Source · Prevention of Future Deaths

Andrew Heys

Ref: 2025-0073 Date: 24 Jan 2025 Coroner: John Pollard Area: Manchester West Responses identified: 2 / 2 View PDF

Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient data.

Date 24 Jan 2025

56-day deadline 21 Mar 2025 est.

Responses identified 2 of 2

Suicide (from 2015)

Coroner's concerns

AI summary

Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient data.

View full coroner's concerns

During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call alter speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS.

Responses

2 respondents

Department for Health and Social Care Central Government

15 Sep 2025 PDF

Action Planned

The Department of Health and Social Care highlights ongoing investment in digital transformation, including rolling out Electronic Patient Records and supporting trusts to reach optimal digital maturity, as well as committing to the delivery of a single patient record (SPR) by 2028. (AI summary)

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Dear Mr Pollard,

Thank you for the Regulation 28 report of 24/01/2025 sent to the Department of Health and Social Care about the death of Andrew Dominic Heys. I am replying as the Minister with responsibility for data and technology.

Firstly, I would like to say how saddened I was to read of the circumstances of Andrew Heys’s death, and I offer my sincere condolences to their family and loved ones. The circumstances your report describes are concerning and I am grateful to you for bringing these matters to my attention. Please accept my sincere apologies for the significant delay in responding to this matter.

The report raises concerns to the Department of Health and Social Care on health professionals being unable to access health records of patients held by another health professional, and systems not ‘talking to each other.’

In preparing this response, my officials have made enquiries with NHS England and the Care Quality Commission to ensure we adequately address your concerns.

I agree that ensuring health and care professionals have access to a single source of digital information about the patients they are treating and caring for is vitally important to delivering the best care possible. The Department of Health and Social Care, and NHS England have programmes of work underway which should assist in preventing future deaths connected to this issue. Since 2022, £1.9bn has been invested in laying the foundations for digital transformation across the health and care system, including rolling-out Electronic Patient Records to NHS trusts that don’t have one, and supporting those with an existing one to replace, extend or optimise it. Currently, 93% of Secondary Care Trusts have an EPR in place, we expect 96% of trusts to have EPRs by March 2026, with the remainder to follow.

NHS England is also providing support to bring trusts up to an optimum level of digital maturity, with all secondary care organisations completing a Digital Maturity Assessment in May 2024, which will be run yearly to track progress and identify areas for improvement, which will further reduce barriers to the sharing of information needed to treat patients. Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single patient record (SPR). This will provide a comprehensive patient record, bringing together all of a patient’s medical records into one place. We have been engaging with the public to help shape our plans, including what information they would like to see included in a single patient record and we will continue to talk to the public and to health and care professionals as we design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028 and be rolled out first in maternity care. Introducing a single patient record will give clinicians all the data they need when treating patients. By having access to all relevant information about a patient, frontline staff will be able make more informed decisions and deliver the best care at the time it is needed. I hope this response is helpful. Thank you for bringing these concerns to my attention.

BARDOC

PDF

Disputed

BARDOC disputes the coroner's finding, stating the GP in question did receive the required training and that the issue was due to a clinical decision made by the clinician. They have referred the matter to the NHS Performance team. (AI summary)

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Dear Sir/Madam

Re: Mr Andrew Dominic HEYS (Deceased)

Official Statement from BARDOC Limited In Response to the Section 28 Regulation Issued by HM Assistant Coroner, Mr Pollard – Bolton Coroners Court, 8th January 2025 Following the inquest held at Bolton Coroners Court on 8th January 2025, BARDOC Limited acknowledges the issue of a Section 28 Regulation (Prevention of Future Deaths) by HM Assistant Coroner Mr Pollard. The regulation was issued after concerns were raised regarding the actions of a General Practitioner (GP) who was working on behalf of BARDOC as part of the Greater Manchester Clinical Assessment Service (GMCAS). During the inquest, the GP stated under oath that she had not received training on BARDOC’s clinical pathways, and expressed confusion over accessing patient’s GP records. As a result of this testimony, the Coroner concluded that a lack of training may have contributed to the incident which is under investigation. BARDOC has since conducted a thorough internal review and investigation. We have submitted to the Coroner detailed and substantial evidence that the GP did, in fact, receive the appropriate and required training prior to recommencing work within the GMCAS. This included access to current Standard Operating Procedures (SOPs), shadowing shifts, and support resources including updated pathways and processes. It is important to note that BARDOC was not requested to attend the inquest either as a witness or an interested party. As a result, we were unable to directly respond to the concerns raised during the proceedings. We believe that the testimony provided by the GP at the inquest was not factually accurate, and regret that this may have influenced the Coroner’s findings. It is our position that the issue did not arise due to any inadequacy in the training or support provided by BARDOC, but rather due to an unfortunate clinical decision made independently by the clinician involved. BARDOC takes our duty of care to patients and commitment to continuous improvement extremely seriously. We are proud of our comprehensive training programmes, operational protocols, and the robust support systems available to all clinicians within our services. We will continue to work PRIVATE AND CONFIDENTIAL The Chief Coroner

Date: 12th August 2025

collaboratively with Coroners, regulators, and NHS partners to ensure the highest standards of clinical governance and patient safety.

The BARDOC board has assessed this matter and concluded that a referral to the NHS Performance team is mandated. This decision has been supported by the Coroner. As the Medical Director, I am duty bound to follow the instruction and refer the matter for further investigation due to concerns mentioned earlier in this letter We extend our sympathies to the family affected by this case, and remain committed to learning from all incidents in the interest of improving care across the healthcare system.

Report sections

Investigation and inquest

On 21 March 2024 I commenced an investigation into the death of Andrew Dominic HEYS aged 29. The investigation concluded at the end of the inquest on 08 January 2025. The conclusion of the inquest was 'Open' and the medical cause of death was established as la) Drowning II) Post-Vaccination Auto-Immune Encephalopathy.

Circumstances of the death

In December 2021 the deceased received the vaccination against Covid 19. This was his booster. He reacted very badly to the vaccination and thereafter suffered from Auto-Immune Encephalopathy, the effects of which were devastating both physically and mentally. On the 12th March 2024 the deceased went to a bridge over the Manchester Ship Canal, climbed over the parapet and fell into the water. His body was discovered four days later.

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Shared signals

Related inquiry recommendations

Report details

Reference: 2025-0073
Date of report: 24 January 2025
Coroner: John Pollard
Coroner area: Manchester West

Responses identified

Responses identified 2 of 2

All listed responses identified

Organisations named in PFD reports are normally expected to respond within 56 days. Deadline: 21 Mar 2025 (estimated).

Sent to

BARDOC

Department of Health and Social Care

Source links

Judiciary.uk page → Report PDF →

Data: judiciary.uk under OGL.