Alexander Reid

Office of the Coroner 

Sent via email 
8th July 2024 

Dear 

, 

GPC England acknowledges the tragedy of this case and the unique chain of events, stretching back 
many years, that led to the death of Mr Reid, ultimately due a rare and unpredictable side effect of the 
Oxford AstraZeneca vaccine. The data entry error where Mr Reid’s weight was incorrectly entered 
informed the decision by NHS England to invite Mr Reid for vaccination earlier than his age category 
would have indicated. Had this error not been present it is likely Mr Reid would have been invited for his 
vaccination at a different time, when more might have been known about the side effects of the different 
vaccines which were available, and the outcome may have been different. It could not have been 
predicted at the time the data entry error was made that there might one day be a future pandemic that 
would necessitate a vaccination strategy that made use of the weight that had been erroneously entered. 
It is important for patient trust that medical records are accurate, and that any clinical decisions made 
based on recorded information are appropriate. If trust is damaged and patients become reluctant to 
make use of vaccination programmes there is the likelihood of future harm, through illness and possibly 
death, that might otherwise have been avoided. 

With regard to the matters of concern, we propose to discuss these at our next Joint GP IT Committee 
meeting (which has representatives of the BMA, RCGP and the NHS) to raise awareness of this case and 
seek a consensus on how systems might evolve to reduce the likelihood of similar data entry errors in the 
future. Given the complex chain of events of this particularly tragic case, where any one step, had it been 
different, might have led to a different outcome, we would propose advocating a way forward that 
addresses the main identified concerns which will transcend this case, namely that patients must know 
why they have been offered a given treatment and that the decision is sound based on the prevailing 
medical understanding at the time. It would seem unlikely that the exact same circumstances of this 
case would ever occur again, but it is clear improvements can be made in the NHS’s IT systems so 
patients can have greater confidence that they are being offered appropriate treatments that take into 
account their own unique circumstances. 

Yours sincerely,  

Co-Chair Joint GP IT Committee  

chief executive officers: Neeta Major & Rachel Podolak  

Registered as a Company limited by Guarantee. Registered No. 8848 England. 
Registered office: BMA House, Tavistock Square, London, WC1H 9JP.

14/06/2024 

RE: Cegedim Healthcare Solutions – Response to Regulation 28 Report to Prevent Future Deaths – Reid 

The following comprises Cegedim Healthcare Solutions’ response to the report referenced above that was issued by the 
Coroner for the area of West Yorkshire (Eastern), dated 18 April 2024. The purpose of this response is to provide details of 
actions taken or that may be taken by Cegedim Healthcare Solutions to prevent other deaths occurring in similar 
circumstances in the future. 

Data entered into Vision clinical systems is subject to validation at two levels, namely, “hard” validation where certain 
data items may not be entered (e.g. text in a numeric field) and “soft” validation where users are alerted to possible errors 
in data entry but may still continue and file the data (e.g. range checking of numeric data).  

Vision clinical systems challenge / alert users at such levels where clinical data values are recorded that are considered 
out of normal / usual range.  

For example, in the Vision 3 GP clinical system: 

Weight (kg) has a “hard” upper limit of 1000. And a “soft” range limit of 0.5 to 180kg. 

The same data validation as above is applied when recording weight values within the Vision Anywhere clinical system. 

When using the BMI calculator tool in Vision+, only “hard” data validation is performed on a weight value entered, with a 
“hard” upper limit of 200kg implemented.  

However, there are rules in place in Vision clinical systems for a patient’s BMI to calculate. 

Vision 3 

For a patient’s BMI to calculate, their height must have been recorded after the date of their 15th birthday and both 
height and weight values recorded for the patient must have a date which is on or after their 16th birthday.  

Therefore, for the patient who died, although their weight value of 145kg which is considered unusually high for a child 
aged 11y, the patient’s BMI would not calculate or be available in their record as the patient's height was not recorded 
after the date of their 15th birthday and the height and weight values recorded for the patient don’t have a date which is 
on or after their 16th birthday. 

In this scenario this leaves the patient without a BMI recording in their patient record, forcing the GP to update their 
records accordingly for this figure to be calculated. Without the recording of a BMI in the patient record, the patient 
would then not appear in any adhoc reports exported from the system that required the need for BMI as a criteria. 

It should be noted that for the purposes of Covid, the call/recall was not done by practices, and was done based on 
data extracted from the clinical systems into national systems.  

It should also be noted that  Childhood BMI charts are implemented in Vision 3 apps (https://help.cegedim-
healthcare.co.uk/Vision_3_Apps_Help_Centre/v1.0/Content/C_Apps_Available/Childhood_Growth_Charts_Screen.htm?t
ocpath=Help%20Topics%7CApps%20Available%7CPatient%20Apps%20%7C_____5) 

In Practice Systems Ltd.  
R

Cegedim Rx Ltd.  

 
 
 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Vision Anywhere 

The following rules are used to determine whether a patient’s BMI is calculated. 

1. Is the patient 18y or older? 

a. YES: Proceed to 2 

b. NO: Do not calculate BMI 

2. Is the patient aged 21y or over? 

a. YES: Is there a height record on or after the age of 21y? 

              i.     YES: Use most recent height record that has been recorded on or after the age of 21y 

              ii.     NO: Do not calculate BMI 

b. NO: Is there a height record in the last 12 months? 

               i.     YES: Use this most recent height record 

               ii.     NO: Do not calculate BMI  

With regards to the concerned scenario/case, the patient’s BMI would not calculate or be available in their record in 
accordance with the above rules. 

Vision+ (internal system tool of calculators) 

For the BMI calculator tool in Vision+, there are no rules in place based on a patient’s age for a patient’s BMI to calculate. 
As long as a patient has a weight and height recorded with values within the “hard” upper limits set for each (200kg and 
2m, respectively). 

Vision+ will present a calculated BMI value for the patient. However, upon saving the BMI measurement in Vision+, it is only 
the height and weight values that are written back to the patient’s record held in Vision 3, but not the BMI value itself.  

Vision 3 then may or may not calculate the patient’s BMI based on the height and weight values written back, 
dependent upon the rules in place in Vision 3 based on the patient’s age (as referenced above).  

Therefore, for the patient who died, although their weight value of 145kg which is considered unusually high for a child 
aged 11y this could still be calculated using the BMI calculator tool in Vision+ and Vision+ would have presented a 
calculated BMI for the patient.  

However, Vision 3, would not then calculate the patient’s BMI in accordance with the rules in place in Vision 3 based on 
the patient’s age (as referenced above) and therefore a BMI value would not be recorded in the patient notes as the 
requirements for value recording would not have been met based on the above explained system rules on data entry 
based on age. 

It should be noted that, such enhanced functionality (to additionally take into account patient age when recording 
weight or height for calculation of BMI, including for patients who are under 16 years of age) is not currently among the 
NHS requirements in the Framework agreements and therefore has not been developed in our clinical solutions. 

Although not currently implemented or on the roadmap for future development work in Vision clinical systems, a potential 
improvement for implementation in future would be the possible development and implementation of functionality to 
additionally take into account patient age when recording weight or height for calculation of BMI, including for patients 
who are under 16 years of age.  

This is to enable Vision clinical systems to identify / challenge any obviously erroneous or unusually high or low values when 
recording this clinical data. It is hoped that the availability of such enhanced functionality in Vision clinical systems would 
provide further mitigation against the risk of the occurrence of further deaths in similar circumstances. 

Sincerely, 

Chief Clinical Information Officer

FAO Oliver Longstaff, Area Coroner, West Yorkshire 
C/O Sharon Baker 
Case Manager, His Majesty’s Coroner’s Office,  
The Coroner’s Courts, 
Burgage Square,  
Wakefield, 
WF1 2TS 
By Email only: 

Dear Mr Longstaff, 

We write in response to the Regulation 28 Report dated 18th April 2024 (the “Report”). 

We  were  sorry  to  read  of  the  passing  of  Mr  Reid,  and  we  would  like  to  take  this  opportunity  to  offer  our 
condolences to his family following their loss.  

We have undertaken an internal review of EMIS Web (the “System”), focussing on the issue raised as a concern 
in the Report that was relevant to EMIS as a healthcare IT supplier. We understand your view is that more needs 
to be done by way of specification design (e.g., the embedding of validation rules) in general practice IT systems 
to allow for challenging and/or correcting data input errors at the point of entry. 

This  review  was  undertaken  by  our  internal  team,  including  a  Product  Manager,  Clinical  Safety  Officer,  and 
Clinical Director. 

Data Entry 

Using the inputting of BMI data as an example, currently a System user can enter information relevant to the 
capture and calculation of BMI in a number of different ways within the System.  Irrespective of which method is 
used, there are numerous safety principles built in, including: 

1.  Displaying a previously recorded height, weight or BMI when entering new values: 

 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 2.  Reference guidance on what a healthy weight should be for the patient: 

3.  An upper and lower expected limit when entering a patient’s height, (with a colour-change to alert to 

values outside of this limit: 

 
 
 
 
 
 
 
 
 
 
    
 
 
 
 
 
 
 4.  A value trend graph, alongside previously entered values: 

Although the examples above are focused on BMI, these safety mechanisms also apply where other clinical 
values are entered into the System.  

Conclusion 

Data may have presented differently in 2004 as the clinical system in place at the time was called EMIS LV, 
which was different visually to EMIS Web. EMIS LV worked in accordance with the specifications as set out by 
the NHS at the time. 

As  detailed  above,  the  System  has  inbuilt  safety  principles  and  is  compliant  with  NHS  specifications. 
Nevertheless, we will continue to review our solutions to determine whether there are changes to be made which 
would improve their performance.   

In this instance, based on the information provided in the Report, and our subsequent review, we do not believe 
there  are  any  software  developments,  beyond  the  existing  functionality  in  the  System,  that  are  required  to 
mitigate the specific risk raised in the Report. 

We  trust  that  the  details  outlined  above  are  helpful.  If  you  have  any  further  queries  then  please  contact  our 
Senior Clinical Director, 

), in the first instance. 

 (via 

Kind regards, 

Chief Medical officer, EMIS Group

Oliver Robert Longstaff 
Coroner’s Service 
West Yorkshire (Eastern) Area,  
71 Northgate 
Wakefield  
West Yorkshire  
WF1 3BS 

National Medical Director  

17 June 2024 

Dear Coroner, 
Re: Regulation 28 Report to Prevent Future Deaths – Alexander Lee Reid who 
died on 29 June 2021.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 18 April 
2024  concerning  the  death  of  Aleander  Lee  Reid  on  29  June  2021.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Alex’s family and loved ones. NHS England are keen to assure 
the  family  and  the  coroner  that  the  concerns  raised  about  Alex’s  care  have  been 
listened to and reflected upon.   

I list below the concerns raised within your Report that NHS England can respond to:  

•  Operation  of  the  COVID-19  Vaccination  Programme,  including  the  inclusion 
criteria for the Shielded Patient List and COVID-19 Population Risk Assessment 
Information  provided  to  patients  who  were  on  the  Shielded  Patient  List  and 
subsequently prioritised for vaccination 

• 

•  Requirements and statutory Clinical Safety duties for GP IT systems suppliers, 

and our responsibilities for their assurance.  

These  reflect  areas  of  NHS  England’s  responsibilities  which  incorporate  some 
activities formerly operated by NHS Digital, which formally merged with NHS England 
in February 2023. I address these concerns below. 

Shielded Patient List 

In  February  2021,  on  the  instruction  of  the  Department  of  Health  and  Social  Care 
(DHSC), a COVID-19 Population Risk Assessment took place. This risk assessment 
used  data  routinely  extracted  from  GP  IT  records  systems  –  obtained  under  the 
General Practice Extraction Service (GPES) – and hospital record systems including 
Hospital Episode Statistics (HES). These data were used to update identification of 
the cohort of people to whom infection with Covid-19 could pose a greater risk, and so 
to whom an invitation for vaccination would be prioritised. The risk assessment used 
the original – and at that time, latest - version of the QCovid® algorithm. This cohort 
was identified as “clinically extremely vulnerable”, and for inclusion on the Shielded 
Patient  List  (SPL).  They  would  receive  further  information  on  shielding  and  be 
prioritised for invitation for vaccination.  

                                                                                                                       
 
 
 
 
 
 
  
  
 
 
  
 
  
 
  
 
 
 
  
 Patients identified as Clinically Extremely Vulnerable were managed on an ongoing 
basis within the SPL, alongside those other patients routinely identified as high risk 
through: 
• 
the existing clinical methodology 
• 
locally by GPs, or  
•  by hospital specialists. 

As and when patients were no longer considered at high risk by GPs and / or clinicians, 
their risk status could be updated in the SPL.  

Due  to  the  speed  and  scale  of  the  vaccine  rollout,  at  the  time  safeguards  were 
introduced into the system to enable curation of the SPL. This included: 

•  A writeback of the reason for inclusion into the GP records  
•  A tool to look up the patient’s inclusion for prioritisation  
•  An enquiry page and email to support patients seeking to understand their 

inclusion.  

Issues  surrounding  this  topic  were  the  subject  of  considerable  media  interest  and 
discussion  at  the  time  of  using  QCovid®.To  support  the  safety  of  the  process, 
safeguards  were  built  into  the  centrally  cohorting  systems.  Regarding  the  specific 
issues raised in your Report, these included: 

•  Use of the most recently recorded patient BMI within the last 5 years 
•  Minimum  BMI  of  15.0  and  maximum  of  47.0  –  data  outside  this  range 
amended to either 15.0 or 47.0 and marked as data corrected in processing 
file. 

•  Default value of 31 used when no BMI data is available.               

These  safety  steps  were  made  publicly  available  at  COVID-19  Population  Risk 
Assessment - NHS England Digital: 

• 

• 
• 

If a person’s BMI was not available, a BMI of 31 was used by default. This 
was the midpoint BMI in the population data. This would have been utilised 
in  Alex’s  case,  where  the  recording  of  the  BMI  was  more  than five  years 
previously.  
If BMI was more than 47, then a BMI of 47 was used to generate the results. 
If BMI was less than 15, then a BMI of 15 was used to generate the results. 
This was because almost all (99.9%) BMIs in the UK are between 15 and 
47. BMIs calculated as being lower than 15 or higher than 47 were likely to 
be a mistake which would affect the accuracy of the result. 

It is therefore unlikely that the BMI of 69.87 incorrectly recorded on the GP record in 
2004 caused Alex to be identified as Clinically Extremely Vulnerable by the National 
COVID-19 Population Risk Assessment. 

Local areas were also able to create their own lists of Clinically Extremely Vulnerable 
patients  for  shielding.  NHS  England  cannot  comment  on  the  processes  that  were 
operated at a local level as this would be subject to local governance and controls. 

 
 
 
 
 
 
 More information can be found about SPL here and details of how the list was created 
are  here.  A  transparency  notice  following  the  closure  of  SPL  provides  further 
information. 

Information to Shielded Patients and their GPs 

Patients on the SPL were issued with a letter outlining that they had been identified as 
Clinically Extremely Vulnerable, that they would be invited for vaccination, and were 
provided additional advice, guidance, and the support available for clinically extremely 
vulnerable  patients  at  that  time.  They  were  informed  that  their  GP  would  be  made 
aware  of  their  inclusion  in  the  SPL  (via  updates  to  the  risk  flag  indicator  in  the  GP 
record for each patient), and the letter stated that, where patients were unaware why 
they would be - or did not believe they were - at high risk from COVID-19, they could 
contact their GP or hospital clinician who could update their records accordingly (as 
described above). To support this, the details of their registered GP were included in 
this correspondence. 

Clinical Safety of Structured Data Entry into GP IT Systems 

Core GP IT records systems are developed - and centrally assured - against standards 
set out in the GP IT Futures Framework. More information about this can be found 
here. 

Over and above this, all Health IT systems used in the NHS must comply with statutory 
duties set out in section 250 of the Health and Social Care Act 2012. These duties are 
described  by  two  Clinical  Safety  Standards,  DCB  0129  and  DCB  0160.  These 
standards  require  that  consideration  be  given  to  all  potential  hazards  or  harms  to 
patients (and users) through use of the product or system. This includes the entry and 
transmission of patient data. 

Depending  on  the  system,  a  GP  IT  system  can  allow  height,  weight,  or  BMI  to  be 
entered  manually.  Most  systems  will  offer  to  calculate  BMI  when  both  height  and 
weight are entered/available. 

Where there is an automated calculation using other data items (such as is the case 
for  BMI),  there  is  no  currently  implementable  means  to  apply  validation  –  or  define 
normal – across domains. It should also be noted that the ranges of values that may 
be possible (or probable) for height, weight and BMI vary by age, gender, and may 
vary by ethnicity.  

We recognise the value in data validation for factors such as BMI. This currently does 
not exist and the implementation of such tools should be balanced against the sizable 
implementation  challenges,  and  subsequent  clinical  risks  and  hazards  that  would 
arise. Such risks and hazards would be considered within the Clinical Safety Case for 
the  product,  and  a  balanced  risk  assessment  would  be  required  to  support 
implementation. 

Central Data Extracts, Validation and Future Cohorting 

 
 
 
 
 
 
 
 
 
 
 Cohorting of patients drives many systems within the NHS – from vaccinations through 
to  screening.  Ensuring  accurate  and  appropriate  cohorting  ensures  the  safety  and 
effectiveness of health protection activities.  

As described above, in this case, data was extracted from the GP records system via 
the General Practice Extraction Service (GPES). Safeguards are developed alongside 
data use for cohorting of patients. This is clinically assured and includes aspects such 
as: 

•  exclusion of data that may not be reliable due to time interval since recording 
•  normalisation/limitation of effect of extremes of recording. 

Patient and Digital Clinical Safety in General Practice 

NHS  England  takes  Patient  Safety  extremely  seriously.  As  such  we  published  our 
Patient Safety Strategy in July 2019 and have developed the Patient Safety Syllabus, 
which is accessible to all staff, including those working in General Practice and Primary 
Care. More information on our Patient Safety Strategy is available here. 

With the increasing use of digital systems in the NHS, we subsequently published the 
Digital  Clinical  Safety  Strategy  in  September  2021.  NHS  England  has  developed 
materials for training on this subject, which includes the safe, effective use of health 
IT systems, and made this available to all staff. More information on the Digital Clinical 
Safety Strategy is available here. 

All staff should be trained in the safe use of health IT systems that they use routinely 
to  perform  their  clinical  duties.  This  is  a  matter  for  local  employers  and  the 
development of policies and procedures to support this are monitored by the relevant 
regulatory bodies – in the case of health care service providers, this is the Care Quality 
Commission. 

Further actions for NHS England 

We note the risks that arise from the inaccurate inclusion of data values in cohorting 
activities and will continue to operate a clinically assured data extraction and validation 
service  to  drive  future  health  promotion  activities.  We  will  work  towards  surfacing 
inclusion data to patients via their NHS App, so that they may discuss their inclusion 
in health promotions with their care providers. 

To support  the  work of  the  Primary  Care  Patient Safety  Team,  we will  promote the 
Digital Clinical Safety Strategy, and all training modules that are available for staff via 
these channels.  

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

Honorary Secretary of Council 

Mr Oliver Robert Longstaff 
Area Coroner for the Coroner area of West Yorkshire (Eastern) 

Sent by email to: 

4 July 2024 

Dear Mr Longstaff 

Regulation 28 Report to Prevent Future Deaths - touching on the death of Alexander Lee Reid 

Thank you for sharing a copy of your report touching on the tragic death of Alexander Lee Reid.  
I am responding on behalf of the Royal College of General Practitioners as Honorary Secretary to 
Council. Firstly, can I convey our sincere condolences to the family and friends of Alexander, I was 
deeply saddened to read of the circumstances around his death.  

The Royal College of General Practitioners (RCGP) is the largest membership organisation in the 
United Kingdom solely for GPs. It aims to encourage and maintain the highest standards of general 
medical  practice  and  to  act  as  the  ‘voice’  of  GPs  on  issues  concerned  with  education;  training; 
research; and clinical standards. Founded in 1952, the RCGP has just over 54,000 members who 
are  committed  to  improving  patient  care,  developing  their  own  skills  and  promoting  general 
practice as a discipline. 

The RCGP Special Interest Group in Health Informatics is composed of members of the RCGP who 
have  an  interest  in  and  work  in  the  area  of  Health  Informatics.  The  Joint  General  Practice 
Information  Technology  Committee  (JGPITC)  comprises  of  members  of  the  British  Medical 
Association,  and  members  from  the  Health  Informatics  Group  at  the  Royal  College  of  General 
Practitioners; it is recognised by paragraphs 4.31 and 4.40 of the National Health Service General 
Medical Services (GMS) Contract 2003/04 for General Practice surgeries. 

This response on behalf of RCGP draws on and includes the expert opinion of our members in the 
HIG and Joint GP IT Committee. 

Royal College of General Practitioners 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 We  have  considered  your  report  and  the  expert  opinion  of  the  GPIT  committee  and  offer  our 
response focusing on the areas where the RCGP might have most significant influence to prevent 
further deaths.   

We set out below out the responses to your matters of concern from the GPIT committee followed 
by actions we can take as RCGP to prevent future deaths. 

Matters of concern 
Issue 1 - When Alex was invited to receive his vaccination early, he did not understand why, and no-

one was able to tell him. 

We  were  made  aware  of  frustration  voiced  by  patients,  their  GP  surgeries  and  those 
delivering  the  immunisation  programme  that  the  indication  for  immunisation  was  not 
transparent to either party at the point of care. These concerns were discussed with NHS 
England. The clinical safety hazard is that, because the precise reasons for inclusion in the 
immunisation programme were not surfaced, neither the patients nor the staff delivering 
their immunisation were able to identify the incorrect invitation. Those hazard logs may 
provide  insights  into  what  was  known  about  these  risks.  The  lesson  learned  nationally 
should be that transparency promotes safety, and in particular that when a patient asks, 
those providing care should be able to investigate and provide a clear answer. 

Issue  2  -  The  inquest  heard  expert  evidence  that  the  combined  vaccination  monitoring  and  recall 
specification designed to identify vulnerable people for the purposes of inviting them to receive 
their Covid vaccinations early had identified Alexander as vulnerable from an incorrect BMI of 
68.97 recorded in his GP records on 06/02/2004. The mistake was due to the relevant clinician 
recording Alexander’s height as 145cm and his weight as 145 kg, giving a BMI of 68.97 for an 
11-year-old boy whose previously recorded BMI aged 9 had been 14.88. 

We note that: 

a)  GP  electronic  patient  record  system  design  typically  allows  a  user  to  enter  all  3 
variables  manually,  but  when  a  height  and  weight  are  present  the  system  offers  to 
calculate a body mass index for the user, in turn filing that calculation when the data 
are saved; 

b)  The  relevant,  validated  child  growth  charts  are  available  at  the  internet  page 
https://www.rcpch.ac.uk/sites/default/files/Boys_2-18_years_growth_chart.pdf; 

c)  Using those charts as reference: 

i. 

ii. 

a height of 145 cm is typical for an 11 year and one month old boy (around the 
65th Centile for his age) 

a  weight  of  145  kg  is  very  atypical.  The  99.6th  Centile  for  him  would  be 
approximately  65  kg.  This  means  that  his  atypical  weight  was  readily 
computable; 

 
 
 
 
 
 
 
 
 iii. 

iv. 

v. 

vi. 

vii. 

the  number  145  is  repeated  across  the  height  and  weight  entries,  which  is 
readily computable and an unlikely coincidence – user error can be reasonably 
suspected; 

the  sudden  significant  change  in  weight  was  readily  computable.  All  sudden 
apparent  significant  changes  in  weight  should  be  of  concern  to  users,  but 
changes  incompatible  with  normal  rates  of  weight  change  can reasonably  be 
treated as suspicious for data error; 

a  recorded  body  mass  index  of  68.97  is  much  less  likely  to  be  entered  by  a 
clinician manually, because it is more clearly erroneous. It is a computably very 
atypical body mass index (especially for a child of 11); 

the sudden significant change in body mass index was also readily computable 
and suspicious for data error; and 

BMI is not a routinely calculated item for a child, as it does not offer significant 
clinical value in normal health, and so any system which interacts with physical 
health parameters for a child could be optimised for the context of height and 
weight  recordings  for  paediatric  populations  and  modified  to  not  routinely 
promote the calculation or recording of a BMI. 

We also observe that there was a 16-year latency between the detectably erroneous data 
being entered, and Alex suffering harm as a consequence. This is relevant to the potential 
for reducing risk, because there was ample opportunity for the data to have been identified 
and corrected if there were system tools to help identify such issues and either correct the 
false data or verify that the data were in fact correct. It also presents an opportunity for 
improving safety by limiting the data extraction time window to ignore very old data. 

Issue 3 - The inquest heard expert evidence that to have built a system that would validate multiple 
data items in an individual’s GP records for the purposes of ensuring that individuals were not 
incorrectly  identified  as  vulnerable  would  not  have  been  feasible  within  the  constraints  and 
context of the Covid-19 programme 

The Committee worked with NHS England and other organisations during the pandemic, 
and we note that many of the systems were developed at a speed and pace commensurate 
with  the  overwhelming  need  to  deliver  the  immunisation  programme,  balancing  speed 
against safety. The Committee agrees with the expert evidence you were provided. 

Issue 4 - The inquest heard expert evidence that an easier and more appropriate option would be to 
embed validation rules in general practice IT systems that would check such information at the 
time of data entry. 

The Committee agrees that embedding validation rules into GP IT systems would reduce the 
likelihood that computably erroneous data are entered into patient records. 

Issue 5 - If the obviously erroneous BMI had not been recorded or had been challenged at the point of 
entry by the relevant IT system, Alex would not have been classed as vulnerable, would not have 

 
 
 
 
 
 
 
 
 
 
 
 been offered a vaccine before guidance was published that the under 30’s should not receive the 
Oxford Astra Zeneca vaccine, and would not have died when he did. 

The Committee identifies that the ability to record data that are likely to be erroneous in 
electronic patient records is a cause of clinical safety hazards including this one. We agree 
that appropriate mitigations to this hazard include consideration of system design. 

a)  A warning at the point of entry would be one example of a control mechanism 
and  we  agree  that  it  would  have  been  likely  that  if  such  a  mechanism  were  in 
place, those data would not have been recorded in Alex’s record. 

b)  We  note  that  in  some  circumstances,  thresholds can be  set  to  entirely prevent 
data entry, such as where numerical variables entered are incompatible with life. 
In this particular case, a body mass index of 68.97 may not have been appropriate 
to exclude from data entry. 

c)  The Committee notes an emergent problem in GP record systems, known as ‘alert 
fatigue’  which  refers  to  the  progressively  increasing  volume  of  safety  issues 
presented to users of the GP systems. During time pressured consultations, a user 
must balance the need to complete a consultation and see the next patient, with 
tackling system alerts for possible safety / data quality issues which may or may 
not be clinically necessary to address. 

Issue 6 - The consequences of the data input error in this case give rise to a concern that more might 
be  done  by  way  of  potential  data  input  errors  at  the  point  of  entry,  with  consequential 
improvements in the reliability of such data and the safety of patients and reducing the risk of 
other deaths occurring in similar circumstances in the future. 

We agree that point-of-entry improvements have the potential to reduce data entry input errors, 
with the consequential risks of death, and other non-fatal harms. 

Comment from the Committee 

1.  The Committee notes that the most effective management of clinical safety relies on not 
only  the  good  articulation  of  hazards,  but  the  holistic  appraisal  of  all  of  the  underlying 
causes before mitigations are planned. A root cause analysis approach would surface those 
issues. 

2.  The absence of a root cause analysis placing this error in context means that the Committee 

cannot quantify the benefits of improving data input errors. 

As RCGP we will ask the GPITC to discuss these matters at the next full Committee meeting, which 
is due to be held in July 2024. 

We will ask NHS England to: 

a)  Consider  coordinating  funded  clinical  safety  workshops  to  document  formally  the 
underlying  causes  of  the  hazard,  identify  existing  controls,  and  define  the  professional 
requirements for how the systems should ideally behave to mitigate the risks  

 
 
 
 
 
 
 
 
 
 b)  Report  to  the  Joint  GPIT  Committee  on  how  these  concerns  might  be  addressed  in 
alterations to the existing standards and capabilities set out in the supplier contracts 

c)  Share  your  report  and  ours  with  the  NHS  England  New  Market  Entrants  programme 
which is currently working with future GP system suppliers; and 

d) We will ask the GPITC to consider what existing reports are available on the quality of 
clinical data in the UK’s primary care records and advise whether or not there is a need for 
a national clinical data quality improvement plan. 

For  our  Members  we  will  highlight  through  our  programme  of  continuing  professional 
development:   

a)  The  importance  of  accurate  data  entry  into  the  record,  the  importance  for  accurate 
systems for data entry within practices and the implications If this does not occur 

b) That risks exist if inaccurate data is shared beyond the practice where there are fewer 
opportunities for it to be rectified  

I trust that this reply is helpful and if you have any questions, please do not hesitate to contact me.  
Our sincere condolences are with Alexander's family. 

Yours sincerely 

RCGP Honorary Secretary

His Majesty’s Coroner’s Office  
The Coroner’s Courts  
Burgage Square  
Wakefield  
WF1 2TS 

By email: 

Your Ref: 

29th April 2024 

Dear Mr Longstaff, 

Re: Regulation 28 Report to Prevent Future Deaths – Alexander Lee Reid DOD 29/06/2021  

Thank you for your Regulation 28 Report dated 18/04/2024 concerning the death of Alex Reid. Firstly, 
I would like to express my deep condolences to the family and friends of Mr Reid.  

I  am 
currently used by the GP practice that Alex was registered with at the point of his tragic death. 

,  the  Clinical  Director  for  TPP,  providers  of  the  clinical  IT  system  (SystmOne) 

The specific concern raised in your report that is relevant to TPP, as a GP system supplier, is about 
the validation of data items entered into GP IT systems. In this instance, the erroneous entry was 
recorded  on  06/02/2004.  This  entry  was  not  made  on  SystmOne,  rather  it  was  made  on  the  GP 
practice’s previous IT system and the data was subsequently migrated to SystmOne when the practice 
changed IT systems on 01/04/2019. 

In SystmOne, there is already validation at the point of entry on height and weight measurements to 
prevent extreme values being entered. For example, a maximum height of 3 metres can be entered, 
with the maximum weight being 500 kilograms. Similarly, a calculated BMI is constrained to between 
0  and  150.  It  is  not  impossible,  however,  for  someone  to  have  a  BMI  as  high  as  the  one  that  was 
calculated in this instance. Thus the system must allow such a BMI to be accurately recorded if this 
is the true calculated BMI. 

The death of Mr Reid, sadly, appears to be the culmination of multiple issues, including:  

1. The initial error made when entering the data by the system user.  
2. The  lack of a suitable  algorithm to detect when  an abnormal BMI calculation (although 
possible) is unlikely.  
3. The  extraction of  data by NHS Digital  (now NHS  England) and subsequent processing to 
detect the at risk population also lacking an algorithm to detect unlikely BMI results. 
4. The error not being identified by the GP practice; GPs were asked to check all patients 
who were flagged as high risk to ensure suitability for vaccination. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 5.  The  vaccinator  not  having  sufficient  information  at  the  point  of  giving  the  vaccine  to 
recognise the error. The vaccinator probably did not have access to the patient’s GP record 
to see why the high risk flag had been added to the record (N.B. The reason for the patient 
being marked as vulnerable was included in the message to GPs in around April 2020). 

To return to the specific concern that could be directed to GP system suppliers, should NHS England 
decide that it would be appropriate to include validation concerning the calculation of BMIs in GP IT 
systems, the requirements for this would be most appropriately set at a national level to ensure a 
consistent approach across all GPs. Of course, in the clinical environment there are already a number 
of alerts, flags, prompts and notifications directed at clinical staff, and consideration would need to 
be taken as to the sensitivity of the validation to ensure this is not triggered so frequently as to cause 
‘alert fatigue’.  

I note that your report has been sent to relevant persons at NHS England but I will also look to make 
contact with NHS England separately regarding this matter. 

Kind regards 

GMC: