NHS England
NHS / Health Body
Action Planned
AI-generated response summary
• NHS England is developing and rolling out neighbourhood mental health hubs to provide integrated care and improve information sharing for complex patients. • It operates national services, including the National Care Records Service and National Record Locator, to facilitate access to patient information across care settings. • NHS England is working to link shared care records across England, with a commitment to developing a single patient record to improve coordinated care.
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Dear Mr Turner, Re: Regulation 28 Report to Prevent Future Deaths – Alex Ganski who died on 20 July 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 June 2026 concerning the death of Alex Ganski on 20 July 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alex’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Alex’s care have been listened to and reflected upon.
Your Report raised the following concerns:
1. There is a lack of national policy, guidance or structure to enable there to be a designated lead or ‘single point of contact’ with full oversight of, and authority over a patient’s care in the community and who could alert all agencies involved in providing care of any changes with the patient.
2. A lack of national protocols means the sharing and updating of information relating to physical and mental health changes and addiction was fragmented.
3. There is no national initiative to share records and information across agencies and currently depends on voluntary local arrangements.
4. There is an absence of guidance or advice to frontline emergency crews who are called to patients with complex and overlapping clinical, behaviour and addiction issues, when such crews may be unaware of the extent of partner agency involvement. This creates a missed opportunity to update and refer them to partner agencies.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
3 August 2026
1. National policy to enable a designated lead for care As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England. These hubs are designed to bring services closer to home, offering round-the-clock support in local settings. They provide walk-in access, co-located support teams, and in some cases, short-stay beds — all helping to reduce hospital admissions and provide earlier, more joined-up care. The 24/7 Neighbourhood Mental Health Centre (NMHC) model represents a fundamental shift in how mental health care is organised, addressing long-standing issues of fragmented provision and poor continuity of care. Traditional systems often require people to navigate multiple services, repeat their story, and experience unclear thresholds and disjointed support. NMHCs respond directly to this by offering an open- access, neighbourhood-based model that simplifies pathways and centres care around the person. A key strength of the model is its focus on continuity of care. Rather than being passed between different teams such as community, crisis, and inpatient services, individuals are supported by one consistent team across their whole journey. This reduces duplication, avoids repeated assessments, and enables staff to build strong, trusting relationships. These relationships are critical in mental health care, supporting better engagement, earlier identification of deterioration, and more personalised care. This integrated approach improves oversight of care. With shared information systems, joint working, and a clear sense of responsibility for a defined neighbourhood population, teams are better able to understand an individual’s needs and respond proactively. The model supports improved information sharing and real-time coordination, meaning risks can be identified earlier and care can be adjusted quickly. As a result, people are less likely to fall through gaps or experience crisis escalation due to disconnected services. NHS England has piloted the approach over the past two years, with an independent evaluation. Further roll-out is currently underway.
2. National protocols for sharing information about changes to a person’s health NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. This is discussed in more detail at point 3below. The Connecting Care Records (ConCR) programme facilitated the extensive and collaborative sharing of patient data and information across care settings and geographic boundaries to enable the delivery of more patient-centred care, in line with the NHS 10 Year Health Plan and Long Term Plan. The NMHC model detailed above, supports improved information sharing and real- time coordination, meaning risks can be identified earlier and care can be adjusted
quickly. As a result, people are less likely to fall through gaps or experience crisis escalation due to disconnected services.
3. Lack of a national initiative to share records and information The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, and it is free to use. NCRS is internet based, accessible via a web browser. NHS England’s national digital team have advised that they would expect the local Mental Health Trust, and the local Drug and Alcohol treatment service to have access to patient’s summary care records via NCRS however utilisation of this resource will vary according to the local business processes. Further information on NCRS can be available here: National Care Records Service - NHS England Digital.
The NCRS provides access to a patient’s Summary Care Records (SCR). The SCR is a national database that holds electronic records of important information such as a current medication, allergies and details of any previous bad reactions to medicines. It is created from GP medical records – whenever a GP record is updated, the changes are synchronized to SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient’s direct care but do not need access to the patient’s full record. As such, the SCR is intended to provide a summary to patient’s during an unscheduled care encounter.
As a minimum, the SCR contains important information about:
• Current medication
• Allergies and details of any previous reactions to medicines
• The name, address, date of birth and NHS number of the patient
In addition, details of long-term conditions, significant medical history, or specific communications needs, are now included by default with an SCR, unless the client has previously told the NHS that they did not want this information to be shared. Further information, and to illustrate the type of content included in an SCR, an example of SCR is available here: Additional Information in SCR - NHS England Digital
Additional information in the SCR includes the active problems and significant past problems (from Optum/TPP/Medicus provider systems) for a patient as recorded by their registered GP practice.
The SCR can also include more information in addition to the patient’s current medication, allergies and adverse reactions to medicines which is referred to as ‘Additional Information’. This ‘Additional Information’ may include significant medical history, anticipatory care information (such as information about the management of long-term conditions), immunisations or specific communication needs. This is now included by default for patients with an SCR, unless they have previously told the NHS that they did not want this information to be shared. This can include, for example, any history of deliberate self harm, suicide attempts or suicidal ideation. The SCR is not intended to include the full detail of a patient’s care plan and the design/format of the SCR does not support this. However, the SCR can include a signpost to the existence of a care plan, either by a relevant code such as:
• Emergency health care plan
• Emergency medicine care plan
• Liaison psychiatry care plan
• Mental health crisis plan
• Crisis plan
• Treatment escalation plan
• Vulnerable adult care plan
• Community mental health care plan
• Or via a text free entry
Regarding SCR, as of 29 June 2026, 88% of the population of England (approx. 60 million patients) have an SCR with Additional Information, 7.3% have a Core Only SCR (Allergies and Medications only) and 1.5% have Opted Out of SCR. Furthermore, where possible, patient’s need to provide their Permission to View before their SCR can be accessed. However, an Emergency Access option is available for scenarios where a patient is not able to provide their Permission to View e.g. the patient is unconscious.
NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history. The National Record Locator (NRL) removes the need for organisations to create duplicate copies of information across systems and organisations, by facilitating access to up- to-date information directly from the source. It will also provide users with an indication of the organisations with which a patient currently has a care relationship to enable a user to contact the service responsible for a plan to support the individual in the event of a crisis.
Mental Health Crisis plans are one of the pointer types supported by the NRL Service. NRL does not store any of the Mental Health data but points users to where they can find it. NRL Information can be consumed from source through the National Care Records Service (NCRS). In instances where multiple pointers are returned, users have the ability to sort results by creation date. With regards to the sharing of care plans, the NHS tends to share those Care Plans that need to be viewed by multiple different healthcare professionals and organisations with those organisations that are involved with creating, managing and updating these care plans (as well as the patient). However, those care plans which are more service specific that detail how a patient should be cared for by a specific service are less
likely to be shared with multiple other healthcare providers that may be involved in the patient’s care. Connecting Care Records The NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records. Every Integrated Care Board (ICB) has a shared care record (ShCR) in place, which provides, through different suppliers, a mechanism to access shared information between NHS Trusts and general practice. Shared Care Records will include prescribed medications and will typically hold more information about an individual than a Summary Care Record. A number of primary care networks, local authorities and other community organisations are also accessing information from the ShCR and providing information into their local ShCR. Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England. The interoperability programme of work supports the provision of interoperable records across England, sharing patient data across health and social care providers through ShCRs. National interoperability is needed as circa 20% of patients have care provided outside of their home ICB boundary. This work is evolving into the Single Patient Record, which will bring together a patient’s health information so that it is joined up across all health and care settings. We note that ‘Plexus’ provides the shared care record for Sussex, and they are already connected to the National Record Locator (NRL). They are sharing patient pointers to Mental Health Crisis Plans from Sussex Partnership NHS FT, and they went live on 3 November 2025. However, the PDF documents they are sharing do not currently contain any clinical information specific to the patient – it’s a generic document that contains the SPFT team contact information. Further information should be sought with regards to the actual content of the SCR and information held on ConCR in addition to accessed clinical information which may help assist with the identification of the ‘Care Gaps’ to which the Coroner refers. Your Report indicates that Alex had formally been diagnosed with suicidal thoughts, anxiety and depression and drug misuse so it would be reasonable to expect that these diagnoses and medications prescribed for anxiety and depression (including the ‘Last Issued’ dates) would be visible in Alex’s SCR provided the patient had not ‘opted out’. Brief further clinical details, for example, regarding the history of suicidal thoughts, previous overdoses or acts of deliberate self-harm, and the use of illicit drugs (cannabis, ketamine and diazepam) may also have been included in Alex’s SCR
where this information had been coded into Alex’s GP record. The SCR would have been available to paramedics / front line emergency staff.
Furthermore, SCR can include signposting (and possibly contact details) for other healthcare services and professionals that are involved in the patient’s care for example, the local Trust Mental Health assessment and treatment service, the patient’s registered Mental Health Nurse, the local Drug and Alcohol Wellbeing network key worker, the emergency contact details of a specialist support team, where this information had been recorded and coded into the patient’s GP record. However the SCR does not contain correspondence, so would not include information regarding the correspondence between the local Mental Health Trust and patient’s registered GP or other services involved.
The local drug and alcohol service are currently commissioned by the Local Authority and not the NHS and as such they run on different systems. However, the NHS England South East Region advises us that the two services work together where they can.
As noted above, NHS England and DHSC have published Fit for the Future: 10 Year Health Plan for England, which sets out the government’s plan for healthcare in England over the next decade. The Plan includes a commitment to give patients ‘a single, secure and authoritative account of their data – a single patient record’ to support more coordinated, personalised and predictive care.
4. Absence of guidance or advice to frontline emergency crews Ambulance clinicians are primarily responsible for assessing and managing the patient's immediate clinical needs and determining the most appropriate course of action based on the information available at the time. Ambulance clinicians may have access to additional patient information through systems such as the Summary Care Record and other locally available shared care records, where these are available and appropriate to access. Access to information- sharing systems and the extent of information available varies between local areas. National policy and professional guidance are clear that appropriate information sharing is a fundamental part of delivering safe and effective care across the NHS. Clinicians are also able to share relevant information for the purposes of direct care in accordance with established information governance principles. Where a patient consents, or where information sharing is otherwise justified for direct care, ambulance clinicians may contact other healthcare professionals or specialist services involved in a patient's care. However, the availability of referral routes, specialist services and information-sharing arrangements is determined locally and is not subject to a single nationally mandated model. National policy and professional guidance are clear that appropriate information sharing is a fundamental part of delivering safe and effective care across the NHS.
NHS England continues to support improvements in interoperability and the development of shared care records to enable safer, more joined up care. This under pins the approach of moving from analogue to digital, hospital to community and treatment to prevention as outlined in the 10 Year Health Plan. These developments aim to improve information flow while ensuring that data is shared with appropriate clinical context and in line with professional standards, so that information generated in one care setting is not misinterpreted or used inappropriately in another.
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 Alex, 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.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 15 June 2026 concerning the death of Alex Ganski on 20 July 2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Alex’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Alex’s care have been listened to and reflected upon.
Your Report raised the following concerns:
1. There is a lack of national policy, guidance or structure to enable there to be a designated lead or ‘single point of contact’ with full oversight of, and authority over a patient’s care in the community and who could alert all agencies involved in providing care of any changes with the patient.
2. A lack of national protocols means the sharing and updating of information relating to physical and mental health changes and addiction was fragmented.
3. There is no national initiative to share records and information across agencies and currently depends on voluntary local arrangements.
4. There is an absence of guidance or advice to frontline emergency crews who are called to patients with complex and overlapping clinical, behaviour and addiction issues, when such crews may be unaware of the extent of partner agency involvement. This creates a missed opportunity to update and refer them to partner agencies.
National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG
3 August 2026
1. National policy to enable a designated lead for care As part of a national pilot to transform mental health care, six new neighbourhood mental health hubs are being developed across England. These hubs are designed to bring services closer to home, offering round-the-clock support in local settings. They provide walk-in access, co-located support teams, and in some cases, short-stay beds — all helping to reduce hospital admissions and provide earlier, more joined-up care. The 24/7 Neighbourhood Mental Health Centre (NMHC) model represents a fundamental shift in how mental health care is organised, addressing long-standing issues of fragmented provision and poor continuity of care. Traditional systems often require people to navigate multiple services, repeat their story, and experience unclear thresholds and disjointed support. NMHCs respond directly to this by offering an open- access, neighbourhood-based model that simplifies pathways and centres care around the person. A key strength of the model is its focus on continuity of care. Rather than being passed between different teams such as community, crisis, and inpatient services, individuals are supported by one consistent team across their whole journey. This reduces duplication, avoids repeated assessments, and enables staff to build strong, trusting relationships. These relationships are critical in mental health care, supporting better engagement, earlier identification of deterioration, and more personalised care. This integrated approach improves oversight of care. With shared information systems, joint working, and a clear sense of responsibility for a defined neighbourhood population, teams are better able to understand an individual’s needs and respond proactively. The model supports improved information sharing and real-time coordination, meaning risks can be identified earlier and care can be adjusted quickly. As a result, people are less likely to fall through gaps or experience crisis escalation due to disconnected services. NHS England has piloted the approach over the past two years, with an independent evaluation. Further roll-out is currently underway.
2. National protocols for sharing information about changes to a person’s health NHS England is committed to supporting the sharing of critical clinical information across NHS organisations. This is discussed in more detail at point 3below. The Connecting Care Records (ConCR) programme facilitated the extensive and collaborative sharing of patient data and information across care settings and geographic boundaries to enable the delivery of more patient-centred care, in line with the NHS 10 Year Health Plan and Long Term Plan. The NMHC model detailed above, supports improved information sharing and real- time coordination, meaning risks can be identified earlier and care can be adjusted
quickly. As a result, people are less likely to fall through gaps or experience crisis escalation due to disconnected services.
3. Lack of a national initiative to share records and information The National Care Records Service (NCRS) provides a quick, secure way to access national patient information to improve clinical decision making and healthcare outcomes, and it is free to use. NCRS is internet based, accessible via a web browser. NHS England’s national digital team have advised that they would expect the local Mental Health Trust, and the local Drug and Alcohol treatment service to have access to patient’s summary care records via NCRS however utilisation of this resource will vary according to the local business processes. Further information on NCRS can be available here: National Care Records Service - NHS England Digital.
The NCRS provides access to a patient’s Summary Care Records (SCR). The SCR is a national database that holds electronic records of important information such as a current medication, allergies and details of any previous bad reactions to medicines. It is created from GP medical records – whenever a GP record is updated, the changes are synchronized to SCR. It can be seen and used by authorised staff in other areas of the health and care system who are involved in the patient’s direct care but do not need access to the patient’s full record. As such, the SCR is intended to provide a summary to patient’s during an unscheduled care encounter.
As a minimum, the SCR contains important information about:
• Current medication
• Allergies and details of any previous reactions to medicines
• The name, address, date of birth and NHS number of the patient
In addition, details of long-term conditions, significant medical history, or specific communications needs, are now included by default with an SCR, unless the client has previously told the NHS that they did not want this information to be shared. Further information, and to illustrate the type of content included in an SCR, an example of SCR is available here: Additional Information in SCR - NHS England Digital
Additional information in the SCR includes the active problems and significant past problems (from Optum/TPP/Medicus provider systems) for a patient as recorded by their registered GP practice.
The SCR can also include more information in addition to the patient’s current medication, allergies and adverse reactions to medicines which is referred to as ‘Additional Information’. This ‘Additional Information’ may include significant medical history, anticipatory care information (such as information about the management of long-term conditions), immunisations or specific communication needs. This is now included by default for patients with an SCR, unless they have previously told the NHS that they did not want this information to be shared. This can include, for example, any history of deliberate self harm, suicide attempts or suicidal ideation. The SCR is not intended to include the full detail of a patient’s care plan and the design/format of the SCR does not support this. However, the SCR can include a signpost to the existence of a care plan, either by a relevant code such as:
• Emergency health care plan
• Emergency medicine care plan
• Liaison psychiatry care plan
• Mental health crisis plan
• Crisis plan
• Treatment escalation plan
• Vulnerable adult care plan
• Community mental health care plan
• Or via a text free entry
Regarding SCR, as of 29 June 2026, 88% of the population of England (approx. 60 million patients) have an SCR with Additional Information, 7.3% have a Core Only SCR (Allergies and Medications only) and 1.5% have Opted Out of SCR. Furthermore, where possible, patient’s need to provide their Permission to View before their SCR can be accessed. However, an Emergency Access option is available for scenarios where a patient is not able to provide their Permission to View e.g. the patient is unconscious.
NHS England’s National Record Locator (NRL) service allows health or social care workers to find and access patient information shared by other health and social care organisations across England, to support the direct care of a patient. It does this by recording the location of digital (and paper) records within the NHS and provides an index of pointers/bookmarks that contain the information required to retrieve key patient information from the source. The vision is to improve cross-border interoperability and help make data sharing possible by allowing healthcare professionals, such as Care Coordinators within a Mental Health Trust to securely and remotely retrieve information from source at the point of need so that they can get a longitudinal view of a patient’s records and an indication of their treatment history. The National Record Locator (NRL) removes the need for organisations to create duplicate copies of information across systems and organisations, by facilitating access to up- to-date information directly from the source. It will also provide users with an indication of the organisations with which a patient currently has a care relationship to enable a user to contact the service responsible for a plan to support the individual in the event of a crisis.
Mental Health Crisis plans are one of the pointer types supported by the NRL Service. NRL does not store any of the Mental Health data but points users to where they can find it. NRL Information can be consumed from source through the National Care Records Service (NCRS). In instances where multiple pointers are returned, users have the ability to sort results by creation date. With regards to the sharing of care plans, the NHS tends to share those Care Plans that need to be viewed by multiple different healthcare professionals and organisations with those organisations that are involved with creating, managing and updating these care plans (as well as the patient). However, those care plans which are more service specific that detail how a patient should be cared for by a specific service are less
likely to be shared with multiple other healthcare providers that may be involved in the patient’s care. Connecting Care Records The NCRS complements Connecting Care Records (ConCR), also known as Shared Care Records. Every Integrated Care Board (ICB) has a shared care record (ShCR) in place, which provides, through different suppliers, a mechanism to access shared information between NHS Trusts and general practice. Shared Care Records will include prescribed medications and will typically hold more information about an individual than a Summary Care Record. A number of primary care networks, local authorities and other community organisations are also accessing information from the ShCR and providing information into their local ShCR. Responsibility for delivering shared care records sits with local Integrated Care Boards (ICBs). Each ICB’s shared care records are developed in response to the health and care needs of the local area, existing systems, and future planning. This means some of their shared care records are available to neighbouring ICBs, while others are only supported within their own ICB. Future plans include making shared care records link together regardless of where you live or receive care in England. The interoperability programme of work supports the provision of interoperable records across England, sharing patient data across health and social care providers through ShCRs. National interoperability is needed as circa 20% of patients have care provided outside of their home ICB boundary. This work is evolving into the Single Patient Record, which will bring together a patient’s health information so that it is joined up across all health and care settings. We note that ‘Plexus’ provides the shared care record for Sussex, and they are already connected to the National Record Locator (NRL). They are sharing patient pointers to Mental Health Crisis Plans from Sussex Partnership NHS FT, and they went live on 3 November 2025. However, the PDF documents they are sharing do not currently contain any clinical information specific to the patient – it’s a generic document that contains the SPFT team contact information. Further information should be sought with regards to the actual content of the SCR and information held on ConCR in addition to accessed clinical information which may help assist with the identification of the ‘Care Gaps’ to which the Coroner refers. Your Report indicates that Alex had formally been diagnosed with suicidal thoughts, anxiety and depression and drug misuse so it would be reasonable to expect that these diagnoses and medications prescribed for anxiety and depression (including the ‘Last Issued’ dates) would be visible in Alex’s SCR provided the patient had not ‘opted out’. Brief further clinical details, for example, regarding the history of suicidal thoughts, previous overdoses or acts of deliberate self-harm, and the use of illicit drugs (cannabis, ketamine and diazepam) may also have been included in Alex’s SCR
where this information had been coded into Alex’s GP record. The SCR would have been available to paramedics / front line emergency staff.
Furthermore, SCR can include signposting (and possibly contact details) for other healthcare services and professionals that are involved in the patient’s care for example, the local Trust Mental Health assessment and treatment service, the patient’s registered Mental Health Nurse, the local Drug and Alcohol Wellbeing network key worker, the emergency contact details of a specialist support team, where this information had been recorded and coded into the patient’s GP record. However the SCR does not contain correspondence, so would not include information regarding the correspondence between the local Mental Health Trust and patient’s registered GP or other services involved.
The local drug and alcohol service are currently commissioned by the Local Authority and not the NHS and as such they run on different systems. However, the NHS England South East Region advises us that the two services work together where they can.
As noted above, NHS England and DHSC have published Fit for the Future: 10 Year Health Plan for England, which sets out the government’s plan for healthcare in England over the next decade. The Plan includes a commitment to give patients ‘a single, secure and authoritative account of their data – a single patient record’ to support more coordinated, personalised and predictive care.
4. Absence of guidance or advice to frontline emergency crews Ambulance clinicians are primarily responsible for assessing and managing the patient's immediate clinical needs and determining the most appropriate course of action based on the information available at the time. Ambulance clinicians may have access to additional patient information through systems such as the Summary Care Record and other locally available shared care records, where these are available and appropriate to access. Access to information- sharing systems and the extent of information available varies between local areas. National policy and professional guidance are clear that appropriate information sharing is a fundamental part of delivering safe and effective care across the NHS. Clinicians are also able to share relevant information for the purposes of direct care in accordance with established information governance principles. Where a patient consents, or where information sharing is otherwise justified for direct care, ambulance clinicians may contact other healthcare professionals or specialist services involved in a patient's care. However, the availability of referral routes, specialist services and information-sharing arrangements is determined locally and is not subject to a single nationally mandated model. National policy and professional guidance are clear that appropriate information sharing is a fundamental part of delivering safe and effective care across the NHS.
NHS England continues to support improvements in interoperability and the development of shared care records to enable safer, more joined up care. This under pins the approach of moving from analogue to digital, hospital to community and treatment to prevention as outlined in the 10 Year Health Plan. These developments aim to improve information flow while ensuring that data is shared with appropriate clinical context and in line with professional standards, so that information generated in one care setting is not misinterpreted or used inappropriately in another.
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 Alex, 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.