Rachelle Ross

Carly Henley 
HM Assistant Coroner, Newcastle upon Tyne  
Coroner's office 
Lower ground floor 
Block 1 
Civic Centre 
Barras Bridge 
Newcastle upon Tyne 
NE1 8QH 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

31 August 2023  

Dear Ms Henley  

Re: Regulation 28 Report to Prevent Future Deaths – Rachelle Naomi Ross who 
died on 20 April 2022.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  17 
February 2023 concerning the death of Rachelle Ross on 20 April 2022. In advance 
of responding to the specific concerns raised in your Report, I would like to express 
my deep condolences to Rachelle’s family and loved ones. NHS England are keen to 
assure the family and the coroner that the concerns raised about Rachelle’s care have 
been listened to and reflected upon.  

On 1 February 2023 the functions of NHS Digital transferred to NHS England and NHS 
Digital ceased to exist. I apologise for the delay in our response to your Report which 
was  sent  during  the  transition  of  processes  for  responding  to  Regulation  28  reports 
formally  addressed  to  NHS  Digital.  I  realise  that  responses  to  Coroner  Reports  can 
form part of the important process of family and friends coming to terms with what has 
happened to their loved ones and appreciate this will have been an incredibly difficult 
time for them. I apologise for any anguish this delay has caused.  

This  response  addresses  the  points  directed  to  the  Chief  Executive  of  NHS  Digital 
clarifying  concerns  raised  about  the  Cervical  Screening  System,  and  its  links  to  GP 
systems. 

HM Coroner  has raised the following matters of concern with regards to this case: 

1.  ‘GP  practice  records  do  not  include  an  alert  from  EMIS  or  System  1  IT 
systems to provide an automatic flag on a patient’s GP medical records if they 
are classed as a non-responder for a smear test by the National Screening 
Service. 

2.  The alert system is only triggered after a patient attends a smear test. For a 
non-responder,  they  go  back  into  the  three-  or  five-year  waiting  list  for  a 
National Screening invitation for a smear test. 

3.  An automatic flag or alert when a patient fails to attend for a smear test as 
part of the National Screening Service, would mean that a GP surgery would 
not  have  to  manually  add  a  warning  as  an  entry  onto  an  individual’s  GP 
records.  It would standardise the approach across all GP surgeries and could 
increase patient safety.’’ 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 Background 
Cervical screening is available to women and people with a cervix aged 25 to 64 in 
England. People aged 25-64 years, registered with a GP as female are automatically 
invited through a digital call/recall process to participate in cervical cancer screening. 
The national programme sends the first invitation to eligible people at the age of 24.5 
years. People aged 25 to 49 receive invitations every 3 years. People aged 50 to 64 
receive invitations every 5 years. A reminder letter is sent at 8 weeks after the first 
invitation. A person is deemed a non-responder 8 weeks after the reminder letter (i.e., 
16 weeks after the first invitation).  

When  a  person  attends  for  screening  their  details  are  recorded  on  the  Cervical 
Screening System. Screening results are likewise recorded on the Cervical Screening 
System, as is the date of the next recall (based on the findings). Further, the Cervical 
Screening  Service  produces  worklists  for  GPs  to  process  which  includes  the  Prior 
Notification List and the Non-Responders List. 

Response to Coroner concerns  
As  described  above,  invitations  are  offered  for  routine  cervical  screening  every  3 
years. The cervical screening system produces electronic cards for each patient who 
is a non-responder and these can be viewed by their GP Practice on the electronic 
card summary screen of the Cervical Screening System. If the person’s electronic card 
is not actioned - to defer or cease cervical recall - non-responders will not be contacted 
again by the screening agency until their next screening cycle commences (i.e., in 3 
or 5 years depending on age, or sooner in the case of previous abnormal test results). 

GP Practices receive the results of cervical screening through laboratory integration 
systems. It is usual practice for these results to be filed in the GP IT software system, 
along with the date the next screening test is due (Due Diary). 

GP IT software systems typically have inbuilt alerts to notify users when a person’s 
cervical screening is overdue. Such alerts appear automatically in the person’s record 
without any further manual input, when they reach their 25th birthday. Once a person 
has had a cervical screening test done, the alert next appears if that person is overdue 
their next test. This alert stays present even if the national service has recorded the 
person as a non-responder and has set their recall to the next screening cycle date. 
These  alerts  appear  to  the  user  when  in  a  patient’s  records  in  an  alert  tab.  This  is 
visible in EMIS (bottom right-hand side of the screen) and in TPP (top right-hand side 
of the screen) along with other alerts pertinent to that person’s health status. 

Alerts can be removed or deactivated manually by the GP Practice but, in the case of 
cervical screening, their main purpose is to prompt opportunistic health promotion and 
engagement with cervical screening testing. 

Under the Quality and Outcomes Framework (QOF) scheme Cervical screening may 
be provided as an additional service by GP practices. In addition to tests offered, this 
scheme enables payment where a patient has not engaged with screening after failing 
to respond to the third invitation letter, based on a search facility that is set up by the 
GP IT System suppliers. However, exempting a person through this mechanism does 
not cancel the alert on their record. Further, some practices routinely invite people who 
are overdue their cervical screening, regardless of QOF, using their own searches or 
the searches set up by the GP IT Suppliers. 

 
 In this case, if Rachelle Ross lived in England, and was registered with a GP as female, 
she should have received two invitations from the national Cervical Screening Service 
when she turned 24 years 6 months, and then two further invitations every three years. 
This  means  she  should  have  received  at  least  six  invitations  through  the  National 
Cervical Screening programme prior to her death. This does not include any prompts 
or reminders she received from her GP. It should be noted that an alert would have 
been present on her GP IT records from the age of 25 years unless this was manually 
removed or deactivated. 

Screening uptake in women aged 25-45 years has been declining over the past 10 
years  at  a  greater  rate  than  other  age  groups.  Jo’s  Cancer  Trust  has  carried  out 
research on why people are not taking advantage of cervical screening, with common 
reasons  for  non-engagement  including  embarrassment,  pain,  fear  of  results,  and  a 
lack of understanding (including myths around cervical screening especially prevalent 
on social media). 

I would 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. 

Yours sincerely 

National Medical Director   
NHS England

The Rt Hon Andrew Stephenson CBE MP 
Minister of State for Health and Secondary Care 

39 Victoria Street 
London 
SW1H 0EU 

Carly Elizabeth Henley 
Newcastle Upon Tyne and North Tyneside 
Coroner’s office 
Lower Ground Floor, Block 1 
Civic Centre 
Barras Bridge 
Newcastle upon Tyne 
NE1 8QH 

1st May 2024 

Dear Ms Henley,  

Thank you for the Regulation 28 report to prevent future deaths of 17 February 2023 
about the sad death of Ms Rachelle Ross.  I am replying as Minister with responsibility 
for health and secondary care. 

Firstly,  I  would  like  to say  how saddened I was  to  read of  the  circumstances  of  Ms 
Ross’ death and I offer my sincere condolences to their family and loved ones. The 
circumstances  your  report  describes  are  concerning  and  I  am  grateful  to  you  for 
bringing  these matters  to  my  attention.  Please  accept my  sincere apologies  for the 
significant  delay  in  responding  to  this  matter.  I  would  like  to  assure  you  that  the 
department is mindful of the statutory responsibilities in relation to prevention of future 
deaths reports and we take every case extremely seriously.  

The report raises concerns over patient records systems used in GP services and how 
alerts operate for non-responders for a smear test.  

In  preparing  this  response,  Departmental  officials  have  made  enquiries  with  NHS 
England and the Care Quality Commission (CQC). I am also aware of the published 
responses provided by the GP surgery, the system provider and NHS England.  

Professor Steven Powis in his capacity as the National Medical Director of NHS 
England has responded in detail to the concerns you have raised. I do hope that, as 
an executive non-departmental public body, sponsored by the Department of Health 
and Social Care, the response provided by NHS England has addressed your 
concern. I would also add that, NHS England is also in the process of creating a new 
IT Cervical Screening Management System (CSMS), which is due to go live in 
Quarter 1 2024/25. This system will enable general practice users to review a list of 

1 

 
 
 
 
 
 
 
  
 
  
 
 
 
 
 
 
 
 their non-responders for their individual GP practice. This function will provide 
practices with the ability to identify and proactively remind and/or invite their non 
attending eligible patients to take up the offer of a cervical sample taking 
appointment. 

In our discussions with CQC, they agree that the concerns raised by the coroner have 
highlighted  an  important  area.  Although  CQC  does  not  have  statutory  powers  in 
relation to clinical system providers they will consider engaging with them to enquire 
and encourage an improvement in this area. 

I hope this response is helpful and further reassures you of the work being 
undertaken in this vital area. Thank you for bringing these concerns to my attention. 

Kind regards, 

THE RT HON ANDREW STEPHENSON CBE MP 
MINISTER OF STATE

HM Assistant Coroner, Miss Carly Henley,  
North Tyneside Coroners 
Civic Centre 
Barras Bridge 
Newcastle Upon Tyne 
NE1 8QH 

4th April 2023 

Ref: REGULATION 28 – 21st February 2023 

Dear Miss Henley, 

We write in response to the Regulation 28 report dated 21st February 2023 (the “Report”). 

Firstly, we were saddened to read of the death of Ms Ross and would like to take this opportunity to 
express our sincere condolences to their family. 

As a company, we work very hard to support health care services across the UK and patient safety is 
of paramount importance to us. We have reviewed and considered your concerns raised in the Report 
and have undertaken an internal review.  

As stated in the Report, the patient first became eligible for invitation for cervical screening via the 
National Screening Programme, in 2012, at the age of 25.  EMIS Web was the Electronic Patient Record 
system (“the System”) used by Ms Ross’s GP surgery (as part of the Collingwood Health Group) until 
2017, when they migrated to another Electronic Patient Record system. 

Your first concern was in relation to evidence provided during the coroner’s inquest by a GP Partner 
from the Collingwood Health Group, namely that the System does not provide an automatic flag, or 
alert, on a patient’s medical record if they are classed as a non-responder to an invitation for a National 
Screening Programme event, such as cervical screening (“Cervical Screening Event”).  

However, we feel it important to note that in the case of a patient failing to respond to an invitation 
for  a  Cervical  Screening  Event,  an  automatic  alert  (triggered  by  the  absence  of  a  code  indicating 
completion of Cervical Screening Event), which reads “Cervical Smear due or outstanding”, will display 
each time the patient’s record is opened in the System.  This alert is triggered regardless of whether 
the patient has historically attended for a Cervical Screening Event or not (in accordance with the NHS 
Cervical Screening Programme).  The alert remains visible on the patient record until the patient is 
recalled by the National Screening Programme in 3 or 5 years depending on age.  

A  clinical  user  may  choose  to  suppress  alerts  during  a  clinical  session;  however  this  automatically 
reverts to the default of ‘visible’ when they next log in to the System as alerts cannot be turned off at 
a Practice level. 

In addition to the automatic alert described above, any GP practice using the System has the ability to 
extract a list of patients who remain eligible, but are not up to date, with their cervical screening.   This 
can be undertaken by accessing the ‘Population excluded’ file from the QOF reporting screen (part of 
the Population Reporting module).  It is possible to exclude patients from cervical screening recalls 
(and therefore this list), but should only be after an informed discussion between the patient and a 

 
 
 
 
 
 
 clinician which is documented on a disclaimer letter (known as informed consent for withdrawal from 
the  Cervical  Screening  Programme).    EMIS  Web  has  included  QOF  alerts  since  before  this  patient 
would have been eligible for her first cervical smear in 2012. 

We can confirm that all of the functionality described above meets the specification provided by NHS 
Digital (now, NHS England). 

Conclusion 

At EMIS we are proponents of continuous improvement, and we will continue to review our solutions 
to determine whether there are changes to be made which would improve their performance.  

In  this  instance,  we  believe  that  the  System  already  meets  required  specifications  as  well  as  your 
recommendation  of  including  an  automatic  flag/alert  when  a  patient  fails  to  attend  for  cervical 
screening as part of the National Screening Programme.   

EMIS will continue to review and investigate any cases of a similar nature, and review effectiveness of 
any current and ongoing mitigations.  

We trust that the details outlined above are of help. 

If  you  have  any  further  queries  then  please  contact  our  Senior  Clinical  Director, 

, in the first instance. 

Kind regards 

Chief Medical officer, EMIS Group

Miss Carly Henley 
Assistant Coroner 
Civic Centre 
Barras Bridge 
Newcastle upon Tyne 
NE1 8QH 

7th March 2023 

Dear Miss Henley 

Re:  Rachelle Naomi ROSS 

Thank you for your letter of 21st February 2023. This is a very sad situation. 

I am a GP by background (
TPP) in 1999. I have been the clinical director of TPP for 18 years. 

 and was the first user of SystmOne (the product supplied by 

SystmOne has a built in report in support of the Quality Outcomes Framework that alerts GPs on the 
home screen (the screen that is first seen when a patient record is opened) when a patient is due a 
cervical smear. This is not dependent on the patient having had a cervical smear. The list of patients 
who are requiring a smear are also available in the reporting system as a list of patients ready for 
letters / reminders / SMS messages to be sent as the practice decides. 

With regard to your specific point about an alert when a patient has not responded to an invitation 
by the National Screening Service – my understanding is that GPs are not informed of this, and there 
is no mechanism for this information to be sent directly into the electronic patient record. As a result 
that computer cannot alert the GP as it does not hold this information.  

In summary – there is an automatic alert within the system when a patient is due a smear, irrespective 
of whether they have had one or not. 

I  firmly  believe  that  information  from  all  the  NHS  adult  screening  services  should  be  sent 
automatically to the GP IT systems. Currently only the bowel screening service is sent in this way. All 
other screening services are sent via a paper note that may or may not be entered into the patient 
way in such a manner that can be computed. I would support any action you recommend to enhance 
the flow of information to the GP systems from the national screening services. 

Yours sincerely