Odichukwumma Igweani

15th February 2023 

Mr Sean Cummings 
Assistant Coroner for Milton Keynes 

BY EMAIL ONLY 

Medical Directorate 
BLMK ICB 
Priory House 
Monks Walk, Chicksands  
Shefford Bedfordshire  
SG17 5TQ 

Dear Mr Cummings 

Re: Regulation 28: Report to prevent future deaths 

Thank you for the Regulation 28 report dated 16th August 2023 following the inquest into the 
death  of  Mr  Kelvin  Igweani.  I  am  writing  to  provide  Bedfordshire  Luton  &  Milton  Keynes 
Integrated Care Board (BLMK ICB)’s response to the concerns raised in the inquest report. 

Firstly, BLMK ICB would like to extend our sincere condolences to Mr Igweani’s family and 
friends. 

The matters of concern raised in the regulation 28 report to prevent future deaths are as 
follows: 

Out of hours and emergency mental health care for people who are not registered with 
an NHS GP in Milton Keynes may be obtained by attending the Emergency Department 
at the Milton Keynes University Hospital where mental health professionals are based. 
Through Kelvin's period of deteriorating mental health, which was obvious to those who 
knew him, his mother made repeated attempts to secure mental health assessment and 
care for him. Kelvin’s mother was not directed clearly by the professionals she did have 
contact with, to take him to the Emergency Department for assistance. There was a gap 
which Kelvin fell through and he did not receive either mental health assessment or care. 
It was not possible to say that the failure to receive assessment or care resulted in Kelvin 
attempting  to  take  the  lives  of  others  and  succeeding  in  taking  the  life  of  his  male 
neighbour. 

It was clear that the lack of clear information and direction in regard to how to obtain that 
mental health assessment or care contributed to Kelvin not presenting for assessment 
which  may  possibly  have  averted  the  tragic  events  which  unfolded  on  the  26th  June 
2021.This in  turn  raises  the  prospect that  others, in  similar predicaments  may  also  be 
unable to obtain the care required. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 BLMK ICB acknowledge the concerns raised and have worked with our providers to look at 
pathways  and  to  understand  where  learning  is  needed  to  ensure  that  others,  in  similar 
situations, can access appropriate care as required. 

We will work with our primary care practices across BLMK to ensure that when patients are 
declined registration, which is appropriate as part of their contract such as  with boundary 
limitations, the practices are able to share appropriate details on how to find  and register 
with a GP practice such as through NHS Choices or through the ICB  

Find a GP - NHS (www.nhs.uk) 
Contact us - Bedfordshire, Luton and Milton Keynes Integrated Care Board (icb.nhs.uk) 

Through our primary care forums, weekly bulletins and working with Central and North West 
London  (CNWL),  we  will  ensure  that  practices  in  Milton  Keynes  are  aware  of  the  mental 
health single point of access which is a 24 hour and 7 day a week service, that gives advice 
on  how to access  local mental health  services  and  can  be  accessed  via email  and/or by 
telephone. 

We  will  work  with  CNWL  to  ensure  that  information  regarding  mental  health  crisis  is  
available  in  surgery waiting areas across  Milton  Keynes.  Will we extend  this to  our other 
mental health providers across BLMK to ensure crisis information is readily available in all 
BLMK primary care practices. 

We will continue to work with our 111 providers with regards to the implementation of the 
dedicated process for mental health due to come into affect in Spring 2024. 

These work streams will be reported through our Primary Care Delivery Group and System 
Quality Group. Thank you for bringing the concerns to our attention, we hope this response 
provides both yourself and the family of Mr Igweani with assurance that BLMK ICB takes 
these concerns seriously and are committed to ensure that improvements are made across 
our  systems.  However,  should  you  have  any  further  queries  or  concerns  please  do  not 
hesitate to contact me. 

Kind Regards 

Chief Medical Director | BLMK Integrated Care System

Executive Office 

3 October 2023 

Mr Sean Cummings 
Assistant Coroner for Milton Keynes 
HM Coroner’s Office 
Civic Offices 
1 Saxon Gate East 
Central Milton Keynes 
MK9 3EJ 

Dear Mr Cummings, 

Re: Regulation 28: Report to prevent future deaths 

Thank you for your Regulation 28 report dated 16 August 2023 following the inquest 
into the death of Mr Kevin Igweani.  I am writing to provide Central and North West 
London NHS Foundation Trust (CNWL)’s response to the concerns that you raised in 
that report. 

Firstly, we would very much like to extend our condolences to Mr Igweani’s family 
and friends. 

The matters of concern that you raised were: 

Out of hours and emergency mental health care for people who are not 
registered with an NHS GP in MK may be obtained by attending the ED at the 
MKUH where mental health professionals are based. 

Through Kelvin’s period of deteriorating mental health which was obvious to 
those who knew him, his mother made repeated attempts to secure mental 
health assessment and care for him. 

She was not directed clearly by the professionals she had contact with to take 
him to the emergency department for assistance. There was a gap which 
Kelvin fell through and he did not receive either mental health assessment or 
care. It was not possible to say that the failure to receive assessment or care 
resulted in Kelvin attempting to take the lives of others and succeeding in 
taking the life of his male neighbour. 

It was clear that the lack of clear information and direction in regard to how to 
obtain that mental health assessment or care contributed to Kelvin not 

 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 presenting for assessment which may possibly have averted the tragic events 
which unfolded on the 26th June 2021. This in turn raises the prospect that 
others, in similar predicaments may also be unable to obtain the care required. 

We acknowledge your concerns and confirm that we have reviewed the information 
available on our website.  This advises that urgent mental health support can be 
provided via our Single Point of Access service (SPA) 24 hours a day, 7 days a week 
which is accessible on telephone number: 

mental health services in Milton Keynes, this may include going to A&E. 

  The Single Point of Access gives advice on how to access local 

Nationally, NHS England are working with NHS 111 to create a dedicated process to 
access MH services.  This will mean that if a member of the public calls 111 with a 
MH concern they will automatically be diverted to the MH Crisis Lines which exist 
nationally.  This is due to come into effect in April 2024. 

We will discuss this case in our Care Quality Improvement Forum meeting planned 
for 23 October. These meetings are attended by representatives from all of our 
Mental Health teams, and then further through their team business meetings which 
are held weekly. 

We will also cascade a learning leaflet to local GPs via the Primary Care Network 
(PCN) alliance that we attend jointly with representatives from our local GPs and we 
will supply posters to GP surgeries to be displayed in their waiting areas informing 
how those presenting with acute mental health crisis can access mental health 
services via the ED at MKUH. 

Thank you for bringing your concerns to our attention.  We hope that this response 
provides some reassurance to both you and to Mr Igweani’s family that the Trust has 
taken the matters raised seriously.  Should you have any further questions or 
concerns, please do not hesitate to contact me. 

Yours sincerely, 

Chief Executive

RED HOUSE SURGERY 
241 QUEENSWAY 
BLETCHLEY 
MILTON KEYNES 
MK22EH 

25.9.2023 

Coroners Officer 

Dear Sir/Madam 

REGULATION 28:  REPORT TO PREVENT FUTURE DEATHS 

Further to  your request  for  information regarding regulation  28  report  to  prevent 
deaths we  can confirm that we provided information to the  coroner regarding the 
reasons  why  Red  House Surgery were unable  to  register Odichukwumma Kelvin 
Igweani  at  the  Red  House  Surgery  around  the  16th  of June  2021 .  (Please  see 
attached copy) 

Regarding the  comments posed in your report we  can  confirm that 

 barrister informed our Practice Manager while she was attending as  a 
witness, that she had contacted the surgery one evening to request that her son be 
registered  at the practice.  At the time  she arrived the  surgery  had  closed,  which 
would indicate that this was after 6.30pm.  However, staff were still on site and so 
opened  the  door  to  speak with  to 
  and  she  requested  that 
her son be registered at the practice.  The staff asked for his address and due to this 
being  given  as  Oldbrook,  she  was  advised  that  this  is  outside  of our  practice 
catchment  area,  and  we  would,  therefore,  be  unable  to  register  her  son.  This 
The  barrister  also  informed  the 
information  is  correct  and  practice  policy. 
Manager  that 
  had  informed  staff that  she  was  worried 
about  her  son's  mental  health,  and  she was  therefore,  given  the  number  for  the 
crisis centre by a member of our practice team.  Again, this is practice policy for 
anyone who raises  a  mental  health  concern and  cannot access  a  GP  at that  time, 
whether a registered patient or not. 

16th

  emailed  the 
of June 
We  can  confirm  that  on  the 
practice asking if her son could re-register at the practice.  She explained that her 
son had de-registered himself.  Patients are automatically removed from a surgery 
list when they register themselves with a new GP practice.  We are not aware if he 
had registered at a local to Milton Keynes but can confirm that he was deregistered 
from the practice on the 23rd ofNovember 2019. 
· 

 
 2 
25.9.23 
Report to prevent future deaths 

In the email (copy  attached) 
 informs  the practice that her 
son has  been "suffering from  his mental health for a very  long time but has so far 
refused  any  sort of help".  She  states  he  is  now  open  to  seeing  someone  and  so 
wishes  for  him to  be registered at Red House Surgery.  She also  states that they 
have  just  gone  through  a  distressing  few  months  since  the  9th  of March  with 
Kelvin  going  AWOL  for  long  periods  and  the  police  being  involved  as  he  had 
been reported missing. 

An  email  response  was  sent  to 
  on  the  21st  of June, 
explaining that the request had been discussed at the practice but due to the policy 
of not accepting patients who do not live within the practice catchment, the request 
to register was refused. 

We  appreciate  the comments  made  by the coroner that action should be taken to 
prevent future deaths but as discussed at the investigation the  following had been 
undertaken. 

Staff had informed 
her  son  at  The  Red  House  Surgery.  Looking  at  the  email  from 
 this appears to have been on the 16th ofJune 2021. 

 that it would not be possible to register 

  by  her own  admission had been given the  number of the 
crisis team by the practice staff at this time.  We have no knowledge as to whether 

 contacted the crisis team. 

ofJune and received a response on the 21 st  of June 2022. 

 then emailed the practice with the same request on the 16th 

Had 
 requested help in finding an alternative practice where 
her son  could  register,  we  could have  been able to  provide the contact details  of 
the  then  Clinical  Commissioning  Group  (CCG)  who  would  be  able  to  provide 
details of local GP surgeries.  There are 26 practices within Milton Keynes, but we 
are not aware of their individual catchment areas. 

It should  be  noted  that 
  had  said  her  son  was  living  in 
Oldbrook  at  the  time,  however,  the  coroner' s  report  stated  that  he  was  resident 
with  his  partner  at  74  Denmead,  Two  Mile  Ash  and  so  it  would  have  been 
appropriate for him  to  register with a  GP surgery who  looks after that estate/area. 
This area is also not within  our catchment.  It could be presumed that his partner 
and children were registered with a local GP  and  could therefore,  have joined the 
same practice as them. 

 3 
25.9.23 
Report to prevent future deaths 

We continue to instruct our staff that anyone who raises concerns that they have a 
mental  health  crisis  are provided with the telephone number  for the crisis centre. 
We  have produced  both  a  text  message  and  a  paper slip  to  give to patients  with 
different organisations to contact for support, copy attached. 

We  do  have  a  Duty  doctor  of the  day  and  wherever  possible  the  duty  doctor  is 
informed of any patient who either states or appears to be in a mental health crisis. 

However,  should a GP not be available for any reason or in an event such as this 
when the staff are  on site,  but out of core hours, without GP support they should 
offer the crisis number to the person involved. 

It may  well  have  been  helpful  to  provide 
  with  the  crisis 
number again  in the  email  response  and the contact details  of the  CCG,  now the 
BLMK Integrated Health Board (ICB) to assist with finding an alternative practice 
and this will be considered for future responses. 

It should be remembered that practice staff are not responsible for recommending 
GP practices to patients and that it is patient choice as to which surgery they wish 
to  register  with,  dependent  on  their  catchment  area.  Staff are  also  not  familiar 
with catchment areas  for individual practices.  Our policy  if asked,  is to suggest 
an  internet  search  or  to  ask  neighbours,  people  in  the  locality  or to  contact  the 
BLMKICB. 

This  event has  been  discussed  several  times  at GP  meetings  with  a  view to  any 
learning outcomes  and  staff have  been made  aware  of the  need  to  be  vigilant  if 
anyone they encounter raises concerns about their mental health or that of another 
person. 

We will further discuss this event at a future protected learning session and ensure 
that  all  staff are  reminded  about  the  crisis  team  and  contact  numbers  for  other 
support organisations and should GP interaction not be possible to refer anyone at 
risk to attend A&E. 

We will  ensure  that all  new  staff as  part  of their  induction,  are  informed  of the 
need to be aware of patients who may be in a mental health crisis and the relevant 
steps to be taken. 

 4 
25 .9.23 
Report to prevent future deaths 

We remain unable to accept the registration of any patients who do not live within 
our catchment area.  Our catchment area has been set up with the approval of the 
now ICB and we have been instructed that acceptance of any one from outside our 
catchment will make us liable to accept all patients from that area. 

The  curtailment  of our  practice  catchment  area  took  place  in  2003  and  many 
outlying patients were asked to register with an  alternative practice closer to their 
home  address.  Due to  issues  within MK around this time,  some  practices  were 
struggling  with  capacity,  and  we  were  asked  to  halt  this  process.  It is  for  this 
reason that we still have some outliers registered with our surgery.  Had we been 
able  to  continue  with  our  catchment  area  programme,  the  Igweani  family  would 
have been asked to register at an alternative practice.  There are many drawbacks 
to having patients registered out-side of the catchment: -

•  Difficulty in attending for appointments. 
•  Excessive time for doctors and paramedics on home visits 
•  Delayed time in getting to visit an unwell patient. 
•  Patients  under  the  care  of  district  nurse/health  visiting  team  are  often 
referred to an alternative team which does not help with interaction with the 
referring GP. 

We hope this information is helpful but please do not hesitate to contact us if you 
require any further information. 

With kind regards 

Yours faithfully 

GP Partners of Red House Surgery 

Encs: 

•  Original report to Coroner 
•  Emails exchange re request to register from Mrs Igweani-Gilmartin / Jane 

Hanlon 

•  Handout of where to obtain support when in  mental health crisis. 

 RED HOUSE SURGERY 
241  QUEENSWAY 
BLETCHLEY 
MILTON KEYNES 
MK22EH 

31.3.2022 

Coroners Officer 

Dear Sir/Madam 

RED HOUSE SURGERY - Catchment Area Policy 

This is  to confirm the policy of The  Red  House Surgery  not to accept new patients who 
do not have a home address that falls within our catchment area. 

Historically  Red House Surgery had a  large catchment area but a considerable number of 
years  (2003)  ago with the approval  of the then  Primary Care Trust (PCT)  it was agreed 
that we could change our catchment area and over a  period of time we contacted patients 
living  outside  our  catchment  and  requested  that  they  change  surgeries.  This  was  an 
extensive  piece of work  but  was  necessary  in  order that  we  could  accommodate all  the 
new builds and additional population within the Bletchley area. 

The  surgery  premises  are  a  converted  house  and  space  is  extremely  limited.  We  are 
unable  to  extend  the  site to  enable  us  to  take on  further  clinicians to  accommodate  an 
expansion to our practice list size. 

Another  main  reasons  for  this  decision  was  that  it  was  very  difficult  for  GPs  to  visit 
patients within  a  timely  manner  if a  home visit was  required.  The  GPs raised  this  as a 
concern as had  on occasion visited  unfamiliar estates/areas at the end of evening surgery 
and  found  that  patients  would  have  benefitted  from  a  visit  earlier  in  the  day  but  this 
hadn't been  possible due to the distance from  the surgery and the number of visits spread 
across the MK area.  This they felt offered a sub-standard service to their patients. 

A  further issue arose with patients requiring the services of District Nurses and  midwives 
in  particular as they have strict areas and have to organise for patients to be seen by other 
teams which  can create  problems with  the teams  not  linking with  the GP practice  where 
the patient is registered. 

It  was  therefore,  agreed  that  our  policy  would  be  to,  not  accept  any  new  patients  or 
change  of address  detai Is  for  existing  patients  to  any  areas  outside  of our  practice 
catchment. 

We have a core practice area for any  new patients and an extended area for those existing 
patients who  move outside our core catchment area.  See attached  I ist.  As you  will  see 
Oldbrook does not fall  within our core or extended area. 

 
 2 
31.3.22 
Coroners Officer 

We  agreed  that  there  would  be  some  patients  who  remained  registered  with  us  whose 
address  was  out  of catchment  but  decided  to  accept  these  and  would  allow  them  to 
remain registered with  us  until such time as they  moved from  the area or perhaps decided 
to  move to a practice closer to their home. 

We  were informed  by  the  PCT at the time that we are  unable to  make exceptions to our 
policy  as  by  accepting any  new  patient from  an  area would  make  us  liable to  accept  all 
requesting patients from  that area. 

We  have  made  an  odd  exception  to  keep  a  patient  registered  for  a  short  length  of time 
(approx.  3  months)  but these have  been  patients who are terminally  ill  and  at end  of life 
and a few pregnant ladies who were close to  the end of their pregnancy who we kept until 
they  gave birth and they and their new born then  registered with doctor in their new area. 

With  regard  to  case  that  you  are  currently  involved  with  (Kl)  I  can  confirm  that  his 
mother  emailed  the  practice  on  the  16th  June  asking  if her  son  could  re-register  at  the 
practice.  She explained that her son  had  de-registered himself.  This would  imply that he 
had  registered at an  alternative practice.  She said she had been informed by the practice 
staff that  this  would  not  be  possible  as  he  would  be  considered  a  new  patient  and  as 
Oldbrook is outside our catchment area we  would be unable to accept him.  However, as 
she subsequently emailed in, her request was raised with the GP  Partners who agreed that 
they  were  unable to  make  an  exception  to  the  practice  policy  and  a  response  email  was 
sent explaining this. 

I hope this  information  is  helpful  but  please do  not  hesitate to  contact me  if you  require 
any  further  information, 

With  kind regards 

Yours faithfully 

Practice Manager 

 
 
 
 red~ ouse 

S  U  R  G  E  R  Y 

In the event that you find yourself in 

crisis or unable to keep yourself safe, 

you may contact the following services 

for support: 

l.CNWL Out of Hours Urgent Advice 

and Crisis Support on 0800 0234 650 -

24 hours a day, 7 days a week 

2.BLMK Milton Keynes Crisis Cafe:  226 

Queensway, Fenny Stratford, Bletchley, 

MK2 2TE, 01525 722  225- drop in and 

phone line open 7 days a week, 17:00 -

23:00 

3.The Samaritans on 116 123 

4.NHS 111 

5.Attend A&E