Myles Scriven

Dear Mr Oliver, Re: Regulation 28 Report to Prevent Future Deaths – Myles Edward Scriven who died on 16 April 2023.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14 July 2025 concerning the death of Myles Edward Scriven on 16 April 2023. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Myles’ family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Myles’ care have been listened to and reflected upon.

Your Report raises concerns that Myles’ GP surgery were ignorant of the regulatory requirements and reasonable adjustments required for Myles in light of his learning disability and autism, that they failed to record numeric observations properly, and that they failed to undertake a detailed and rigorous internal review for learning purposes following Myles’ death.

Learning disability information A learning disability is defined by the Department of Health and Social Care (DHSC) (2001) as a significantly reduced ability to understand new or complex information, to learn new skills (impaired intelligence), with a reduced ability to cope independently (impaired social functioning), which started before adulthood. A learning disability is different for everyone. The degree of disability can vary greatly, being classified as mild, moderate, severe, or profound. In all cases, a learning disability is a lifelong condition and cannot be cured. A learning disability is different to a learning difficulty, which is a reduced ability for a specific form of learning and includes conditions such as dyslexia (reading), dyspraxia (affecting physical co-ordination), and attention deficit hyperactivity disorder (ADHD). A person with a learning disability may also have one or more learning difficulties. Training requirements Under the Health and Care Act 2022, since 1 July 2022, Care Quality Commission (CQC) registered providers have been required to ensure that their staff, including National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

2 September 2025

GPs, receive specific training on learning disability and autism appropriate to their role. On 19 June 2025, NHS England published a Code of Practice which sets out expectations for training content and delivery. This training helps to ensure that staff have the right knowledge and skills to provide safe and informed care. To support this, we have been rolling out the Oliver McGowan Mandatory Training on Learning Disability and Autism to the health and adult social care workforce. The training includes content on understanding learning disability and autism, frequently co-occurring conditions, reasonable adjustments, and reflection on own attitudes and professional behaviour. Over 3 million people have completed the e-learning package which is the first part of Oliver’s Training, and is freely available on the Elearning for Health Hub. Health checks and reasonable adjustments NHS England is working with the Royal College of GPs and other stakeholders to improve the quality of annual health checks for people with a learning disability and will be publishing a framework for annual health checks in coming months. In providing the learning disability health check scheme, GP practices are encouraged to provide a more proactive and coordinated approach to care, improving liaison with carers and secondary care, and developing a health action plan with individual patients in response to their needs. The Equality Act 2010 places a legal duty on health and care services to make changes to their approach or provision to ensure services are as accessible for people with disabilities as they are for everyone else. NHS England has introduced the reasonable adjustment digital flag to enable health and care services to record, share and view details of the reasonable adjustments a person needs to support their care. Organisations are required to use their own systems and processes to record reasonable adjustment needs, and staff e-learning training has been rolled out for all health and care staff to support this. Accurate recording The GP contract requires that accurate patient records are maintained, including for patients with a learning disability. The Learning Disabilities Health Check Scheme continues to be offered via the Direct Enhanced Services Directions, to encourage the maintenance and updating of learning disability registers and the completion of annual health checks and health action plans for each registered patient aged 14 years and over on the learning disabilities register. The Investment and Impact Fund continues to directly incentivise delivery of annual health checks and health action plans. NHS England has also produced guidance for general practice on Improving identification of people with a learning disability. ICB contract management of GP practices

Integrated Care Board (ICBs) are responsible for the commissioning and contract management of GP practices. ICBs will undertake intelligence led and routine contractual reviews based on a combination of national and local data sources, alongside other soft intelligence, and practice visits to identify practice variation and improvement needs. NHS England publishes guidance for ICBs, which includes an assurance framework for contractual reviews. As part of these reviews, NHS England would expect ICBs to ensure GP practices have processes in place for learning from patient safety events. The national GP contract has introduced new requirements in 2025/26 to ensure practices have regard to the primary care patient safety strategy published in September 2024, and are registered with the learn from patient safety events service (LFPSE) for the purposes of:
• recording patient safety events at the practice about the services delivered by the practice, thereby contributing to the national NHS-wide data source to support learning, improvement and learning culture.
• enabling the practice to record patient safety events occurring in other health care settings (for instance if a GP practice wished to record an unsafe discharge from hospital).
• individuals recording patient safety events being able to download a copy of the record for purposes of supporting appraisal and revalidation. GP practices are now required to declare annually their compliance which, alongside data from the LFPSE, will support the ICB contractual review processes described. Regional learning and improvements My regional clinical quality colleagues for the North East and Yorkshire region have also been engaging with NHS West Yorkshire Integrated Care Board on the concerns raised in your Report. The ICB is undertaking a LeDeR review to understand what local learning can be taken from this tragic death and will implement actions at a local level because of their findings. NHS England is advised by the ICB that the GP surgery involved in Myles’ care has taken learnings from Myles’ death. These include:
• Improved processes for the management of patients with learning disabilities and autism, to include all staff completing the Oliver McGowan training and adopting a low threshold for offering face-to-face reviews for patients with learning disabilities.
• Reminding clinical staff of the importance of accurate documentation for clinical decision-making, safety netting and continuity of care, which will be monitored through protocols and audits.
• Undertaking Practice Protected Time meetings and Significant Event Analyses (SEAs) to discuss Myles’ care and lessons learned (early triage of breathless patients, same day face-to-face review of patients, etc.)

We refer the Coroner to the GP surgery’s response to you for further information. I would also like to provide further assurances on the 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 events, such as the sad death of Myles, are shared across the NHS at both a national and regional level and helps us to 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.

Dear Mr Oliver, Re: Regulation 28 Report to Prevent Future Deaths – Myles Edward Scriven We write in formal response to the Regulation 28 Report issued to Dalton Surgery on 17 July 2025, with submission requested by 8 September 2025, concerning the tragic circumstances surrounding Mr Myles Edward Scriven (MS). Firstly, on behalf of the GP partners and all staff at Dalton Surgery, we extend our deepest sympathies to Mr Scriven’s family. We wish to assure you that we have taken the concerns raised in the Regulation 28 Report, and the family’s feedback, very seriously. Our priority is to ensure that such a situation does not reoccur for other patients. In this response, we address the three key areas of concern highlighted in your notice. To support the GP Partners in comprehensively addressing these issues, we have enclosed a detailed action plan. This plan outlines specific measures, assigns named accountable leads, includes auditable evidence, and sets clear timescales for monitoring through our Bimonthly Practice Protected Time (PPT) meetings. Working collaboratively with our ICB colleagues, progress will also be reported to the place- based Quality Sub Committee and a full review of actions will be undertaken at a six month follow up meeting involving key stakeholders. Since receiving the Regulation 28 notice, we have implemented a range of actions to enhance patient safety, strengthen clinical practice, and embed learning throughout the practice. We also provided NHS England ( , Head of Clinical Quality, Northeast and Yorkshire) with written assurance on 29 July 2025 regarding progress in these areas.
1. Understanding and Supporting Patients with Learning Disabilities and Autism Dalton Surgery

Mr Crispin Oliver HM Assistant Coroner West Yorkshire (Western) Coroner Area HM Coroner’s Court Cater Building 1 Cater Street Bradford BD1 5AS

We acknowledge that our practice historically did not have sufficiently robust systems in place to ensure consistent, proactive care for patients with Learning Disabilities (LD) and Autism. Specifically, there was variable awareness amongst staff of the additional challenges faced by these patients in expressing symptoms, the need for collateral history from carers, and the importance of reasonable adjustments in clinical practice. Summary of key actions undertaken: a) Designated three Learning Disability (LD) and Autism champions: a GP, a nurse, and an administrative team member. The role of the LD Champions will include advocacy and support for patients, improving health outcomes and wider primary care engagement. b) All practice staff have completed Oliver McGowan Level 1 training, with Level 2 training scheduled for October 15th and 28th 2025. c) New administrative staff receive mandatory LD training before commencing duties; locum doctors are provided with LD awareness packs. d) Implemented standard reasonable adjustments for patients, including extended appointment times, easy-read correspondence, health passports, and proactive recall systems. e) Practice Manager received bespoke training on discussing reasonable adjustments with patients. f) Engaged with Jessica Atkinson (Strategic Health Facilitator for Kirklees Adult Learning Disability) to jointly review the LD register and enhance communication aids, recall processes, and patient resources. A follow-up visit is planned for October 2025. g) Extended appointment length for LD and Autism Health Checks from 45 minutes to one hour. h) Embedded improved safety-netting practices and clinical tools (CURB-65, MEWS, CHA2DS2-VASc) to ensure systematic patient assessments and recalls. i) Added patient icons in SystmOne to flag LD and Autism status; employed a dedicated coder to maintain accurate records. j) Scheduled Capacity and Consent training for designated GP with DAC Beachcroft on 8th October 2025. k) Adjusted invitation scheduling for LD health checks to ensure all patients are invited appropriately, with staff trained on tailored invitation management. These measures reflect both training completion and practical application, safeguarding patients with LD and ensuring prioritised, appropriate care. The Practice plans to undertake bi-monthly audits of all patients on the LD Register to confirm its accuracy and updated care plans and hospital passports where necessary. The purpose of the audit is to affirm that the LD Register is being used with 100% accuracy and regular audits will continue to be carried out. Please refer to the attached action plan for audit details and scheduling.

2. Improvement in Recording of Clinical Observations We fully acknowledge the Coroner’s concern that the GP consultation on 20 March 2023 did not include adequate recording of numeric observations (e.g. oxygen saturation, pulse, respiratory rate). Reflection from GP (also stated during the Inquest) “I acknowledge that my consultation record was poor and lacking in important details – particularly quantitative values for examination findings. This is not usual for my way of working. I am confident that such observations were in fact undertaken and were satisfactory, but unfortunately, they were not recorded. In light of this, I have changed my practice: I now use internal systems and templates to prompt and facilitate proper capture of these values in every consultation.” Summary of key actions undertaken: a) Reiterated the importance of thorough documentation of vital clinical observations during consultations, particularly for acute symptoms such as breathlessness, through targeted clinical safety refresher training where needed. b) Introduced enhanced triage protocols and promoted face-to-face assessments when clinically indicated. c) Reminded clinical staff of documentation’s role in decision-making and safety-netting; compliance monitored via audits and peer reviews, detailed in the enclosed action plan. d) Implemented consultation templates, digital prompts, Ardens templates, and AI-supported dictation/scribing tools to improve accuracy. e) Adopted a low threshold for same-day reviews or A&E referral for patients presenting with breathlessness. f) Provided additional training for administrative staff to escalate urgent symptoms promptly. g) Recent case reviews demonstrate effective triage and urgent management of patients presenting with breathlessness, including timely admissions and diagnoses of pulmonary embolism. h) The practice has recognised the necessity of immediate same-day review or direct A&E referral for breathlessness presentations, now standardised in our clinical approach. The Practice plans to undertake monthly audits of 20 consultations for the three months to assess compliance with observation documentation. Our target will be 100% compliance consecutively on each occasion.
3. Learning from Significant Events and Internal Reviews We accept that, immediately after Myles’ death in April 2023, our internal review processes were not as rigorous or structured as they should have been. While reflection occurred, the depth and documentation of this initial review did not fully meet expected governance standards.

Summary of actions undertaken: a) Conducted two Practice Protected Time (PPT) sessions in June and October 2023 focusing on clinical decision-making, triage, and prevention. b) Held two further Significant Event Analyses (SEAs) in April and July 2025 to review the case and coroner’s findings. c) All clinical staff participated; acknowledged Myles should have been referred to secondary care between 16 – 20 March 2023 and that the failure to do so made a direct contribution to his death. d) Enhanced policies and processes for incident reviews now include clearer documentation, minutes, and explicit learning outcomes. e) Promoted an open culture of reporting, reflection, and continuous learning. f) Updated the Practice Significant Event Policy, accessible on Microsoft Teams and in hard copy with signed staff acknowledgements, is being aligned with the NHS England Patient Safety Incident Response Framework (PSIRF) and the Primary Care Patient Safety Strategy for GP practices. g) Bimonthly PPT meetings regularly incorporate SEA discussions and policy review to reinforce staff understanding. Going forward, the Practice will schedule quarterly Learning from Events meetings to review SEAs and share learning from both internal and external cases to promote shared learning. The first quarterly meeting is scheduled for January 2026.This will be in line with the Primary care patient safety strategy and Learning from Patient Safety Events (LFPSE). This comprehensive approach ensures thorough investigation, learning, and sustained improvements in patient safety.
4. Support from System Partners and Collaborative Networks As a GP practice in Kirklees we: a) Benefit from the Strategic Health Facilitator for Kirklees Adult Learning Disability (SWYPFT), providing training and support across local GP practices. b) Utilise Kirklees Get Checked Out resources and LD-friendly template letters uploaded in SystmOne for consistent communication. c) Following migration to SystmOne, collaborated with the ICB Data Quality team to verify and ensure accurate coding of patients with LD and Autism. d) Participate in the Tolson Primary Care Network’s ‘Mondays at the Museum’ Creative Health initiative, promoting wellbeing activities in a stigma-free environment, actively encouraging patients with LD and Autism to engage. Dalton Surgery has taken robust and sustained action in response to the Regulation 28 report. We have strengthened clinical processes, embedded new policies, enhanced training, and fostered a culture of transparency and continuous improvement.

We trust this response and the enclosed action plan demonstrate the significant steps we have already taken and that you are assured of our commitment to delivering safe, inclusive, and accountable care. We would be happy to provide any further information or supporting documentation as required.

Dear HM Coroner,

Prevention of future death report following inquest into the death of Myles Edward Scriven (

Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation 28: Report to Prevent Future Deaths, which was issued following the death of Myles Edward Scriven, in which CQC was named as a respondent.

Firstly, we would like to extend our condolences and sympathies to Myles’ family and friends.

CQC has a process to follow whenever a Regulation 28 report is received, including where CQC is named within the report.

In line with CQC’s enforcement and internal specific incident guidance, policies and procedures, a Decision Review Meeting (DRM) has taken place. This initial assessment enables CQC to consider and determine any appropriate regulatory response. This can include monitoring, inspection and/or civil enforcement action to protect service users from ongoing risks; and to assess and determine whether there may be reasonable grounds to suspect that a service user may have sustained avoidable harm or been exposed to a significant risk of avoidable harm, as a result of registered person failure to provide safe care and treatment.

Specifically in relation to Calderdale and Huddersfield NHS Foundation Trust, the local CQC operational team have held an initial DRM where relevant information from stakeholders and internally held information within CQC is shared and a course of action is decided on. Following this we have contacted the Trust to inform them we have received the Regulation 28 report, and they are sending us further

information about the full circumstances surrounding this sad case and the actions they have taken, or are planning to take, to prevent reoccurrence.

Calderdale and Huddersfield NHS Foundation Trust were last inspected in June 2018 at a well led level, when it was rated as good overall and for all key lines of enquiry. However, given your report into the death of Myles Scriven, and the length of time since we last inspected, we are considering our regulatory response following the initial DRM which may include carrying out an inspection. Please note this is confidential at this stage. The DRM particularly focused on concerns in relation to those outlined in your report including:

• The impact of mental capacity assessments auditing, the nursing leadership walkaround of all wards auditing that LD and autism policies are applied in practise.
• How the outcomes of any audits were acted on
• Taking into consideration that much of the above which is now in place was already in place in 2022. But in Myles’s case it had no impact
• Specialist staff recommendations were not followed up
• The culture throughout the staff was not reflective of the specialist’s advice

In response to the known challenges faced by people with a learning disability and autistic people when they access health care services, as well as feedback from people with lived experience, CQC had already begun a program of work focusing on the health inequalities faced by this population group. This includes taking action to review how we consider whether Trusts are providing safe care and treatment for people with a learning disability and autistic people. Specifically, we are reviewing and will update the guidance that we provide for our inspection teams to follow. This aims to prompt inspectors to carry out a more thorough assessment than currently takes place and gives them the necessary tools to do so. Our regulatory leadership teams are leading on this. Additional areas of work in this specific area focus on how CQC can work more closely with the Learning from Lives and Deaths -People with a learning disability and autistic people program ( LeDeR ) – sharing information and building closer links in order to do so more effectively.

We are also taking steps to ensure our inspection teams have the right support and training to review how Trusts provide care and treatment for people with a learning disability.

We are arranging some bespoke upskilling sessions for our secondary care inspection teams. This will cover pertinent issues including what people with lived experience have told us about issues they have faced when accessing hospital care. Further, it will support inspection teams to consider, understand and analyse how services are meeting the needs of their population.

Since the 1st July 2022, all CQC registered health and social care providers have been required by the Health and Care Act 2022 to provide training for their staff in learning disability and autism, including how to interact appropriately with autistic people and people with a learning disability. This should be at a level appropriate to their role.

On the 19th June 2025, the Oliver McGowan Code of Practice was published and laid before parliament by the Department of Health and Social Care. The code commenced on 6th September 2025 and is now legal guidance. The purpose of the code is to explain what is meant by training that is ‘appropriate to the person’s role’ and to provide guidance on how to ensure all staff receive such training.

Compliance with the standards set out in the code of practice, is expected to ensure that every person receives high quality learning disability and autism training that meets their learning needs and is appropriate to their role. Importantly, this aims to improve the experiences and outcomes of autistic people and people with a learning disability when they access CQC regulated health and social care services. This means that CQC registered providers must ensure that they provide each member of staff with training that meets the standards set out in the Code in order to deliver the best possible outcomes. CQC will use the Oliver McGowan Code of Practice when considering whether providers are meeting the requirements of the regulation.

Throughout September, the CQC’s autistic people and people with a learning disability team will be running bespoke upskilling sessions on the mandatory training requirement and code of practice with the aim of equipping inspection teams with the knowledge and skills they need to regulate this requirement effectively and consistently. Specifically pertinent to the case of Myles Scriven, the code of practice enables both providers and CQC to consider the extent to which learning is put into practice.

I hope this response addresses your concerns and clarifies the role and remit of CQC in relation to this matter. If you have any further concerns or queries, please contact us via email .