Meghan Chrismas

Hampshire & Isle of Wight Constabulary 
and Thames Valley Police 

Strategic Police & Fire Headquarters 
Leigh Road 
Eastleigh 
SO50 9SJ  

RE; Regulation 28 Report to Prevent Future Deaths- Meghan Irene Christmas 
who died on 20th October 2021 

Thank you for your report to Prevent Future Deaths (hereafter the report dated 29th 
December  2023  concerning  the  death  of  Meghan  Irene  Christmas  on  20th  October 
2021. In advance of responding to the specific concerns raised in your report I would 
like to express my deep condolences to Megan’s Family and loved ones.  

The Coroner has previously been provided with statements and live evidence from a 
Superintendent.  This  dealt  with  topics  including  the  national  position  on  transfer  or 
enquiries/incidents, the National Police Directory, learning within the Constabulary and 
control room supervision.  This evidence included the updated manner in which risk 
assessments  are  conducted  following  a  system  upgrade  and  the  focus  that  on 
supervisory review of high risk incidents awaiting deployment, as well as being their 
availability to advise staff. Those matters are not set out again in this document. The 
following information is provided in order to update the Coroner with further detail and 
recent developments in relation to training and organisational updates.  

Training  

Staff in the police control room receive five dedicated CPD training days each year. 
The  CPD  training  which  was  provided  in  2023  to  both  supervisors  and  operators 
included THRIVE Risk Assessment and Re-assessment of Risk training as a training 
topic. Further details of these assessments are provided below.  

In  addition,  control  room  supervisors  attend  two  additional  CPD  briefing  days  each 
year,  the  most  recent  training  day  in  November  2023.  The  Coroner  has  previously 
received evidence in relation to the Professional Development Portfolio (PDP) which 
is  completed  by  newly  appointed  supervisors.  This  is  a  comprehensive  portfolio 
team 
dealing  with 

incident  management, 

handovers, 

briefings, 

and 

                
 
 
 
 
 
 
 
 
 welfare/supervision.  All  supervisors  are  expected  to  complete  the  portfolio  prior  to 
being  ‘independent.’  There  is  a  distinct  section  on  incident  management,  and  it 
requires  competence  to  be  shown  in  an  operational  environment.  This  includes 
competency  of  incidents  of  the  following  type:  “High  Risk  Missing  Person  –  Early 
identification of a High Risk missing person incident and ensuring appropriate initial 
lines  of  enquiry.  Assisting  FIM  with  initial  command  and  handing  over  to  duty  R&P 
inspector  when  appropriate.”  It  also  includes  a  unit  on  supervisor  handovers  and 
requires competency in relation to the handovers which includes, quick response to 
new incidents, handovers of incidents of note, and reviewing current, outstanding, and 
deployed incidents to get an overview and understanding of current work, with specific 
reference  to  priority  incidents  for  deployment  and  offering  guidance  and  support  to 
controllers.  It  also  requires  competency  in  checking  Control  Room  dispatch 
group  (CWUN) for outstanding No apparent Risk grading (NAR) and other incidents 
of note, monitoring  the  OOC  (Out  of  County)box, ensuring  reviews  of  NAR missing 
persons are completed and onward tasked if required. The competency requires that 
all tasks are acknowledged and completed in a timely manner.  

In December 2023, the PCR Operations Manager 
 set out clear guidance 
in terms of the expectations on supervisors, specifically in terms of their responsibilities 
to  regularly  review  and  reassess  risk.  Adherence  and  compliance  against  this  is 
tracked  by  our  Quality  Assurance  and  Development  Team  which  is  referred  to  in 
further detail below.  

The December 2023 guidance document was circulated to provide guidance to PCR 
supervisors in terms of Contact Management’s expectation of supervisory reviews, for 
incidents being managed through the PCR in CMP, and what should be included within 
them, and to provide supervisors with a framework to help in the timely completion of 
their reviews.  

The document set out that performance Management is a key accountability of PCR 
supervisors clearly outlined within their Role Profile. Relevant considerations from the 
Performance  Management  section  of  the  role  include  but  are  not  limited  to  the 
following: - 

•  Monitor and review incidents to ensure an effective and efficient response 
in accordance with performance guidelines utilising THRIVE principals and 
the NDM. 

•  Monitor demand from all routes into the Control Room and where necessary 
take proactive action to manage any apparent shortfalls in resourcing. 
•  Liaise with staff across the organisation but in particular with DPT Sergeants 

and Inspectors to optimise service delivery. 

•  Monitor  and  respond  to  service  delivery  demands  using  appropriate  IT 

systems, primarily CMP. 

 
 
 
 •  Support the management of major, critical or significant incidents including 
conducting  dynamic  risk  assessments  to  ensure  the  safety  of  relevant 
persons. 

•  Complete Quality Assurance processes. 
•  Room  Management  –  including  set  up  of  staff,  staff  roles  and  incident 

response. 

•  Ensure that Force Policies and working practices are adhered to, providing 

advice when necessary. 

The December 2023 guidance also set out that although every incident is different and 
therefore  supervisory  input  will  vary  significantly  between  incidents,  the  following 
points are required for consideration and inclusion on CMP as part of a supervisory 
review, unless there is good reason for any of the points not to be covered. 

• 
• 
• 

• 

Is the incident type correct. 
Is the grading appropriate. 
Is the incident appropriate for deployment through the PCR, would it be better 
suited for allocation via the Triage Hub or other specialist team. 
Is 
considerations been missed. 

the  THRIVE  assessment  appropriate,  have  any  relevant  points 

/ 

•  Has any re-THRIVE been completed, is one required. 
• 
If relevant, have action plans been identified and followed. 
•  Have appropriate attempts to resource the incident been made. 
•  Are likely breaches of SLA identified in good time to allow for remedial action 

to prevent any breach. 

•  Has the escalation process been followed. 
• 

If  deployed,  are  the  actions  of  attending  officers  appropriate  (in  line  with  the 
recently shared terms of reference). 

A template was provided to assist supervisors completing each of these reviews and 
provided guidance on each of the steps above to ensure that each of the steps are 
properly considered.  

Introduction of THRIVE Risk Assessments 

In order to improve the quality of initial risk assessments as well as reassessment of 
risk  in  PCR,  Contact  Management  adopted  the  THRIVE  risk  assessment  model 
(October 2023). HMICFRS define THRIVE as ‘a model used to assess the right initial 
police response to a call for service. It allows a judgement to be made of the relative 
risk posed by the call and places the individual needs of the victim at the centre of that 
decision’.  THRIVE  refers  to  Threat,  Harm,  Risk,  Investigation,  Vulnerability  and 

 
 
 
 
 
 
 Engagement. THRIVE is used both as an initial risk assessment tool but also by staff 
and supervisors in the PCR to reassess risk. 

All staff were trained in THRIVE between October and December 2023.  

Quality Assurance and Development Team (QuAD) 

In 2021 Contact Management set up the QuAD team to provide continual audit and 
inspection  of  our  call  handling.  This  is  a  team  of  four  staff,  seconded  from  the 
department who are trained to conduct the audits. Results from the audits drive both 
individual, department and organisational learning. 

In December 2023 the remit of the QuAD team was expanded so that we could audit 
incidents managed in the PCR as well as call handling. Importantly we now audit the 
quality  of  supervisory  reviews  and  re-assessment  of  risk,  providing  immediate 
feedback  to  individuals.  Audit  results  are  also  subject  to  scrutiny  during  a  monthly 
Senior Leadership Team Performance Meeting.  

‘Your Call’ Learning Publication  

In January 2024, Contact Management launched its first ‘Your Call’ publication. ‘Your 
Call’ features a series of anonymised case studies where there has been learning for 
our  staff.  This  provides  another  opportunity to  upskill  our  staff,  learn  from  mistakes 
and improve our service to the public.  

Yours sincerely 

Assistant Chief Constable 
Joint Operations and Contact Management 
Hampshire Constabulary & Isle of Wight Constabulary and Thames Valley Police

Darren Stewart OBE 
Surrey HM Coroner’s Court  
Station Approach 
Woking 
GU22 7AS 

Dear Coroner, 

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

21st January 2024  

Re: Regulation 28 Report to Prevent Future Deaths – Meghan Irene Chrismas 
who died on 20 October 2021.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  29 
December  2023  concerning  the  death  of  Meghan  Irene  Christmas  on  20  October 
2021. In advance of responding to the specific concerns raised in your Report, I would 
like  to  express  my  deep  condolences  to  Meghan’s  family  and  loved  ones.  NHS 
England are keen to assure the family and the coroner that the concerns raised about 
Meghan’s care have been listened to and reflected upon.  

This  response  focusses  on  the  NHS  England  national  and  regional  policy, 
programmes, and commitments relevant to the matters of concern identified in your 
Report,  namely  your  concern  that  the  passage  of  information  between  NHS  and 
private healthcare providers is hindered due to the absence of an adequate structure 
to share important clinical information about patients in a timely and effective manner.  

Meghan’s case highlights the importance of effective information sharing to support 
providing the best care possible where individuals are transferred between different 
care settings.  

When  sharing  information  between  clinicians  looking  after  patients,  the  concept  of 
‘Direct Care’ is relied on as the legal basis of the sharing and explicit consent for this 
sharing is not required from the patient. However, the patient can object to information 
being shared, at which point a clinical decision will need to be made as to whether the 
patient is at risk and the information needs to be shared despite their objections.  

NHS England is currently working to enhance the sharing of patient information to and 
from Voluntary, Charity and Social Enterprise (VCSE) and other independent/private 
sector providers who are commissioned by NHS organisations.  

The Summary Care Record (SCR) was originally designed and communicated as a 
means  to  support  patients  when  they  receive  emergency  care.  Over  time,  the 
significant value of access to SCR to wider healthcare services has been recognised 
and, as a result, the SCR Team have worked with the Expert Advisory Committee to 
extend its use into multiple other care settings through a governance framework into 
which patients and professionals contribute.  

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
  
 
  
 The SCR Team at NHS England have done significant work with a number of private 
sector  organisations,  including  a  range  of  private  hospitals  and  privately  funded 
healthcare services as part of Proof of Concepts (PoCs), into settings where SCRs 
have previously been unavailable. e.g. private GP Services. This work will continue 
throughout  2024.  Clearly,  it  is  difficult  to  define  precisely  what  is  included  within 
“private  hospitals  and  privately  funded  healthcare  services”.  However,  all  “private 
hospitals and independent healthcare services” that have approached NHS England 
to date seeking access to SCR have either been onboarded into the existing proof of 
concepts or there have been discussions with the requesters regarding initial setup 
and their use for access to SCR. Learnings from these PoCs  will be reported back to 
the Expert Advisory Committee to better understand any benefits realised but also any 
potential unintended consequences. The SCR Team will work with the Expert Advisory 
Committee to seek full rollout approval in this sector and consider the scope of this 
approval and any specific exclusions, constraints, or caveats. 

It is worth mentioning that, in the past, the Summary Care Record application (SCRa) 
was the main method to access SCRs for the existing NHS user base and the private 
sector PoCs. However, NHS England have been involved in a programme of work to 
transfer SCR users from the legacy SCRa service to the new National Care Records 
Service (NCRS) service. This work has accelerated during 2023 and is projected to 
conclude during Q2 2024.  

NCRS  is  the  successor  to  SCRa  and  by  design  removes  a  large  amount  of  the 
reported barriers to adoption within many care settings including the private sector. 
The National Care Records Service (NCRS) provides a quick, secure way to access 
national  patient  information  to  improve  clinical  decision  making  and  healthcare 
outcomes, it is free to use and includes additional features and services beyond the 
legacy  SCRa  product.  Further 
found  here: 
https://digital.nhs.uk/services/national-care-records-service. 

information  on  NCRS  can  be 

The NCRS complements Shared Care Records, which is a way of bringing separate 
records from different health and care organisations together digitally in one place and 
joining  up  information  based  on  an  individual  rather  than  one  organisation.  Shared 
Care  Records  will  include  prescribed  medications  and  will  typically  hold  more 
information about an individual than a Summary Care Record.  

Responsibility for delivering shared care records sits with local Integrated Care Boards 
(ICB). Each ICB’s shared care records are developed in response to the health and 
care needs of the local area, existing systems, and future planning. This means some 
of their shared care records are available to neighbouring ICBs, while others are only 
supported within their own ICB. Future plans include making shared care records link 
together regardless of where you live or receive care in England. 

Regarding the duplicate prescriptions administered to Meghan,  the General Medical 
Council (GMC) have produced clear professional standards guidance for doctors on 
the  prescribing  and  managing  of  medicines  and  addressed  where  a  prescribing 
clinician may not be the patient’s regular prescriber. Sections to note are referenced 
below:  

 •  Section 20: You should only prescribe medicines if you have adequate knowledge 
of the patient’s health and you are satisfied that the medicines serve the patient’s 
needs. You must consider … whether you have sufficient information to prescribe 
safely, for example if you have access to the patient’s medical records and can 
verify relevant information. 

•  Section 27: 

a.  It’s  not  safe  to  prescribe  if  you  don’t  have  sufficient  information  about  the 
patient’s health or if the mode of consultation is unsuitable to meet their needs. 
b.  It  may  be  unsafe  if  relevant  information  is  not  shared  with  other  healthcare 
providers  involved  in  the  patient’s  care  –  for  example  because  the  patient 
refuses consent. 

•  Section 28: Before prescribing, you must consider whether the information you 
have  is  sufficient  and  reliable  enough  to  enable  you  to  prescribe  safely.  For 
example, whether … you have access to the patient’s medical records or other 
reliable information about their health and other treatments they are receiving. 
•  Section 29: If you are not the patient’s regular prescriber, you should ask for the 

patient’s consent to: 

a. contact  their  GP  or  other  treating  doctors  if  you  need  more  information  or 

confirmation of the information you have before prescribing, 

b. share information with their GP when the episode of care is completed. 
•  Section 30: If the patient objects to information being shared with you, or does not 
have  a  regular  prescriber,  you  must  be  able  to  justify  a  decision  to  prescribe 
without that information. 

•  Section 31: If the patient refuses to consent to you sharing information with their 
GP,  or  does  not  have  a  GP,  you  should  explain  to  the  patient  the  risks  of  not 
sharing this information. This should be documented in their medical records. 
•  Section 32: If failing to share information could pose a risk to patient safety, you 
should explain to the patient that you cannot prescribe. You should outline their 
options and signpost them to appropriate alternative services. You should clearly 
document your reasons for any decisions made. 

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