Stephen Cassidy

Dr Simon Fox  
Avon Coroner’s Office 
37 Old Weston Road 
Bristol 
BS48 1UL 

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

Dear Coroner, 

9 November 2023 

Re: Regulation 28 Report to Prevent Future Deaths – Stephen William Cassidy 
who died on 5 March 2023.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  18 
September 2023 concerning the death of Stephen William Cassidy on 5 March 2023. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Stephen’s family and loved ones. NHS England 
are keen to assure the family and the coroner that the concerns raised about Stephen’s 
care have been listened to and reflected upon.  

Following several meetings with colleagues at North Bristol Trust (NBT), NHS England 
offer the following responses to each of the points raised. 

1.  There was no provision for clinical staff at SMH to access patients’ Summary 

Care Record routinely or easily. 

The  Summary  Care  Record  (SCR)  have  nationally  established  Pre-requisites  for 
access which are known to organisations. These include: 

▪  access to the internet or a Health and Social Care Network (HSCN) connection. 
▪ 

to ensure your organisation has completed a Data Security and Protection Toolkit. 
(DSPT) self-assessment and or reviewed the latest updates to it. (DSPT - formerly 
known as the Information Governance Toolkit). 
including Identity  Agent and NHS  Credential 
local 
Management as per Warranted Environment Specification on all user computers. 

technical  configuration 

▪ 

▪  an assigned privacy officer for alert and audit purposes when viewing SCR. 
▪  agreed local processes to ensure robust governance - when viewing SCR the user 

▪ 

is informed of the need to follow the Permission to View guidelines. 
to  have  prepared  training  for  users  covering  the  features  the  organisation  plans 
to use. 

The  National  Care  Records  Service  (NCRS)  is  the  improved  successor  to  the 
Summary Care Record application that allows health and social care professionals to 
access and update a range of patient and safeguarding information across regional 
Integrated Care Services (ICS) boundaries. The service is a web-based application 
and can be accessed regardless of what IT system an organisation is using, providing 
a summary of health and care information for care settings where the full patient record 
is not required to support their direct care. 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 Access to SCR or NCRS requires a web link which can be bookmarked or added to 
relevant  desktop  machines.  Alternatively,  access  can  be  via  a  SCR  1-Click/NCRS 
Integration, which allows local access to the National Care Records Service. 

Authentication  is  required  to  ensure  that  only  relevant  healthcare  professionals  are 
able to access special category personal identifiable information / clinical records. 
Smartcards  have  been  a  common  method  to  support  authentication  and  access  to 
Spine  services  over  the  last  few  years  for  healthcare  professionals.  Spine  allows 
information to shared securely though national health services such as the Electronic 
Prescription  Services,  the  Personal  Demographics  Service,  the  Summary  Care 
Record and the e-Referral Service.  

Staff  require  a  smartcard  to  authenticate  to  Spine  services,  it  is  however 
acknowledged that only a limited number of staff at NBT have and carry a smartcard. 
NHS England are working with NBT to identify suitable alternative solutions to the use 
of Smartcards. 

While NBT staff have access to clinical records for patients who live within the footprint 
of their local detailed care record, for patients who reside or are registered with a GP 
outside of this footprint, the National Care Records Service (NCRS) provides a quick, 
secure way to access national patient information to improve clinical decision making 
and healthcare outcomes and it is free to use. 

2.  This was despite provision existing for South West Ambulance clinical staff 

to do so before a patient arrived at hospital. 

It is understood that South West Ambulance Trust have the technical ability to access 
Spine  services  including  SCR  and  have  embedded  organisational  procedures  to 
access this information routinely. 

A  paramedic  from  South  West  Ambulance  Trust  accessed  this  patient’s  SCR  and 
noted  that  this  patient  had  an  allergy  to  Ceftriaxone  in  their  record.  The  paramedic 
included information that this patient had an allergy to Ceftriaxone, in their handover 
to A&E staff at SMH. 

3.  There was no provision for the Summary Care Record to be integrated with 
SMH’s hospital electronic patient record (known as Careflow/Connect) or the 
primary  care  electronic  patient  record  (EMIS  –  Egton  Medical  Information 
System) – such that the Ceftriaxone allergy automatically appeared in SMH’s 
electronic patient record; 

NHS  England  Summary  Care  Records  team  and  digital  safety  experts  within  the 
National Patient Safety Team have worked collaboratively with North Bristol Trust to 
discuss and identify suitable options to access SCR. 

The  implementation  of  National  Care  Records  Service  (NCRS)  will  address  two  of 
these points: 
▪  The NCRS Integration ‘Deep Link’ is a quick and easy way of integrating NCRS 

into local clinical systems. 

 
 
 
 
 
 
 
 
 
 
 
 ▪  CIS2  (the  authentication  mechanism  used  by  NCRS)  permits  a  variety  of 

authentication methods in addition to Smartcards. 

SCR is fully integrated with EMIS, a provider GP IT system for 60% of GP Practices 
in England. EMIS update the data which is displayed in SCR every time the information 
in the SCR is updated (approximately 1 million updates per day).  

In addition, there is the ability to view SCRs within the EMIS system, which multiple 
practices  routinely  do  to  support  the  care  of  temporary  resident  patients  and  newly 
registered patients.  

The  SCR  viewing  requirements  require  clinical  systems  and  organisations  that 
consume the SCR to only present the information as human readable and not machine 
processed  i.e.,  a  human  must  read  the  information,  assimilate  this,  and  transcribe 
relevant content in the correct way, into their local patient record. 

NHS England is committed to other programs of work (e.g., GP Connect / MIG) which 
are  currently  delivering  solutions  that  convey  allergy  information  end  to  end  in  a 
machine processable way.  

4.  As  a  result  none  of  the  emergency  department  doctors,  the  trauma  and 
orthopaedics team or the anaesthetist who administered the antibiotic with 
induction were able to ascertain Mr Cassidy’s Ceftriaxone allergy; 

All  healthcare  providers  are  required  to  perform  medicines  reconciliation  during 
relevant  patient  contacts.  Medicines  reconciliation  includes  obtaining  an  accurate 
allergy history for each patient, this requires at least two sources of information e.g., 
from the patient / carer, and from the SCR. 

In the case presented it appears that Mr Cassidy did not self-report the Ceftriaxone 
allergy or the patient was only able to report vague details about an allergy which could 
not be matched to a unique drug when they were asked about allergies by NBT staff. 

It is recognised that some NBT staff may not have been aware that out of area patients 
may not have their allergy information recorded on local NBT systems.  

5.  This led to an avoidable fatal anaphylactic reaction. 

NHS  England  is  fully  committed  to  working  with  provider  organisations  to  improve 
access to all available sources of critical patient information.  

I would also 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

14th November 2023 

The Coroner’s Court  
Old Weston Road 
Flax Bourton 
BS48 1UL  

Office of the Chief Medical Officer 
Trust Headquarters 
Southmead Hospital 
Westbury on Trym 
BS10 5NB 

FAO: Dr Simon Fox KC, Assistant Coroner Area of Avon 

Dear Dr Fox, 

Re:  Regulation  28  Prevention  of  Future  Deaths  report  following  Inquest  into  the  death  of  Stephen 
Cassidy 

I write further to the Regulation 28 report, dated 19th September 2023, issued as a result of the inquest 
into the death of Mr Stephen Cassidy. North Bristol NHS Trust offers the following responses to the 
points raised: 

a)  There  is  no  provision  for  clinical  staff  at  SMH  to  access  patients  Summary  Care  Record  (SCR) 

routinely or easily. 

North Bristol NHS Trust (NBT) moved to Careflow EPR in July 2022 and changed its authentication 
method from Smartcard-based to password-based authentication. The routine use of smartcards 
since then has declined as they are not required for access to NBT local systems, or to the wider 
primary  care  interface  –  Connecting  Care.  Since  the  receipt  of  the  Regulation  28  report,  the 
following actions have been taken and planned: 

1.  Non-smartcard-based  access  to  NCRS  (National  Care  Record  Service):  Following  discussions 
with NHSE, NBT IT team have explored access to the new NCRS with existing authentication 
protocols without having to use Smartcards. This has already been trialled successfully for a 
pilot cohort, and after a planned limited clinical deployment we would be in a position to make 
access available to all Trust staff in the first quarter of 2024. This would allow staff to access the 
NCRS from any browser by using the Microsoft authenticator app and without having to use a 
Smartcard. 

2.  One-click/in-context access to NCRS: The ability to access the SCR (and  its follower NCRS) in 
context unfortunately could not be deployed in 2022 at the time of the move to Careflow owing 
to technical incompatibilities. Following discussions, the IT teams of NHSE, NBT, and System C 
(producers of Careflow) have had a meeting on the 6th of November to agree a way forward on 
integration, and the Director of IT at NBT has communicated the requirement to System C so 

 
 
 
 
 
 
                   
 
 
 
 
 
 
 
 
 
 
 that  this at  the  highest  priority for rapid deployment.  This is a complex  piece of integration 
work which requires System C, NBT, and NHSE to align digitally, the pathway was agreed in the 
last meeting and we are aiming for its completion in the first half of 2024. 

3.  Smartcard use in NBT: The majority of NBT staff have active Smartcards even though they are 
not required for access to Careflow EPR. Following the issuance of the Trust safety alert in April 
2023 which encouraged staff to access the NCRS/SCR we requested NHSE interrogate access 
requests and they could confirm that the NCRS was accessed 3,810 times and SCR 2,787 times 
from NBT since 17th April 2023, with 473 access events for NCRS in the week of 23 October 
2023. In the same week the SCR (which can only be accessed with a Smartcard) was accessed 
356 times. NHSE were further able to confirm that in the 12 months leading up to October 2023 
SCR was accessed from NBT  using Smartcards on 30,247 occasions. While  we are  unable to 
audit the details of such access, the data confirms that Smartcard use in NBT for accessing NCRS 
and SCR remains frequent, making information visible to clinicians upon request. 

b)  This  is  despite  provision  existing  for  SWAS  clinical  staff  to  do  so  before  a  patient  arrives  at 

hospital. 

SWASFT access the SCR on a regular basis and populate this information in their documentation. 
NBT have implemented a process by means of which the ambulance handover letter is printed and 
scanned into the Electronic Database Management System (EDMS) upon arrival of the patient. All 
information from the ambulance handover is therefore available to clinicians within minutes after 
arrival of the patient by ambulance. Safety alerts encourage clinical staff to access the information 
from EDMS and from Connecting Care, in addition to seeking it from the patient or their relatives, 
and if an allergy is identified they are expected to add it as an alert to Careflow which then remains 
visible to clinical staff. This process is now reflected in policies published on the NBT Intranet. Since 
April  2023,  the  recording  of  allergy  related  alerts  in  Careflow  is  audited  and  has  seen  a  500% 
increase in recording of such alerts compared to the preceding period prior to the alert and change 
in process. 

c)  There  was  no  provision  for  the  Summary  Care  Record  to  be  integrated  with  SMH’s  hospital 
electronic  patient  record  (known  as  Careflow/Connect)  or  the  primary care  electronic  patient 
record  (EMIS  –  Egton  Medical  Information  System)  –  such  that  the  Ceftriaxone  allergy 
automatically appeared in SMH’s electronic patient record. 

We have addressed the progress towards integration of SCR/NCRS in-context in a) 2. The ability to 
populate alerts across systems was discussed in meetings with NHSE in October, however this poses 
significant logistical challenges in definition of data points and creation a ‘single source of truth’ 
across  systems.  NHSE  are  aware  of  the  challenges  faced  and will  be  best  placed  to  address  the 
specific  question of ‘seamless  integration’ of  EPR  systems  across England  spanning  primary  and 
secondary care. 

 
 
 
 
 
 
 
 
 d)  As a result, none of the emergency department doctors, the trauma and orthopaedics team or 
the  anaesthetist  who  administered  the  antibiotic  with  induction  were  able  to  ascertain  Mr 
Cassidy’s Ceftriaxone allergy. 

Until we achieve seamless access to the NCRS, we have taken the following actions: 

1.  Clarified to staff about the requirements to ascertain allergy information from a minimum of 

two sources and updated the trust guidelines to reflect this. 

2.  Actions to be taken to record and communicate allergy alerts in Careflow along with simple 
guidelines  on  how  to  do  this  have  been  communicated  and  reinforced  with  reminders  by 
email, face to face, and in safety bulletins. 

3.  Face  to  face  teaching  on  this  topic  has  been  provided  to  junior  doctors  in  their  teaching 

sessions by the Pharmacy team. 

4.  We have worked closely with the ICB and the Connecting Care team, they have updated their 
system to provide clear advice if Connecting Care is unable to reflect the information contained 
in the NCRS/SCR/EMIS to "Connecting Care cannot display information on this patient at this 
time,  PLEASE  access  this  information  from  the  National  Summary  Care  Record  (NCRS)  by 
accessing the NHS Spine Portal". 

e)  This can lead to avoidable patient harm including death. 

NBT  recognises  the  cross  system  digital  processes  and  human  factors  which  contributed  to  this 
tragic avoidable death. 

In  addition  to  the  work  set  out  above  to  improve  accessibility  to  the  NCRS/SCR,  NBT  are  also 
working on two other projects: 

1.  Electronic  Prescribing  and  Medicines  Administration  (EPMA)  –  EPMA  systems  have  been 
demonstrated  to  reduce  medication  error  across  healthcare.  NBT  have  commissioned  the 
implementation of this system, with plans for this to be deployed in the third quarter of 2024. 
In addition to providing safeguards to medical prescribing, this will also serve as a repository 
for allergy information across the trust. 

2.  Red Wrist Bands – We have completed a scoping exercise for deployment of ‘Red Wrist Bands’ 
for patients with allergy alerts. This is designed to be a ‘human factor’ intervention to bring 
forth an appreciation for recognition of allergy or similar alerts. This is in business  planning 
stage, and we hope to implement this by the third quarter of 2024. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 I  hope  you  will  take  some  assurance  from  this  letter  setting  out  our  response  in  relation  to  the 
concerning points that you made in your Regulation 28 report.  

Yours sincerely, 

Medical Director - Safety and Quality 
North Bristol NHS Trust