only NHS England can do this. We have therefore focused our review and response on the training that is provided to Emergency Call Takers and Health Advisors who use the NHS Pathways system and the process in place for identifying any themes or that indicate additional wider training may be required.

Core NHS Pathways training is set by NHS England, and it is a condition of the NHS Pathways licence that their training programme is followed. This training is delivered within SCAS by local trainers who have attended national ‘train the trainer’ sessions to ensure consistency across all providers. In addition to the core training, the Trust has a dedicated CCC Quality Improvement team who are responsible for sharing learning with call centre staff as new and emerging themes and trends are identified from a wide range of sources including, but not exclusively, case reviews in preparation for Coronial proceedings (See SCAS Shared Learning Processes_CCC document enclosed with this letter). Generic common themes are reviewed monthly by the Quality Improvement team and associated shared learning material is issued at least once a month. Factsheets, posters, and anonymised case studies are issued as their main media for this because these methods have been identified through staff feedback as being an effective way of disseminating learning. The team also use podcasts and share links to other associated reference materials where relevant.

Shared learning is issued via email with an embedded MS Forms acknowledgement link that is mandatory for colleagues to click on to acknowledge that they have read and understood

3 the content. Compliance with shared learning acknowledgement is monitored and managed by operational line managers. All acknowledgement forms have the option for individuals to flag that they require further information to aid their understanding, and the CCC Quality Improvement team will then follow up with those individuals to ensure that they have a good understanding of the relevant topic, and they are safe to continue working in their role.

To further gauge understanding and comprehension of the content within any shared learning materials issued, there is a monthly Quick Quiz for both service lines (111 and 999) comprising of 10 true / false and / or multiple-choice questions. The questions are drawn from any recent Standard Operating Procedure (SOP) Change Notices, shared learning materials, existing SOPs, and general triage principles for the NHS Pathways system. The quiz is facilitated via MS Forms which allows staff who submit incorrect answers to see explanations of the correct answer with sign posting to the source reference materials. Quick Quizzes have included questions regarding assessing a patient’s breathing in July 2024, August 2024, September 2024 and April 2025 and regarding when and how to pass a call to a clinician every month since December 2024.

The Quality Improvement team have confirmed to me that because assessing the adequacy of breathing can be difficult over the telephone, a bespoke ‘breathing’ package was developed to aid the education of staff. In this package, staff select a sound recording to play which demonstrates a type of breathing pattern and they then have to confirm which type of breathing they have heard. This package is provided to all new starters and is available for all staff to access on an ongoing basis. All shared learning material is available for staff to access on a dedicated page on the staff intranet along with Hot Topics issued by NHS Pathways. It is the intention of the Quality Improvement team to include questions specifically related to assessing breathing in children (including neonates) over the coming months.

Having considered the robust processes and additional training that the Trust currently has in place, I am satisfied that these measures are sufficient to mitigate the chance of a similar error occurring when a call is taken by a member of our call centre team. This does not take away from how truly tragic baby Oscar’s death was. Should NHS England decide to update the algorithm contained within NHS Pathways, this will of course mean that SCAS staff will have access to this updated version upon its release.

I hope that this letter has adequately addressed the concerns that you have raised. Should you wish to discuss these matters further, please contact , Head of Legal Services at the Trust who will be able to facilitate this.

Dear HM Assistant Coroner Ms Judith Leach,

Re: Regulation 28 Report following the inquest into the death of Oscar Michael Thomas Keenan

Thank you for raising the Regulation 28 report with us, following the inquest into the sad death of Oscar Michael Thomas Keenan on 26 June 2024 that occurred following his admission to the emergency department at the John Radcliffe part of the Oxford University Hospitals NHS Foundation Trust.

I note the legal requirement upon the CQC to respond to your report within 56 days, and I would like to express my gratitude for kindly providing us with two days’ extension.

I would like to express my deepest condolences to Oscar’s parents and wider family for their loss.

Following the receipt of your letter the local inspection team reviewed the risk profile of the service and all information we held including any other concerns received.

We contacted Unity Health, the provider who confirmed they launched an investigation and were reviewing how to improve their systems to prevent reoccurrence. We also shared these concerns you flagged up with the relevant Integrated Care Board for the area.

Care Quality Commission Citygate Gallowgate Newcastle upon Tyne NE1 4PA Telephone: 03000 616161

You identified the following three areas of concern which I responded to below:

The misunderstanding and miscommunication that registration with a GP cannot take place until a birth is registered.

GP practices in England that offer NHS services do this through a GP contract that is held between the practice and the relevant Integrated Care Board (ICB). As part of this contract, practices are mandated to provide emergency treatment to anyone within their practice area, regardless of whether they are registered with the practice or not.

The Care Quality Commission does not regulate against the GP contract, and therefore the oversight of this process is better placed with the practice's ICB as the commissioner.

Anyone can register and consult with a GP without charge, as outlined within the NHS Constitution, however, specific points regarding how the registration process should operate, and when practices can refuse a patient's registration request are outlined within the GP contract. Practices should not refuse a patient's registration if they cannot provide proof of identity or immigration status. Therefore, practices should not typically be refusing a patient's registration if a birth certificate cannot be produced. However, this would again be for the ICB to oversee as the Care Quality Commission does not have jurisdiction over when practices register or do not register patients.

We may include aspects of practices’ registration processes as part of our inspection, under the 'Equity in Access' quality statement. However, we would not be able to take enforcement action against practices, purely around the registration of new patients, as it is not within our regulations to do so. Where we comment on registration concerns, it could be due to a practice excluding a particular patient group such as homeless patients, because of a lack of ID or fixed address. In such circumstances, we may need to take action from an equity perspective.

Communication between the GP surgery and the external filtering company.

We are unable to comment on the communication between the GP surgery and the external filtering company, and the practice is best placed to provide this information.

That Instructions to commence treatment can be lost in similar circumstances.

It is not in the Care Quality Commission’s powers to implement or enforce a uniform process whereby treatment of patients is transferred from hospitals to other providers to avoid a similar incident occurring in the future.

We recognise this may be a particular concern for other patients who may not be registered with GPs, such as Travellers, those with no fixed abode or people non-resident in the UK. Therefore, the hospital should have procedures in place to ensure aftercare can be provided to these patient groups.

Integrated Care Boards and NHS England will be better placed to assist with implementation of a uniform process to avoid a situation such as this occurring in the future.

We contacted the provider in question, and they confirmed they promptly reviewed their processes and implemented a new system, when as soon as they’re notified about a birth, they will create a new profile i.e. ‘Baby (Surname)’. The provider recognised this approach was not completely fail safe, as it could potentially mean there is a duplicate account at another provider for said child, should the parents wish to register their child elsewhere.

We have already flagged this issue with the ICB for the area and will continue liaising with them and the local NHS England teams. The ICB and NHS England will be able to consider how to address these concerns via their contracting processes and how to disseminate this to other practices.

We will be sharing details of this incident and the associated findings with the Care Quality Commission’s Primary Care inspection teams at our monthly update and upskilling call. We will continue to monitor the intelligence about the practice in line with our regulatory processes.

Dear Madam,

Prevention of Future Deaths Report Concerning Oscar Keenan

I am one of the GP Partners at Unity Health who operate five GP Practices, including Princes Risborough Surgery. I write to provide the Practice’s response to your Prevention of Future Deaths Report dated 12 June 2025.

You have raised concerns regarding new birth registrations at the Practice, the communication between the Practice and the external company we use to assist us in dealing with incoming correspondence and also that instructions to commence treatment could be lost in similar circumstances. At the outset, I would again like to extend my sincere condolences to Oscar’s parents and wider family.

As you are aware, nobody from the Practice was asked to attend Oscar’s Inquest and I am therefore grateful to you for providing us with the opportunity to access the recording of the proceedings in order to fully understand the concerns raised. I hope that the response from the Practice set out further below provides yourself and Oscar’s parents with some degree of reassurance that this matter has been taken extremely seriously and that improvements have been made.

New Baby Registrations at the Practice

As set out in my statement of 12 March 2024, a baby does not and did not need to have been named or formally registered with the Registrar in order to be registered as a patient at the Practice. Unfortunately, it transpired subsequently that Oscar’s parents had been told incorrectly by a member of the reception team that they could not register Oscar at the Practice until they had formally registered his birth for which I sincerely apologise. The Practice conducted a Serious Event Analysis after this issue and Oscar’s sad death came to light. Following this, a new process was put in place for new baby registrations which was circulated to the Practice team on 11 December 2024.

Brill Surgery 22 Thame Road Brill Bucks HP18 9SA

Tel: 01844 238284 Fax: 01844 238568 Chinnor Surgery 5 Station Road Chinnor Oxon OX39 4PX

Tel: 01844 351230 Fax: 01844 354328 New Chapel Surgery High Street Long Crendon Bucks HP18 9AF

Tel: 01844 208228 Fax: 01844 201906 Thame Health Centre East Street Thame Oxon OX9 3JZ

Tel: 01844 212553 Fax: 01844 260243 Practice Manager

VAT Reg No 879 1204 06 Within that email, the staff were reminded that newborn babies do not need to be registered at the Registry Office before being registered at the Practice. When new staff join the reception team, training is provided and the information as to the process for new baby registrations and the fact that the baby does not need to be registered with the Registrar is shared with them.

The process for new baby registrations at the Practice now in force is as follows:-

1. All birth notification letters from the hospital are sent to the Practice via an electronic filing system (called Docman). Docman is a cloud-based platform primarily used in healthcare for managing clinical content and co-ordinating workloads related to the transfer of care. It helps healthcare professionals capture, organise, workflow and transfer healthcare documents, both clinical and non-clinical. Docman is used by thousands of GP Practices and hundreds of thousands of healthcare professionals to streamline processes, reduce administrative burden and improve patient care. All electronic correspondence from hospitals are sent to the Practice via Docman. The correspondence automatically delivers into a folder within the “filing” section of Docman and is automatically placed in date and time order. The workflow team at the Practice then work through these documents one by one filing them into the relevant patient records. When a member of the workflow team identifies a birth notification/maternity discharge summary, they will register the baby with the Practice immediately.

2. Once the baby has been registered with the Practice, the birth notification will sit at the top of the electronic filing pile on Docman for 24 hours as Docman takes 24 hours to link the new patient into their system. The birth notification will then be filed into the patient records the following day. The patient will however be active on the clinical system (EMIS) as soon as they are registered and so any care required within that 24 hour period would not be delayed.

3. With the new system in place, all babies will be registered with the Practice within 24 to 48 hours of the birth notification letter arriving at the Practice and without any action being required on the part of the parents. Were a parent to seek an appointment for a baby within the very short window of time before the birth notification letter is actioned by the Practice, the baby would be immediately registered and an appropriate appointment made.

4. A new baby welcome letter is then sent to the parents advising them that the baby has been registered with the Practice and asking them to complete a registration form for the baby to complete the process. The baby would however already be formally registered with the Practice and so the need to complete this form would not delay or prevent any care being provided should it be needed in the intervening period.

Communication between the GP Practice and the external filtering company

Your Prevention of Future Deaths Report has also raised concerns in relation to the communication between the Practice and the external filtering company that we use to assist us with the correspondence received by the Practice in relation to patients. Whilst the Practice in the past dealt with all incoming correspondence “in-house”, we receive between 1,000 and 1,200 items of electronic correspondence via Docman each week (with some hard copy post on top) and this became unmanageable and unsafe for patients. Assistance in managing this is therefore now provided by an external company.

Brill Surgery 22 Thame Road Brill Bucks HP18 9SA

Tel: 01844 238284 Fax: 01844 238568 Chinnor Surgery 5 Station Road Chinnor Oxon OX39 4PX

Tel: 01844 351230 Fax: 01844 354328 New Chapel Surgery High Street Long Crendon Bucks HP18 9AF

Tel: 01844 208228 Fax: 01844 201906 Thame Health Centre East Street Thame Oxon OX9 3JZ

Tel: 01844 212553 Fax: 01844 260243 Practice Manager

VAT Reg No 879 1204 06 Any urgent correspondence received by the Practice will be filtered out and actioned by the workflow team when accessing this via Docman. The workflow team scan read every piece of correspondence and are trained to identify matters requiring urgent attention even if a letter is not obviously marked as “urgent”. Any urgent correspondence therefore will not be sent externally as it will already have been picked up and dealt with by the workflow team based at the Practice. In addition, as set out above, all new birth notification letters will be picked up and actioned by the Practice team with the baby being immediately then registered with the Practice. These letters are therefore no longer sent externally.

All other documents are filed onto the patients’ records by the workflow team (and so are immediately available for clinicians to see) and are sent to the external company in a batch every Friday. The external company will then summarise and code all relevant correspondence into patient’s records. Any correspondence that requires action on the part of the Practice will be returned on a daily basis and highlighted to the Practice as requiring action. Under the agreement between the Practice and the external company, they have 5 working days to deal with any correspondence which is passed to them. As indicated above, however, anything requiring urgent action will already have been picked up and dealt with by the workflow team. Anything that is returned as it requires action on the part of the Practice is sent to an inbox within Docman which is cleared by the Practice workflow team on a daily basis.

Although the majority of correspondence is received at the Practice electronically, some correspondence is still received by post. Any hard copy correspondence is scanned by the reception team on a daily basis and will be sent externally with the batch of documents that has been received electronically that week. Any urgent correspondence would not usually be sent to the Practice via post and if it is it would be backed up by an email from the sender which would then be picked up and actioned by the workflow team.

The work undertaken by the external company is audited on a monthly basis by our Data Quality and Compliance Lead at the Practice and an audit on random letters is also carried out on a daily basis by the same person. Any issues that may have been identified are fed back on a weekly basis with appropriate action then put in place to deal with any concerns. The Practice intends to shortly carry out a review of the process in place concerning how incoming correspondence is dealt with to ensure that matters are being dealt with as efficiently as possible.

Concern that instructions to commence treatment could be lost in similar circumstances

As indicated above, anything requiring urgent action will be picked up by the workflow team and dealt with internally. It will not therefore be sent externally. Correspondence requiring non-urgent action would be returned to the Practice by the external company who are regularly audited by the Practice to ensure that they are providing an appropriate level of service. In Oscar’s case, the letter from the Trust regarding the prescription of antibiotics was not sent externally. As Oscar had not been registered with the Practice, there was no patient record to attach the letter to on our system. The “pending” folder that this letter was erroneously moved to has now been deleted as the Practice process for new baby registrations has been amended as above and thus there is no need for this folder.

If correspondence were to be received for a patient who had never been registered at the Practice before (e.g. likely sent to us in error), this could be rejected electronically on Docman which sends the document back to the sender

Brill Surgery 22 Thame Road Brill Bucks HP18 9SA

Tel: 01844 238284 Fax: 01844 238568 Chinnor Surgery 5 Station Road Chinnor Oxon OX39 4PX

Tel: 01844 351230 Fax: 01844 354328 New Chapel Surgery High Street Long Crendon Bucks HP18 9AF

Tel: 01844 208228 Fax: 01844 201906 Thame Health Centre East Street Thame Oxon OX9 3JZ

Tel: 01844 212553 Fax: 01844 260243 Practice Manager

VAT Reg No 879 1204 06 informing them of the reason (checks having been done by us first to ensure that they really are not registered with us). If the patient has moved surgeries and thus is no longer registered at the Practice, we can either reject that correspondence as mentioned above or if we know where the patient has registered, we can print and send it on by post/email to the new surgery to avoid any delay.

Summary

To conclude, I hope that you and Oscar’s parents are reassured that this matter has been taken extremely seriously by the Practice and that our processes have been reviewed and improved (and will continue to be reviewed and improved), particularly with regards to the registration of new babies at the Practice.