Bituin Pimlott

Ms Alison Mutch 
Senior Coroner for Area of  
Greater Manchester South 
Coroner’s Court,  
1 Mount Tabor Street,  
Stockport  
SK1 3AG 

National Medical Director & 
Interim Chief Executive, NHSI  
Skipton House 
80 London Road 
London 
SE1 6LH 

17th November 2021 

Dear Ms Alison Mutch,  

Re: Regulation 28 Report to Prevent Future Deaths –  Bituin Pimlott  
 22nd February 2021  

Thank you for your Regulation 28 Report dated 13th August 2021 concerning the 
death of Mrs Bituin Pimlott on 22nd February 2021. Firstly, I would like to express my 
deep condolences to Mrs Pimlott’s family.  

I note that the recent inquest earlier this year concluded that the medical cause of 
Mrs Pimlott’s death was: 1a hanging.  

Following the conclusion of the inquest you have raised concerns in your Regulation 
28 Report to NHS England with the following matters of concern: 

1.  The inquest heard evidence that Mrs Pimlott had been struggling with her 

mental health in the weeks preceding her death and had contacted her GP on 
a number of occasions with anxiety and depression.  She was prescribed 
medication but expressed concerns about the impact of the medication.  
Telephone consultations rather than face to face appointments continued to 
be used with her due to the pandemic.  Pre-covid it was accepted she would 
have been seen face to face which would have allowed a more 
comprehensive assessment of her mental health and her reluctance to use 
medication. 

2.  Her GP practice did not refer her to the crisis team, and it was unclear what 

guidance the practice had for their GPs about when they should refer directly 
to the crisis team. 

I note the concerns that you have raised and I can confirm that telephone 
consultations have been in use in general practice for many decades to help patients 
access medical advice and care quickly and conveniently. Where studies have been 

NHS England and NHS Improvement 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 conducted, telephone triage has been shown to be safe. Further telephone 
consultations are part of general practice training schemes.   

The coronavirus (COVID-19) pandemic has brought about an unprecedented 
acceleration in the adoption of delivering NHS services remotely, and standard 
operating procedures (SOPs)  were produced to ensure general practice is able to 
operate safely in this context. The SOP which was last published (now retired) which 
is relevant in this matter is attached for reference.  I can confirm that SOPs were 
iterated throughout the pandemic to meet changing needs and requirements since 
first publication. This SOP was first published in March 2020. 

The procedures within the relevant SOP make it clear that general practices and 
Primary Care Networks should triage patients remotely (to determine the right 
person and timeframe for managing the problem) in advance wherever possible to 
help prioritise patient care based on needs; and that clinicians should determine the 
most appropriate consultation method with the patient - telephone, video, online, 
face to face. This should be determined by taking into consideration the patient’s 
preferences, needs (including accessibility, privacy, capacity and communication 
requirements), clinical circumstances and currently, local risks of COVID-19. Whilst 
we do not have all the clinical details regarding the circumstances surrounding Mrs 
Pimlott’s death, such as her preference of face to face vs remote appointment, we 
would ordinarily expect the GP practice to have taken the patient’s appointment type 
preference into consideration had they indicated one. 

In determining the most appropriate consultation method, considerations regarding 
patient safety, ability to make a satisfactory assessment, gain a sufficient 
understanding of the problem and whether information can be provided in a way the 
patient understands including assessing a patient’s understanding of the advice 
provided should be factors in determining the most appropriate consultation 
method.  If a particular concern did arise following a remote assessment or remote 
advice being given, then a decision could be made to move to an alternative 
approach, for example, face to face consultation or for remote advice to be followed 
up in writing or with the patient’s permission with their carer. 

Professional guidance published by the General Medical Council sets out high level 
principles of good practice expected of everyone when consulting and or prescribing 
remotely for patients https://www.gmc-uk.org/ethical-guidance/learning-
materials/remote-prescribing-high-level-principles and guidance to support shared 
decision making https://www.gmc-uk.org/ethical-guidance/ethical-guidance-for-
doctors/decision-making-and-consent. 

Additionally, guidance was developed jointly between NHS England and the Royal 
College of General Practitioners (RCGP) on Remote vs Face to Face: which to use 
and when? and  RCGP publish a range of guidance and learning materials on their 
Covid-19 Resource Hub. These resources underline the importance of ensuring 
patient safety, shared decision making and that an individual’s needs are paramount. 

The joint NHS England and RCGP guidance (linked above), which is now in place, 
refers to the importance of ‘safety netting’. I note that the Clinical Commissioning 
Group medical director that investigated Mrs Pimlotts death indicates that the 

 
 
 
 
 
 
 consultations that took place where appropriate and safety netting was in 
place. Every GP practice must continue to provide face to face consultations 
alongside telephone, video and online consultations as part of making general 
practice as accessible as possible. 

Finally in response to your secondary concern regarding unclear guidance for when 
GP practices should refer directly to the crisis team, I can confirm that Mental Health 
services are commissioned locally and to this end I note that the local CCG Medical 
Director has provided you with a separate response detailing relevant information 
and confirming steps that have been taken. The CCG are best placed to respond to 
this concern and they have kindly provided me with a copy of their response, the 
content of which I note, as well as a copy of the leaflet that has been developed and 
delivered to all households in the area listing the locally available Mental Health 
crisis facilities. I note that a reminder is also to be sent to all practices confirming the 
support available. 

Given the steps that have been taken at the local level and the completeness of the 
response from the CCG, I do not propose responding further on a national level. 
However 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, 
and in particular if you still consider there to be any issues that require a further 
national response. 

Yours sincerely, 

National Medical Director 
NHS England and NHS Improvement and 
Interim Chief Executive, NHS Improvement

4th Floor 
Stopford House 
Piccadilly 
Stockport 
SK1 3XE 

08 March 2022 

Private & Confidential 
Via e mail 

Dear Sarah 

B Pimlott (RIP) - Update following Regulation 28 Report  

I refer to your recent email in which you request an update of actions identified on review 
of the Regulation 28 Report issued following the inquest into the death of Ms Pimlott.  

Matters of Concern 

The  Regulation  28  Report  identified  that  when  Mr  Pimlott  contacted  her  GP  prior  to  her 
death, the contacts / consultations were managed remotely (via the telephone as opposed 
to face-to-face); a number of actions were therefore identified in an effort to ensure that 
Stockport GPs did offer access to face-to-face consultations where clinically appropriate and 
that our GP colleagues were reminded of the referral options available for any patient in 
mental health crisis.  

Actions  

•  Access to blended appointments and patient choice in relation to the way in 

which they wish to consult with their GP 

A key issue within the Regulation 28 Report was the fact that consultations with this patient 
were  managed  remotely.    I  am  satisfied that  following  a  review  of  appointment booking 
systems across the Stockport patch, there is an option for face-to-face consultation where 
clinically appropriate or directly requested by the patient.  

I attach herewith a slide from a presentation which sets down the ways in which Stockport 
patients  can  access  primary  care  services.  As  you  know,  at  the  start  of  the  Covid  19 
pandemic, the way in which GPs consulted with their patients changed with new telephony 
and digital options being introduced.  Whilst it is recognised that telephony/ digital access 
is well received and indeed preferable to many patients, there remains a demand for face-
to-face  consultations,  and  I  am  satisfied  that  this  option  is  available  at  every  Stockport 

      
 
 
 
                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 practice and that clinical triage is effective in identifying those patients who do need to be 
seen in person.  I can report that there are numerous examples where patients have chosen 
to access services via the telephone or alternative digital options but have been asked to 
attend in person.  This includes patients reporting mental health concerns and in the main 
these patients are seen on the same day whereas prior to the pandemic there would often 
be a wait of a few days for a face-to-face consultation. 

Many  patients  informed  us  that  they  preferred  to  be  able  to  book  a  face-to-face 
appointment  in  advance  so  as  to  enable  them  to  manage  their  healthcare  around  other 
commitments  and  forward  booking  of  appointments  has  therefore  been  re-introduced 
across the Stockport patch.  

A recent review identified that at the start of the pandemic there was a 76% decrease in 
the  number  of  face-to-face  consultations  in  line  with  infection  prevention  measures.  
However, this increased to 86% against pre-covid data by January 2021 and I am pleased 
to  report  that  between  September  and  November  2021  Stockport  saw  its  highest  ever 
appointment volumes.  

Appropriate consultations with safety netting 

I am satisfied that in addition to the offer of face-to-face consultations where appropriate 
/ requested, there is a robust process of triage, to include safety netting, in circumstances 
where a patient presents via the telephone reporting mental health concerns.  Many such 
patients are offered same day face-to-face appointments and an information sheet detailing 
options for referral has been re-circulated to all GP Practices in Stockport.  This document 
was developed as a single sheet which can be shared with patients, setting down referral 
options.    I  have  attached  a  copy  of  the  document  which  has  been  delivered  to  every 
Stockport address.   

In addition, as part of our GP Masterclass programme, presentations in relation to suicide 
prevention have been delivered with updates; the most recent in 2021.   

Significant Event Reflection Exercise 

I can confirm that the practice involved in this case have completed a reflection exercise; 
learning from all Regulation 28 reports / significant events is cascaded at the Quality Board 
and shared anonymously with our GP colleagues.   

I hope the above is acceptable to you and that you are satisfied that we have responded 
appropriately to the concerns detailed within the Regulation 28 Report in this case.   

If you require any further information, please do not hesitate to contact us.   

Yours sincerely 

Medical Director