Harry Mellor

AG Rt Hon Alistair Burt MP>
Minister of State for Community and Social Care

Department
of Health
Richmond House
79 Whitehall
London
SW1A 2NS
Ms M. Mulrennan, Tel: 020 7210 4850
Office and Main Court,
The Council House,
Old Market Square,
Nottingham
NGI 2DT

et (K 5 (Mu Crean on +

Thank you for your letter of 22 October 2015, following the inquest into the death of
Harry Mellor. I was sorry to hear of Harry’s death and wish to extend my
condolences to his family.

Your concerns in this case focus on the system of registration and de-registration of
patients with General Practitioners. You are worried that the practice of de-
registering a patient, particularly a child patient as in this case, could lead to children
being put at risk and ask that we consider the following:

e There is no legal requirement to register or re-register a child with a General
Practitioner.

e There is no reliable system in place to identify when a child has been de-
registered from a General Practice.

e There are potential safeguarding concerns if a General Practitioner can de-register
a child, particularly a child with chronic health needs, before a new General
Practitioner has been identified and notified of the proposed de-registration.

e The paediatric team and physiotherapy services were not directly informed that
Harry was going to be de-registered or had been de-registered.

I was extremely concerned on reading your report that a vulnerable child could lose
touch with services so quickly and without anyone apparently becoming aware of it.
While the GP de-registration is relevant, the failure by King’s Mill Hospital to
follow up the complete loss of contact is, in my view, more serious. There is perhaps
an assumption that the patient or the patient’s parents will always maintain contact
with services: Harry’s case however demonstrates clearly that this cannot be taken

for granted, Harry’s mother retained her parental authority to make decisions about
his care, and legal proceedings would have been needed to change that position. It
seems however that the NHS lost contact with Harry, but was unaware of the loss of
contact and therefore no action followed.

I intend to ask the Department of Health and NHS England to look at current
processes in the NHS to ensure that the possibility of anything like this reoccurring
is reduced as far as possible and preferably eliminated. It would however be useful
to describe the current system.

There is no legal requirement for any person (adult or child) to be registered with a
GP, and there are no plans to make registration compulsory. There is also no legal
power to require any individual with capacity to receive medical treatment. The
NHS Constitution allows patients and the public to register with a GP practice. In
addition, patients and the public have inherent rights under the same constitution:

e ....... f0 choose your GP practice, and to be accepted by that practice unless
there are reasonable grounds to refuse in which case you will be informed of
those reasons.

Reasonable grounds for refusal include, amongst other things, a patient not living in
the GP practice area. These are also grounds for a patient (whether adult or child) to
be removed from a GP practice list, with the necessary notice being provided to the
patient or guardian.

When a patient is to be de-registered from a GP practice list, the practice and NHS
England should notify the patient that they will be removed from the practice’s list
and advise them to register with another practice.

Although the information we have on the case is limited, it seems reasonable for the
GP to have de-registered Harry once his family moved out of the practice area.
There was nothing to prevent Harry’s mother registering him with another GP,
although there was no legal obligation on her to do so. Had Harry been re-registered
with a GP the break in contact with paediatric services should have been picked up.

There are other opportunities for ensuring a child receives basic health care. For
example, when a child starts school, as Harry did, the school is required to hold
certain pupil records which include details of the relevant GP and whether the child
has specific health problems or needs. School nursing services visit schools to
administer vaccines and offer health advice, and therefore have an opportunity to
ascertain whether a child has any unmet health needs.

Whilst the above information explains the current system of patient GP registration
and the opportunities available for protecting a child’s health needs, no-one in this
case, even the physiotherapist who had remained in contact with Harry throughout,
was aware of the loss of contact with the paediatric service at Kings Mill Hospital.

As indicated above, I am concemed that King’s Mill hospital failed to realise that
Harry had not had a further paediatric review, and that no action was taken in the
intervening period by the paediatric service at the hospital to re-establish contact
with Harry.

Information regarding missed appointments and the break in contact should have
come to light via Harry’s case records. From the information you have sent, it
appears that the hospital relied on each successful appointment triggering the next.
The use of an appropriate IT system by the Sherwood Forest Hospitals NHS
Foundation Trust to regularly collate and review Harry’s case records and ensure
automatic follow-up letters ought to have indicated his missed appointments. It
would also have enabled the sharing of this information with all those involved in his
care.

Jam grateful to you for bringing the circumstances of Harry’s death to my attention
and hope that you find this reply helpful.

Ja <cncanly
Aut 1.

ALISTAIR BURT

Your Ref: 
Our Ref: EM/FB/HGM 
Direct dial: 01623 673481 
Email: elaine.moss@newarkandsherwoodccg.nhs.uk 
Date: 8 December 2015 

Mansfield and Ashfield Clinical Commissioning Group 
Hawthorn House 
Ransom Wood Business Park 
Southwell Road West 
Rainworth 
Mansfield 
Notts 
NG21 0HJ 
Web: www.mansfieldandashfieldccg.nhs.uk 

Dear Ms Mulrennan, 

Re Regulation 28: Report to Prevent Future Deaths request dated 22.10.15 
Subject: - Harry George Mellor - inquest conclusion 5th October 2015 

Thank you for drawing our attention to the issues arising from the above inquest into the circumstances 
of the tragic death of Harry Mellor who had resided in the Mansfield and Ashfield Clinical Commissioning 
Group (CCG) area.  

The  CCG  is  aware  of  this  case  through  representation  on  the  Nottinghamshire  Safeguarding  Children 
Board (NSCB) Serious  Incident  Review Panel  which is currently  considering this case as part of a multi-
agency serious case review. As commissioners of health services we will be appointing an independent 
author to undertake  a  review  into  the GP  involvement in the case to ensure that any resulting lessons 
learned for health organisations arising from this review are implemented. 

With regard to the specific requests raised in the report I would like to inform you of the following: - 

1.  There is no legal requirement to register or re-register a child with a General Practitioner 
The  legislative  framework  is  outside  the  remit  of  the  CCG  but  we  support  your  request  to  the 
Secretary of State regarding this matter. The principle of Parental Responsibility requires parents to 
make decisions in the best interests of children. In this case, this principle did not result in the best 
outcome  for  the  child.  We  will  request  that  this  aspect  is  considered  as  part  of  the  terms  of 
reference for the NSCB serious case review 

2.  There  is  no  reliable  system  in  place  to  identify  when  a  child  has  been  de-registered  from  a 

General Practice 

The CCG recognises that this is a risk for children with health needs, whose parents do not access 
appropriate primary care services. The circumstances around GP de-registration in this case will be 
examined in detail by the CCG Independent Review into GP Contracted Services as part of the NSCB 
Serious Case Review. This review will be complete by 31.03.16 and any recommendations relating to 
GP contracted Services will be implemented by the CCG as part of the resulting action plan. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In the meantime this risk is mitigated locally by the following arrangements: - 

Current  arrangements  require  specialist  services  and  urgent  healthcare  settings  to  ask 
parents at each attendance the GP registration status.  
Paediatric  pathways  revised  in  2015  promote  multi-disciplinary  communication  and  care 
planning  (the  paediatric  pathway  requires  an  Early  Help  Assessment  Framework  (EHAF) 
“team around the child” approach to children referred to specialist services.) 

This should promote communication between professionals including the GP.  

3.  There  are  potential  safeguarding  concerns  if  a  General  Practitioner  can  de-register  a  child, 
particularly  a  child  with  chronic  health  needs,  before  a  new  General  Practitioner  has  been 
identified and notified of the proposed de-registration 

a)  Parental  responsibility  places  the  responsibility  of  GP  registration  on  parents.  If 
families do not inform GPs of changes of address and telephone numbers GPs face 
significant challenges  in tracing mobile families.  The circumstances around  GP  de-
registration in this case will be examined in detail by the CCG Independent Review 
into GP Contracted Services as part of the NSCB Serious Case Review.  

b)  To mitigate this problem, specialist paediatric services should have robust “Did not 
attend” (DNA) procedures which ensure primary health services communicate with 
GPs when patients do not attend specialist appointments. As a result of this case the 
CCG  has  requested  assurance  from  specialist  paediatric  services  that  the  (DNA) 
procedures are being effectively implemented. 
If children with complex needs are found not to be receiving appropriate specialist 
services,  then  safeguarding  children  procedures  apply.  These  procedures  were  not 
mobilised in this case and this issue will be further scrutinised as part of the serious 
case review. 

c) 

I  hope  this  response  gives  you  some  assurance  that  the  CCGs  and  NHS  England  are  taking  the  issues 
identified around the circumstances of this Childs death very seriously. However solutions to the issues 
you  have  highlighted  are  complex  and  require  detailed  investigation.  We  will  ensure  these  issues  are 
considered as part of the Terms of Reference for the Multi-agency Serious Case Review which is due for 
completion by 31st March 2016.  

We will be pleased to share the CCG GP IMR and subsequent action plan by the 31st March 2016 with 
you,  to  give  assurance  that  the  CCG  has  fully  reviewed  the  circumstances  of  this  case  and  is 
undertaking all appropriate actions to meet any recommendations made.  

Yours sincerely 

Chief Nurse, Mansfield & Ashfield and Newark & Sherwood CCG 

Director of Nursing & Quality, Nottingham North & East CCG 

 
 
 
 
 
 
 
 
 
 
 
 Medical Director, NHS England (North Midlands) 

Director of Quality and Personalisation, Nottingham City CCG

General
Medical
Council

Regent's Place

11 December 2015 350 Euston Road

London NW1 3JN

Miss M Mulrennan, Email: gmc@gmc-uk.org

Assistant Coroner for Nottinghamshire Flac HA BEA EC

Office and Main Court Fax: 020 7189 5001

The Council House

Old Market Square

Nottingham |
NG1 2DT

Dear Ms Mulrennan
Our ref: SR1-1280119182

Thank you for your letter dated 22 October 2015 which recommended we review
procedures for the registration of children with general practitioners, following your
investigation into the death of Harry Mellor. We are sorry to hear of Harry’s death
and understand your concern to consider whether organisations that have a role in
healthcare delivery might be able to take some form of preventative action.

In your letter, you set out four matters of specific concern and recommended we
review procedures around the registration of children with general practitioners
(GPs). In responding to the recommendations, it may be helpful to set out our role
and functions. We are an independent organisation that helps to protect patients
and improve medical education and practice across the UK:

e We decide which doctors are qualified to work here and we oversee UK
medical education and training.

e We set the standards that doctors need to follow, and make sure that they
continue to meet these standards throughout their careers.

e We take action when we believe a doctor may be putting the safety of
patients, or the public’s confidence in doctors, at risk.

We publish guidance setting out the professional values and standards of practice
expected of all doctors working in the UK - our core guidance is Good medical
practice which is supported by a range of explanatory guidance on topics such as
patient confidentiality, consent to treatment, child protection and other issues in
healthcare practice. We do not have a direct role in the design and operation of
healthcare services and the systems for managing patients’ clinical care, although
the standards in our guidance will touch on doctors responsibilities for ensuring

. . . . The GMC hari din
Working with doctors Working for patients “England Wales (1069278)

and Scotland (SC037750)

that organisational systems and services operate in a way that provides safe and
effective standards of care , as explained below.

Responsibility for registration of a child with a GP

Our guidance sets out a number of duties on doctors which are relevant to Harry’s
case, as they concern responsibilities for managing or participating in
organisational systems set up to prevent and reduce harm to patients, and
responsibilities to work with child patients and their parents or guardians in ways
that ensure the health needs of children are met and action is taken on child
protection concerns. We do not have any powers to create obligations for parents
or guardians such as requiring them to register their children with a GP or to notify
their GP when leaving the practice area.

Doctors’ responsibilities for ensuring continuity of care for child patients

Good Medical Practice (GMP) provides guidance on doctors’ roles in ensuring
continuity of care and this makes clear that doctors are expected to provide all
relevant information about a patient to those taking over a patient’s care (see
paragraphs 44-45). It alerts doctors to the need to:

‘...check, where practical, that a named clinician or team has taken over
responsibility when your role in providing a patient’s care has ended. This
may be particularly important for patients with impaired capacity or who are
vulnerable for other reasons.’

However, this is in the context of situations where, for example, a doctor is going
off duty, or delegates care to another practitioner, or knows that a patient’s care
has been transferred to another practitioner.

Doctors have a number of responsibilities in relation to patient support and
protection from harm, set out in GMP and related explanatory guidance which,
taken together, require them to:

- contribute to the safe handover of care between different providers (in Good
medical practice 44 and Ending your professional relationship with a patient
6.d)

- support vulnerable patients, contribute to their protection and help them if
their rights have been denied (in Good medical practice 27, and Protecting
children and young people 8, and Confidentiality paragraph 63)

- support patients and families to ensure their health needs are met (in Good
medical practice 49 and 51 and Protecting Children and young people
paragraphs 1b and 8)

- participate in systems to share information about children at risk of serious
harm (in 0-18 years: guidance for all doctors paragraphs 61 and 63
Protecting Children and young people paragraphs 5 and 25)

. . . . he i hari i dit
Working with doctors Working for patients bag Se dee nity 0

and Scotland (SC037750)

to act on concerns where they suspect that a child may be at risk of neglect
or abuse (Child protection paragraphs 6-8, 32).

We believe it’s clear from our guidance that, if a GP suspects that a child may be at
risk of neglect or abuse, s/he would have a responsibility to act to protect the
interests of the child. And more broadly, GPs have a responsibility to work with
parents in ways that support them to provide a good standard of care to their
children for example by sign-posting or referring parents to local advice and
support services. Other organisations provide more detailed guidance on how GPs
can meet their obligations, for example the Royal College of General Practitioners
(RCGP) and NSPCC provide clinical guidance in the form of a safeguarding toolkit to
assist GPs to make decisions about what assessments to offer and when to raise
concerns, including when children who are the subject of safeguarding concerns
leave the GP practice.

Responsibility for systems and processes around the transfer of care

We understand that, the NHS doesn’t impose a requirement on patients to notify
their GP that they are leaving the practice, nor is there an obligation to be
registered with a GP. So a GP may be unaware that a patient has left a practice
area for a long time after the patient has moved on. They may also be unaware of
the patient's new location. Requests to transfer a patient’s records are triggered
when a patient registers with a new GP, and it may be months or years before this
takes place. We also understand that it is standard practice for GPs to remove
patients from their lists should they become aware that they have left the practice
area, which is described as ‘administrative removal’. GPs in England are expected
to notify their Primary Care Organisation of administrative removals.

Bearing this in mind, it seems that a GPs ability to make a judgement about
whether a deregistration notification or a decision about administrative removal
should trigger child protection action, may be constrained by having no or limited
knowledge of a patients circumstances at that point in time.

The design and management of national systems of clinical monitoring and quality
in England are the responsibility of NHS England. NHS England is also the primary
care organisation responsible for receiving administrative removals from GP
practices and the recipient of any requests for records to be transferred once a
patient has registered with a new practice. NHS England is currently developing a
system to improve the protection of children who have previously been identified
as vulnerable by social services, the Child Protection — Information Sharing (CP-IS)
project. More information about NHS systems, including the CP-IS project are
available from NHS England, and information about how these services work at the
local level can be obtained from the GP contracting team at NHS England.

We have discussed the issues raised by your correspondence with the RCGP as the
body responsible for setting clinical standards for primary care and they advised
that:

The GMC is a charity registered in

Working with doctors Working for patients England and Wales (1089278)

and Scotland (SC037750)

There are potential safeguarding concerns if a General Practitioner can
administratively de-register a child with chronic health needs, before a new
General Practitioner has been identified as taking over the care of that child.

- Work is ongoing to improve the clinical guidance available to doctors to
support decision making in relation to children with long term conditions.
The Royal College of Paediatrics and Child Health is working to produce
standards for the care of children with long term health conditions (with
input from the RCGP). Publication is due for 2017.

- Incases of child deaths where abuse or neglect is thought to be factor, the
national system for carrying out a serious case review offers an effective
way of engaging local and national organisations in a process to evaluate
existing systems and identify any need for change.

Conclusions

While our standards make it clear that doctors need to take steps to ensure the
care of their patient is transferred safely, clearly their ability to do so is bound up
with the systems they work within, so you may wish to pursue your concerns with
the NHSE, RCGP and RCPCH who are better placed to advise on whether and how
systems and processes within the NHS in England can be changed to address your
concerns.

Finally, from your correspondence, you have not indicated that any individual
doctor has failed in their duty of care or has been criticised by your inquiry.
However, if your investigation has identified concerns about individual doctors
including any concerns that they have failed to follow our guidance on good
practice, we would appreciate your providing us with any relevant information so
we can consider whether action is needed through our fitness to practise
procedures.

I hope you find this response helpful to the process.

Yours sincerely,

nterim Director of Education and Standards

Responsible Officer and Senior Medical Adviser
were

The GMC is a charity registered in

Working with doctors Working for patients England and Wales (1089278)

and Scotland (SC037750)

Public Health
England

Protecting and improving the nation’s health

OFFICIAL SENSITIVE
Maria Mulrennan
Assistant Coroner for the coroner area of Nottinghamshire
St. Mary’s Chambers

26-28 High Pavement

The Lace Market

Nottingham NG1 1HN

Your ref: MC/LB/05177/2014
Dear Ms Mulrennan

Harry George Mellor

Duncan Selbie

Chief Executive
Wellington House
133-155 Waterloo Road
London SE1 8UG

Tel: 020 7654 8090
www.gov.uk/phe

13 November 2015

Thank you for your letter of 22 October reporting your concerns about the unfortunate

circumstances surrounding the death of this 8 year-old boy.

PHE does not have a direct role in determining the process for the registration of patients in
General Practice. NHS England, as commissioners of primary care services, will be able to
comment further on the regulation and procedure for GP registration and where there are
concerns about loss of continuity of care, will be able to take action to address them.

PHE has alerted the relevant NHS England team in North Midlands and the Director of Public
Health for Nottinghamshire and we have subsequently received confirmation from the
Nottinghamshire Safeguarding Board that the child’s death is known to them and is being
considered for review. | fully expect the issue of GP registration will form part of this review.

With best wishes

Yeas incerely

ca,

Duncan Selbie
Chief Executive

ce: Director of Commissioning Operations, NHS England (North Midlands)
Director of Public Health, Nottinghamshire and Nottingham City Council