NHS England
NHS / Health Body
Noted
NHS England acknowledges the concerns, explains information sharing systems, refers to GMC guidance, and mentions internal discussions of PFD reports. They also refer to the Trust's response. (AI summary)
View full response
Dear Coroner,
Re: Regulation 28 Report to Prevent Future Deaths – Sarah Mitchell who died on 22 September 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 January 2024 concerning the death of Sarah Mitchell on 22 September 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sarah’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Sarah’s care have been listened to and reflected upon.
In your Report you raised the concern that Accident & Emergency Department staff could not access Sarah’s medical records detailing the medication she was already receiving and the rationale for her dispensing regime. Sarah was prescribed 28 days’ worth of medication within a 48-hour period, at a time where there were concerns that she was hoarding medication and despite her history of overdose events.
Healthcare organisations use a combination of locally / regionally provided and nationally provided information sharing systems to support patient care. A contribution from the Shared Care Records programme would be helpful in this case to understand what information is provided in the area where the deceased received care through any local Shared Care Record or other local sharing agreements. You may wish to refer to Norfolk and Waveney Integrated Care Board (ICB) on this matter as ICBs are responsible for the delivery of Shared Care Records. This response focuses on nationally provided services.
NHS England monitor the accesses made by organisations to the services that we support, including the Summary Care Record application (SCRa) and the National Care Records Service (NCRS). We publish some of this information here:
accessing-data/deployment-and-utilisation-hub/summary-care-records-deployment- and-utilisation.
In this case specifically, our dashboards indicate that healthcare professionals at James Paget University Hospitals NHS Foundation Trust (“the Trust”) have been using the Summary Care Record application and the National Care Records Service to view National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
4 March 2024
Summary Care Records (among other information e.g. Demographic Information, Child Protection - Information Sharing system, Covid Vaccination information, etc). Accident & Emergency (A&E) staff should be among the staff groups who have access to these records at the Trust.
For background, it is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work was accelerated during 2023 and is projected to conclude during Q2 2024. NCRS is the successor to SCRa and by design removes a large amount of the reported barriers to adoption within many care settings. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, it is free to use and includes additional features and services beyond the legacy SCRa product. Further information on NCRS can be found here:
SCRa and NCRS both provide access to a patient’s Summary Care Record (unless the patient has opted out). The Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medications, allergies and details of any previous bad reactions to medicines, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care. Patients are asked for their permission to view before this information can be accessed. Further information about SCR is available here: https://digital.nhs.uk/services/summary-care- records-scr.
With regards to current repeat medications in the SCR specifically, the information includes details of all current repeat medications including the medication item (including drug name, dosage, and formulation), dosage instructions (e.g. take one daily), quantity prescribed and last issue date. Principally, this provides a list of those medications prescribed by the patient’s GP Practice (but it is possible to include information about those medications which have been prescribed elsewhere, though this functionality is often not used for a variety of reasons). Thus, in this case, clinicians at James Paget University Hospitals NHS Foundation Trust are likely to have had access to information about the Morphine, Promethazine, Gabapentin and Fluoxetine prescribed to the patient from their registered GP Practice.
Provision of medication in quantities of less than a month’s supply usually suggest attempts are being made in General Practice to control a patient’s access to medication (although this approach might also on some occasions be used for older patients who are receiving medications in monitored dosage systems).
In addition, summary details about the overdose events in this patient’s clinical history would likely be captured within a patient’s GP Summary, and as a result would be
likely to be present in this patient’s Summary Care Record with Additional Information. Further information about SCR Additional Information can be found here:
scr. Currently, 89% of patients have an SCR with Additional Information.
It is noted in the Regulation 28 letter that this patient suffered from chronic back pain for a period of over 15 years. As a result, this patient may have had some form of healthcare management plan e.g. emergency healthcare plan, treatment escalation plan, etc. Details of a healthcare management plan can be shared using a local Shared Care Record or summary details of a healthcare management plan can be shared using the Summary Care Record. SCR also contains provision for inclusion of information relating to a ‘Special Patient Note’ where this has been coded into the patient’s GP record and the patient has an SCR with Additional Information. Clinical information is best shared when these ways of working have been agreed up front across the local healthcare economy.
There is also clear guidance from the General Medical Council (GMC) on prescribing responsibilities for healthcare professionals. This includes:
• Consideration of whether a prescriber has the ‘sufficient information to prescribe safely, for example if you have access to patient’s medical records and can verify relevant information’.
• If not a patient’s regular prescriber, prescribers should seek the patient’s consent to contact their GP for further information.
• If a patient objects to information being shared, prescribers must have justification for prescribing without that information.
NHS England would refer you to James Paget University Hospitals NHS Trust for further information on Sarah’s care and your concerns, including their prescribing policies and we note that you have also addressed your Report to them. We understand that the Trust has contacted the coroner to clarify some of the issues referenced within your Report. We have been asked to be sighted on their response and will consider this carefully once we are in receipt.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.
Re: Regulation 28 Report to Prevent Future Deaths – Sarah Mitchell who died on 22 September 2022.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 January 2024 concerning the death of Sarah Mitchell on 22 September 2022. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Sarah’s family and loved ones. NHS England are keen to assure the family and the coroner that the concerns raised about Sarah’s care have been listened to and reflected upon.
In your Report you raised the concern that Accident & Emergency Department staff could not access Sarah’s medical records detailing the medication she was already receiving and the rationale for her dispensing regime. Sarah was prescribed 28 days’ worth of medication within a 48-hour period, at a time where there were concerns that she was hoarding medication and despite her history of overdose events.
Healthcare organisations use a combination of locally / regionally provided and nationally provided information sharing systems to support patient care. A contribution from the Shared Care Records programme would be helpful in this case to understand what information is provided in the area where the deceased received care through any local Shared Care Record or other local sharing agreements. You may wish to refer to Norfolk and Waveney Integrated Care Board (ICB) on this matter as ICBs are responsible for the delivery of Shared Care Records. This response focuses on nationally provided services.
NHS England monitor the accesses made by organisations to the services that we support, including the Summary Care Record application (SCRa) and the National Care Records Service (NCRS). We publish some of this information here:
accessing-data/deployment-and-utilisation-hub/summary-care-records-deployment- and-utilisation.
In this case specifically, our dashboards indicate that healthcare professionals at James Paget University Hospitals NHS Foundation Trust (“the Trust”) have been using the Summary Care Record application and the National Care Records Service to view National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
4 March 2024
Summary Care Records (among other information e.g. Demographic Information, Child Protection - Information Sharing system, Covid Vaccination information, etc). Accident & Emergency (A&E) staff should be among the staff groups who have access to these records at the Trust.
For background, it is worth mentioning that, in the past, the Summary Care Record application (SCRa) was the main method to access SCRs for the existing NHS user base. However, NHS England have been involved in a programme of work to transfer SCR users from the legacy SCRa service to the new National Care Records Service (NCRS) service. This work was accelerated during 2023 and is projected to conclude during Q2 2024. NCRS is the successor to SCRa and by design removes a large amount of the reported barriers to adoption within many care settings. The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, it is free to use and includes additional features and services beyond the legacy SCRa product. Further information on NCRS can be found here:
SCRa and NCRS both provide access to a patient’s Summary Care Record (unless the patient has opted out). The Summary Care Record (SCR) is a national database that holds electronic records of important patient information such as current medications, allergies and details of any previous bad reactions to medicines, created from GP medical records. It can be seen and used by authorised staff in other areas of the health and care system involved in the patient's direct care. Patients are asked for their permission to view before this information can be accessed. Further information about SCR is available here: https://digital.nhs.uk/services/summary-care- records-scr.
With regards to current repeat medications in the SCR specifically, the information includes details of all current repeat medications including the medication item (including drug name, dosage, and formulation), dosage instructions (e.g. take one daily), quantity prescribed and last issue date. Principally, this provides a list of those medications prescribed by the patient’s GP Practice (but it is possible to include information about those medications which have been prescribed elsewhere, though this functionality is often not used for a variety of reasons). Thus, in this case, clinicians at James Paget University Hospitals NHS Foundation Trust are likely to have had access to information about the Morphine, Promethazine, Gabapentin and Fluoxetine prescribed to the patient from their registered GP Practice.
Provision of medication in quantities of less than a month’s supply usually suggest attempts are being made in General Practice to control a patient’s access to medication (although this approach might also on some occasions be used for older patients who are receiving medications in monitored dosage systems).
In addition, summary details about the overdose events in this patient’s clinical history would likely be captured within a patient’s GP Summary, and as a result would be
likely to be present in this patient’s Summary Care Record with Additional Information. Further information about SCR Additional Information can be found here:
scr. Currently, 89% of patients have an SCR with Additional Information.
It is noted in the Regulation 28 letter that this patient suffered from chronic back pain for a period of over 15 years. As a result, this patient may have had some form of healthcare management plan e.g. emergency healthcare plan, treatment escalation plan, etc. Details of a healthcare management plan can be shared using a local Shared Care Record or summary details of a healthcare management plan can be shared using the Summary Care Record. SCR also contains provision for inclusion of information relating to a ‘Special Patient Note’ where this has been coded into the patient’s GP record and the patient has an SCR with Additional Information. Clinical information is best shared when these ways of working have been agreed up front across the local healthcare economy.
There is also clear guidance from the General Medical Council (GMC) on prescribing responsibilities for healthcare professionals. This includes:
• Consideration of whether a prescriber has the ‘sufficient information to prescribe safely, for example if you have access to patient’s medical records and can verify relevant information’.
• If not a patient’s regular prescriber, prescribers should seek the patient’s consent to contact their GP for further information.
• If a patient objects to information being shared, prescribers must have justification for prescribing without that information.
NHS England would refer you to James Paget University Hospitals NHS Trust for further information on Sarah’s care and your concerns, including their prescribing policies and we note that you have also addressed your Report to them. We understand that the Trust has contacted the coroner to clarify some of the issues referenced within your Report. We have been asked to be sighted on their response and will consider this carefully once we are in receipt.
I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us 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.