Samuel Jordan

Nicholas Leslie Rheinberg 
Exeter and Devon Coroner’s Service 
Room 226 County Hall 
Topsham Road 
Exeter 
Devon 
EX2 4QD 

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

9th April 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Samuel Thomas Jordan 
who died on 26 March 2020.   

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  2 
February 2024 concerning the death of Samuel Thomas Jordan on 26 March 2020. In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Samuel’s family and loved ones. NHS England are 
keen to assure the family and the coroner that the concerns raised about  Samuel’s 
care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report and I apologise for 
any anguish this delay may have caused to Samuel’s family or friends. 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.  

Your Report raised the concern that NHS Spine only operates to transmit records from 
a  GP  Practice  where  a  patient  is  registered  as  permanent,  and  not  a  GP  Practice 
consulted  on  a  temporary  basis.  In  Samuel’s  case,  this  meant  that  Exeter  Prison 
Healthcare were not aware of Samuel’s mental health issues or current prescription. 
Your  Report  raised  the  point  that  prisoners  were  frequently  nomadic  and  may  be 
registered with GP practices on a temporary basis.  

NHS England has been working to improve the processes around information sharing 
between the detained estate and the wider NHS. This includes enabling access to a 
range of Spine connected services including Personal Demographics Service (PDS), 
Electronic Referral Service (eRS) and GP2GP Transfer. As a result of these changes, 
some  patients  transferring  into  the  detained  estate  will  have  a  GP2GP  transfer 
whereby the patient’s electronic GP record is sent from their previously registered GP 
Practice  to  the  new  GP  Practice  that  they  register  with  within  the  detained  estate. 
Further details are available via the links below:  

•  Detained estate overview: https://pcse.england.nhs.uk/services/medical-

records/detained-estates 

•  GP2GP Transfer: https://pcse.england.nhs.uk/services/medical-

records/gp2gp-transfer  

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 
 
 
  
 •  Primary Care Support England (PCSE) web guidance regarding registering 
patients with the detained estate: https://pcse.england.nhs.uk/help/patient-
registrations/patient-registrations   

Patients within the adult male and children and young people’s secure estate (adult 
male  prisons,  young  offender  institutions  and  secure  training  centres)  have  the 
opportunity to register with healthcare at their place of detention. This means a GP2GP 
transfer  can  now  take  place,  electronically  transferring  the  patient’s  community  GP 
record into the clinical system in place across the secure estate, and then back out to 
the  community  when  the  patient  registers  with  a  GP  on  release.  The  ability  for  a 
GP2GP  transfer  of  a  community  GP  record  into  the  prison  healthcare  system  was 
rolled out to the male prison estate between February and July 2022, so this option 
was not available at the time of Samuel’s death, but I hope provides assurance around 
current practice.  

Regarding  management  of  temporary  resident  patients  and  information  flow,  the 
relevant  NHS  England  guidance 
found  here: 
https://pcse.england.nhs.uk/help/patient-registrations/patient-
registrations. Specifically, within the ‘Managing temporary registrations’ section,  this 
guidance includes the following points:  

to  GP  practices  can  be 

• 

• 

• 

‘A temporary registration (GMSE) can be in place for three months. A GMSE 
form will need to be completed by the patient.’ 
‘GP  practices  can  apply  discretion  in  judging  when  it  is  appropriate  to 
permanently  register  the  patient  with  their  GP  Practice’.  We  note  that  in  this 
matter,  Samuel  was  a  temporary  resident  at  the  GP  Practice  in  Cornwall  for 
four months.  
Information sharing back to the patient’s permanent registered GP Practice is 
currently 
process: 
via 
https://pcse.england.nhs.uk/services/medical-records/temporary-resident-
forms-gms3 

managed 

PCSE 

a 

•  Once  a  GMSE  form  is  received  by  the  patient’s  registered  GP  Practice,  the 
information  should  be  transferred  into  the  patient’s  GP  record  and  made 
available via the Summary Care Record.  

The Summary Care Record has been enabled for viewing in the detained estate for a 
number  of  years.  In  2020,  when  Samuel  died,  SCRs  were  accessed  using  the 
Summary  Care  Record  application.  However,  currently  users  across  the  detained 
estate will access the SCR via the National Care Records Service NCRS (see further 
information below). 

In  summary,  there  are  existing  processes  around  the  management  of  temporary 
resident  patients.   These  support  GP  Practices  to  take  over  the  management  of 
patients by registering them permanently at the new practice where this is appropriate. 
Where  care  continues  to  be  provided  on  a  temporary  basis,  there  are  existing 
information  flows  to  send  information  about  the  care  episode  back  to  the  patients’ 
registered GP Practice via the GMS3 form, where the patient has consented, and for 
this information to then be integrated into the patients’ registered GP record so that 

 
 
 
 
 the information can be made available in SCR and other GP extracts. Separate work 
over the last few years has also enabled patients’ healthcare information to flow into 
and out of the detained estate via the GP2GP process with GP Practices within the 
detained estate being able to receive and manage the patient’s longitudinal GP record. 
If a patient has not consented to a GP2GP transfer via the GMS3 form, the GP2GP 
transfer cannot take place and the registered GP should instead be contacted directly 
for a summary.  

For  further  background  information,  the  NCRS  is  the  improved  successor  to  the 
Summary  Care  Record  application  (SCRa).  SCRa  has  provided  access  to  Spine 
services for clinical users for a number of years. NCRS has been developed gradually 
over the last four to five years, and as the NCRS product has matured, we have been 
migrating users across from SCRa to NCRS throughout 2023. 

As a minimum, the SCR contains important information about: 

•  current medication 
•  allergies and details of any previous reactions to medicines 
• 

the name, address, date of birth and NHS number of the patient 

In  addition,  details  of  long-term  conditions,  significant  medical  history,  or  specific 
communications needs, is now included by default for patients with an SCR, unless 
they  have  previously  told  the  NHS  that  they  did  not  want  this  information  to  be 
shared. For more information, and to illustrate the type of content included in an SCR, 
an example SCR is available here: Additional Information in the SCR 

Additional Information in the SCR includes the active problems and many significant 
past problems for a patient as recorded by their registered GP practice.  In reference 
to Samuel’s case, this could include mental health conditions (e.g. bipolar disorder) or 
previous  psychotic  episodes.  In  addition,  a  history  of  deliberate  self-harm,  suicide 
attempts  or  suicidal  ideation  where  these  have  been  recorded  as  problems  in  the 
patient’s GP record. However, apart from the date, the SCR would not include further 
details of the episodes of deliberate self-harm, suicide attempts or suicidal ideation. 
Therefore, the SCR does not contain any documents (e.g. a mental health care plan 
or mental health crisis plan) but the SCR can act as a signpost to unscheduled care 
clinicians  to  seek  further  information  from  other  teams  involved  in  the  care  of  the 
patient. 

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