Ronald Tilley

1 Trevelyan Square
Boar Lane
Leeds LS1 6AE

FAO: Joanne Andrews 
North East Kent Coroners 
Cantium House 
Country Hall  
Sandling Road 
Maidstone 
Kent  
ME14 1XD 

By Email Only: kentandmedwaycoroners@kent.gov.uk 

Your ref: 

Our ref: 

4 February 2021 

Dear Ms Andrews 

Inquest into the death of Mr Ronald Richard Tilley 

I am writing in response to the Regulation 28 report received from HM Coroner dated 
4 December 2020. This follows the death of Ronald Richard Tilley, who sadly died on 
23 October 2019. This was followed by an investigation and inquest which concluded 
on 29 October 2020. I would like to express my sincerest condolences to Mr Tilley’s 
family.  NHS Digital provided written statements in advance of the inquest, but did not 
attend the inquest.   

NHS Digital is a non-departmental public body created by the Health and Social Care 
Act 2012 and is the national information and technology partner for the health and care 
system. We use technology to support the NHS and social care.  

NHS  Digital  operates  and  maintains  the  Personal  Demographics  Service  (‘PDS’) 
under the Spine Services No.2 Directions issued by the Secretary of State for Health 
and Social Care to maintain a register of NHS patients in England. PDS is the national 
electronic database of NHS patient details such as name, address, date of birth and 
NHS  Number  (known  as  demographic  data).  It  also  records  the  primary  care 
registration (i.e. the GP practice with which the patient is registered for general medical 
services1) held by each registered patient and as notified through other NHS systems. 
PDS enables NHS and partner organisations delivering health and care services to 

1 General medical services are a range of essential services which general practitioners are required to provide 
to meet the needs of its patients as covered by their contract with NHS England. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 
 
 collect, record, access and share information about patients. This is so that they can 
be accurately identified and that the correct health and care records can be retrieved 
from local and national systems. Additionally, PDS supports national communication 
with patients in relation to their health and care needs. 

In  the  initial  statements  from 
information was provided:  

,  the  following 

•  who updated Mr Tilley’s GP practice code on PDS; 
•  when Mr Tilley’s GP practice code was updated on PDS; 
• 
•  security governance of, including access to, NHS Spine. 

the functions of the NHS Spine; and 

NHS Digital was unable to explain why the GP practice code at Mr Tilley’s record on 
PDS had been updated, as that information is not held on our systems.  

In HM Coroner’s Regulation 28 report of 4 December 2020, the matter of concern was 
that when a record on the PDS is updated or amended, there is no notification sent to 
the  existing  GP  noted  on  the  system.  As  this  inquest  concerned  the  change  to  Mr 
Tilley’s GP practice code on PDS, I shall focus my response on the management of 
this data. I  will provide information on the business processes that would ordinarily 
lead to a GP practice code being updated on PDS, the information that is available to 
GP  practices  when  accessing  PDS,  and  statistical  data  with  respect  to  PDS  data 
quality. 

The  primary  care  registration  management  process  within  the  NHS  in  England  is 
managed through a range of different systems which, when operated correctly, ensure 
a patient’s GP registration transfers from one GP practice to another. The successful 
registration of a patient with a new GP practice includes the appropriate generation of 
notifications to the different systems involved in the process. 

Registration for general medical services (GMS) 

A  patient  wishing  to  register  with  a  GP  for  general  medical  services  is  normally 
required to complete the Family Doctor Services Registration form known as GMS1. 
This includes information to identify the patient and, where possible, the GP practice 
that the patient is leaving. Using the information provided, the new GP practice will 
register the patient on their clinical system.  

At this stage of the registration process there are two paths available. Either: 

1. The GP clinical system updates PDS directly with the new GP code and notifies 
National  Health  Application  and  Infrastructure  Service2  (‘NHAIS’)  via  the  GP  Links 
Registration message; or 

2 NHAIS is an NHS Digital service providing a suite of software implemented across primary care which 
manages services, patient registration, and demographic details. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 2. The GP clinical system does not update PDS directly and notifies NHAIS via the GP 
Links Registration message. 

In either case, Primary Care Support England (‘PCSE’), who have responsibility for 
managing  primary  care  registration  on  behalf  of  NHS  England,  will  validate  and 
complete the registration by updating PDS with the GP practice code, depending on 
the  chosen  pathway,  and  apply  a  geographic  administrative  indicator  known  as  an 
NHAIS cipher. In completing this action, a series of notifications is triggered from PDS 
to inform the old GP practice of the transfer and deduct the patient from the practice’s 
patient list and, separately, to initiate the transfer of the patient’s paper medical record 
envelope, which is often referred to as “the Lloyd George”. 

In cases where the GP practice updates PDS directly (option 1 above), and the patient 
is transferring from another practice, this update will trigger the GP2GP process which 
allows the patient’s electronic health record to be transferred directly between the old 
and new GP practice. 

Therefore, in the event of the GMS registration being changed the old GP practice is 
notified of this. 

Registration for ‘Other’ services 

It is common for a patient to receive services from a GP practice other than the one 
which holds their GMS registration. In such cases, the practice providing these other 
services will register the patient on their clinical system for ‘Other’ services3. 

A registration for ‘Other’ services will not update the GP practice code on PDS and 
therefore,  will  not  trigger  the  GP2GP  interaction.  Nor  will  it  generate  a  GP  Links 
registration  message  to  NHAIS.  This  ‘Other’  registration  is  held  only  on  the  local 
clinical system. 

GP practice interaction with PDS 

GP  clinical  system  interaction  with  PDS  is  dependent  on  the  individual  user  being 
logged on using their smartcard. This enables them to trace and update PDS patient 
records in line with their designated access rights.  

It  is  standard  practice  in  care  settings,  including  primary  care,  to  routinely  check  a 
patient’s  demographic  data  with  them  at  each  new  encounter.  This  action  should 
include  interaction  with  PDS  to  ensure  the  most  up  to  date  information  about  the 
patient  is  available  to  them  and  other  users  with  a  legitimate  relationship  with  the 
patient.  

When a patient record is retrieved (traced) from PDS, the clinical system presents, on 
a split screen, the patient demographic data that is held locally against the information 

3 Other services are provided by general practitioners in addition to those provided as general medical 
services, examples include contraceptive services, vaccines and immunisations, minor surgery. 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 
 
 on the PDS record. This allows the user at the GP practice to compare the data, see 
any  differences  and  take  appropriate  action  to  synchronise  systems,  thus  keeping 
them in-line with each other.  

Neither the split screen nor any other part of this interaction will identify the GP practice 
code that is held on the PDS record. The logic around this is that GMS registration is 
managed through other means (GP Links Registration messages and NHAIS) and, in 
the absence of such notifications as described above, the legitimate relationship with 
the patient does not need to be reaffirmed during this interaction. 

A user can still update their clinical system independently of PDS if they are not using 
their smartcard. In such circumstances, the update will be available only on the local 
clinical system. 

Circumstances around Mr Tilley’s GP update 

It has been established that Mr Tilley was receiving ‘Other’ services from Bethesda 
Medical Centre and that there was a requirement for him to be recorded on their clinical 
system.  Correct  process  would  have  seen  him  registered  for  ‘Other’  services  as 
outlined above. This action would, correctly, not have generated any update to PDS. 

Audit logs available to NHS Digital have been checked and there is no evidence of a 
GP Links Registration message from Bethesda to NHAIS. This indicates that Bethesda 
did not attempt to undertake a GMS registration for Mr Tilley.  

In the course of investigating the background to this case we also contacted PCSE 
who confirmed that Bethesda Medical Centre had informed them that Mr Tilley was 
seen at their anticoagulant clinic regularly (since 2009, but particularly between 2015 
and 2016). PCSE also advised that they did not receive any notification that Bethesda 
Medical Centre were to be the GMS provider. 

GP Registration mismatch occurrence  

It has been shown through this inquest that it is possible for a clinical system to update 
the GP practice code outside either the GMS or ‘Other’ services registration process. 
As  far as  can  be determined,  Bethesda  appears to  have  acted  outside  of  standard 
procedures (as outlined above). 

There are around 60 million patients registered for primary care in England.  Between 
April  2018  and  December  2020  there  were  almost  16  million  patient  registration 
transfers  between  GPs.  Allowing  for  business-as-usual  differences  where  a  new 
registration  has  been  recorded  but  not  yet  validated  in  line  with  processes  already 
described, it is unusual for there to be a mismatch between the GP practice code held 
on PDS and that recorded on the GP clinical systems across England. Recent analysis 
undertaken on this metric has shown the level of mismatch to be less than 1% of the 
total registered population, which is illustrative of the strength of the data quality across 
the system. This also demonstrates that the business processes and systems in place 

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk 

 
 
 
 
 
 
 
 to  manage  patient  primary care  registration  in  England  are  well established,  robust 
and effective in safeguarding patient care.  

In cases where there may be a problem with the system flows, especially if associated 
with a patient death, I would expect these to come to our attention. Since the inception 
of the NHS Spine over 10 years ago and the introduction of current data flows, I have 
not been aware of another case with such an outcome. A low level of GP practice code 
mismatch  does  exist  within  the  system,  as  outlined  above.  However,  the  correct 
application  of  business  process  allied  with  good  technology  enables  similar  cases 
affecting active patients to be identified and corrected through the national data quality 
management service at NHS Digital. 

Whilst statistics may reflect positively on the system as a whole, I recognise that the 
key element of a quality service is the experience of individual patients and NHS Digital 
will take steps within its power to further reduce the risk of such untoward events. A 
programme of work is running which is in the process of rationalising and streamlining 
the  systems  and  data  flows  in  the  management  of  primary  care  registration.  The 
circumstances  surrounding  Mr  Tilley’s  death  will  be  brought  to  the  attention  of  this 
programme  so 
through  appropriate 
improvements  may  be  considered 
consultation with system users and stakeholders. 

that 

If HM Coroner requires any further clarification in relation to any point, please do not 
hesitate to contact us and we can assist further. 

Yours sincerely, 

Service Manager 

Personal Demographics Service National Back Office 

NHS Digital  

www.digital.nhs.uk 
enquiries@nhsdigital.nhs.uk