Judith Obholzer

Parliamentary Under Secretary of State  
for Patient Safety, Women’s Health and Mental Health 

From 

39 Victoria Street 
London 
SW1H 0EU 

12 September 2024 

Our Ref: 

Ellie Oakley 
Assistant Coroner 
Westminster Coroner's Court 
3 Tachbrook Street 
Pimlico 
London  
SW1V 2JR 

By email:

Dear Ms Oakley 

Thank you for your Regulation 28 report to prevent future deaths dated 12 July about 
the death of Judith Maike Obholzer. I am replying as the Minister with responsibility 
for Patient Safety, Women’s Health and Mental Health.      

Firstly, I would like to say how saddened I was to read of the circumstances of Judith’s 
death  and  I  offer  my  sincere  condolences  to  her  family  and  loved  ones.  The 
circumstances your report describes are deeply concerning and I am grateful to you 
for bringing these matters to my attention.  

Thank  you  for  highlighting  your  important      concerns  about  the  pressures  on  NHS 
mental health services, the interface between private practitioners and NHS providers 
and the sharing of medical information between the two. I know that you have also 
addressed these matters of concern to NHS England and South West London and St 
George’s  Mental  Health  NHS  Trust  and  I  look  forward  to  working  with  both 
organisations,    where  appropriate,  to  avoid  a  repetition  of  the  tragic    events  of  this 
case. 

It is clear that many people, like Judith, with mental health issues are not getting the 
support or care they need, which is why this Givernment is taking action to fix the 
broken system to ensure we give mental health the same attention and focus as 
physical health and that people can be confident of accessing high quality mental 
health support when they need it.  

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 As  part  of  our  mission  to  build  an  NHS  that  is  fit  for  the  future,  we  will  recruit  an 
additional 8,500 mental health workers to reduce delays and provide faster treatment 
which will also help ease pressure on busy mental health services. To help reduce the 
lives lost to suicide, these new workers  will be specially trained to support people at 
risk.  More  broadly,  we  will  modernize  legislation  of  the  Mental  Health  Act  to  give 
greater  choice,  autonomy,  enhanced  rights  and  support,  and  ensure  everyone  is 
treated with dignity and respect throughout treatment. 

I  know  that  NHS  England  has  outlined  to  you  the  work  they  are  taking  forward  to 
improve sharing of information and records overall.  I understand that work is also in 
progress at NHS England to review the interface between NHS and non-NHS funded 
independent health providers, and that NHS England has offered to update you on this 
important work as it progresses. I assure you, I have written to NHSE colleagues to  
ensure this is driven forward and these points are addressed.  

I hope this response is helpful and thank you again for bringing these concerns to my 
attention.  

Yours sincerely,

Ms Ellie Oakley 
Assistant Coroner 
Inner West London Coroner’s Court 
33 Tachbrook Street 
London  
SW1V 2JR 

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

04/09/2024 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Judith Maike Obholzer 
who died on 12 July 2023.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 12 July 
2024 concerning the death of Judith Maike Obholzer on 12 July 2023. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Judith’s family and loved ones. NHS England are keen to assure 
the  family  and  the  Coroner that  the  concerns  raised  about  Judith’s  care  have been 
listened to and reflected upon.  

Your Report raised concerns over the pathways and ability to share information and 
undertake referrals between private and NHS mental  health services, as well as the 
ability for private medical practitioners to access GP details. You raised this within the 
context  of  the  significant  pressures  currently  being  placed  on  NHS  mental  health 
services  and  the  impact  of  this  likely  increasing  the  number  of  patients  turning  to 
private mental health services. 

As  part  of  its  Long  Term  Plan  commitments  to  improve  mental  health  care,  NHS 
England has increased investment in adult and older adult community mental health 
services  by  £1  billion  per  year  since  2019/20.  Commitments  in  the  plan  have  also 
included  a  significant  expansion  of  urgent  and  emergency  mental  health  care  and 
access to crisis services.  

Your  Report  highlights  the  importance  of  effective  information  sharing,  to  support 
providing the best care possible, where individuals are transferred between different 
care  settings. The  National  Care  Records  Service  (NCRS)  is  the  successor  to  the 
Summary Care Record application (SCRa) and by design removes a large amount of 
the reported barriers to adoption within many care settings including the private sector. 
The  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. It provides 
access to a number of centrally provisioned national digital services that support the 
direct care of patients, including Summary Care Records (SCR), the National Record 
Locator (NRL) service and the Personal Demographics Service (PDS). 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
  
 The  SCR  is  a  national  database  that  holds  electronic  records  of  important  patient 
information  such  as  current  medication,  allergies,  and  details  of  any  previous  bad 
reactions to medicines. It is created from GP medical records - whenever a GP record 
is  updated,  the  changes  are  synchronised  to  SCR.  It  can  be  seen  and  used  by 
authorised staff in other areas of the health and care system who are involved in the 
patient's direct care, but do not need access to the patient's full record. As such, the 
SCR  is  intended  to  provide  a  summary  of  the  patient’s  GP  record,  including  key 
information  most  likely  to  be  of  benefit  to  patients  during  an  unscheduled  care 
encounter. 

The SCR Team at NHS England have undertaken significant work with a number of 
private sector organisations, including a range of private hospitals and privately funded 
healthcare  services  trialling  the  use  of  SCRs  within  settings  where  they  have 
previously  been  unavailable,  and  this  work  continues.  The  Team  will  work  with  an 
Expert Advisory Committee to seek full rollout approval within the independent/private 
sector  and  consider  the  scope  of  this  approval  and  any  specific  exclusions, 
constraints, or caveats.  

Responsibility for delivering shared care records sits with local Integrated Care Boards 
(ICBs). 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. Further information 
on Integrated Care Boards and Systems can be found here: NHS England » What are 
integrated care systems? 

NHS  England’s National Record Locator (NRL) service  allows health  or social  care 
workers to find and access patient information shared by other health and social care 
organisations across England, to support the direct care of a patient. It does this by 
recording the location of digital (and paper) records within the NHS and it provides an 
index  of  pointers/bookmarks  that  contain  the  information  required  to  retrieve  key 
patient  information  from  the  source.  Our  vision  is  to  improve  cross-border 
interoperability  and  help  make  data  sharing  possible  by  allowing  healthcare 
professionals,  such  as  Care  Coordinators  within  a  Mental  Health  Trust,  to  securely 
and remotely retrieve information from source at the point of need so that they can get 
a longitudinal view of a patient’s records and an indication of their treatment history. 
The NRL removes the need for organisations to create duplicate copies of information 
across  systems  and  organisations,  by  facilitating  access  to  up-to-date  information 
directly from the source. It will also provide users with an indication of the organisations 
with which a patient currently has a care relationship, to enable a user to contact the 
service responsible for a plan to support the patient in the event of a crisis. 

Mental Health Crisis plans are one of the pointer types supported by the NRL service. 
The NRL does not store any of the Mental Health data but points users to where they 
can find it. NRL information can be consumed from source through the National Care 
Records  Service  (NCRS).  In  instances  where  multiple  pointers  are  returned,  users 
have the ability to sort results by creation date. 

 Work is also in progress to review the interface between the NHS and non-NHS funded 
independent health providers. This work is in its infancy, but NHS England can provide 
an update to the Coroner in due course if this would assist. We understand that the 
Care Quality Commission (CQC) are also undertaking work regarding standards for 
online care and are exploring opportunities for better sharing of information both into 
private sector providers and receiving information back to the patient’s registered GP 
practice from private providers.  

Access  to the  GP  record  is available  to private  clinicians through some  IT  systems 
suppliers and is being gradually rolled out further.  

NHS  England  has  also  engaged  with  South  West  London  and  St  George’s  Mental 
Health NHS Trust. They have advised us that at the time  Judith required NHS crisis 
support, their website provided clear signposting for private providers needing to make 
an emergency mental health referral. Since receiving your Report, we also note that 
they  have  made  this  more  visually  prominent  on  the  website.  I  will  refer  you  to  the 
Trust for further information, who I understand are issuing their own response to you. 

I  would  also  like  to  provide  further  assurances  on  the  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 events, such as the sad death of Judith, 
are shared across the NHS at both a national and regional level and helps us to 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

Chief Executive’s Office 
South West London and St George’s Mental Health NHS Trust 
Trinity Building 

Springfield University Hospital   
15 Springfield Drive   
London SW17 0YF 

Direct Line: 

 E-Mail: 

04 September 2024 

Ellie Oakley 
Assistant Coroner for Inner West London 
Inner West London Coroner’s Court 
33 Tachbrook Street 
Pimlico 
London SW1V 2JR 

Our Reference: Incident Number 

Dear Madam 

Re: Regulation 28 Report to Prevent Future Deaths –  Judith Obholzer   

I  am  writing  to  you  following  receipt  of  the  Regulation  28:  Report  to  Prevent  Future 
Deaths (PFDR) dated 12th July 2024, regarding the sad death of Mrs Judith Obholzer.   

The PFDR was addressed to NHS England (NHSE), the Department of Health (DH) and 
South  West  London  and  St  George’s  Mental  Health  NHS  Trust  (the  Trust)  being  the 
third listed recipient.  This letter provides the Trust’s response to the matters of concern 
that you have detailed in your correspondence.  

The PFDR was shared with the clinical leadership teams in the Community and Acute 
and Urgent Care Service Lines and the Trust’s Communications Department to ensure 
the Trust responds fully to the points of concern raised by HM Assistant Coroner.   

I therefore respond to each of your concerns and direction as stated within your PFDR 
correspondence: 

(1) In the course of the evidence it was confirmed that there is a significant pressure 
on NHS mental health services.  It seems likely that there will be an increase in 
patients obtaining private support while waiting for NHS support (and often only 
being able to afford such support for a limited time and to a limited extent and 
doing  so  only  while  waiting  for  NHS  support),  as  happened  in  this  case.  
Consideration  should  be  given  to  ensuring  that  there  is  sufficient  clarity  in 
processes  such  as  referrals  and  crisis  support  where  private  practitioners  are 

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 providing  treatment  as  well  as  the  NHS,  ensuring  sharing  of  information  and 
notes where relevant and necessary and ensuring that the NHS provision is not 
assessed as unnecessary simply because someone has obtained private support 
as an interim measure. 

The Trust shares your observation that there could be an increase in patients seeking 
to access private support during these times of high demand for services nationally and, 
in particular, within the London region. 

The Department of Health and Social Care  produced guidance for NHS patients who 
wish to consider additional private care, and we have provided a link to this belowi. In 
line with this guidance, NHS organisations, including the Trust, cannot withdraw NHS 
care where a patient chooses to fund additional private care, additionally that patients 
will  also  have  their  place  for  treatment  on  an  NHS  mental  health  waiting  protected.  
Naturally, we expect the DH response to you in regard to this PFDR will cover this aspect 
in more detail.   

However, in addition to the DH guidance, the Trust has a ‘Private Providers Shared Care 
Policy’  (Appendix  1)  which  was  ratified  in  January  2024.    This  clearly  sets  out  the 
respective roles and responsibilities of the Trust and private providers.  This policy was 
drafted with input from Consultant Psychiatrists from a private provider and supplements 
the DH guidance to add specific clarity for the Trust.  

The Trust accepts that this policy was not referenced and it appears there was a lack of 
appreciation that the policy existed during the Inquest.  In response to the concern raised 
in the PFDR, the Trust will ensure this policy is made accessible on the Trust's website 
(in  the  GPs/Professionals  section  of  our  website)  and  its  existence  will  be  further 
communicated internally and also through our local GP networks.  

Unfortunately, there is currently no national or local system which enables the Trust to 
have the contact details of every private provider operating in its catchment area and, 
therefore, it is not feasible to provide information about the referral process to all these 
providers and those we are not aware exists. Furthermore, In Mrs Obholzer’s case, the 
private  provider  that  gave  evidence  at  the  Inquest  and  who  assessed  Mrs  Obholzer 
shortly before her death, was not based in the catchment for our Trust. 

If a private provider considers a patient is at high risk of harm to self or others, it would 
be expected that they would either seek to make contact with the patient’s local mental 
health services or contact NHS services via 111 or A&E.  With this in mind, the Trust 
has ensured that information for private providers is more clearly visible on the Trust’s 
website (please see below more detail). 

(2) During the evidence the private consultant psychiatrist gave evidence that he was 
unable to refer patients directly to NHS provided crisis teams as a direct alternative to 

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
 
 
 
 
 informal treatment in a private hospital.  The evidence from South West London and St 
George’s  Mental  health  Trust  was  that  direct  referrals  can  be  made  although  the 
evidence on the exact mechanism was unclear. In Mrs Obholzer’s care, the (apparent) 
lack  of  ability  of  the  private  consultant  psychiatrist  to  directly  refer  to  the  crisis  team 
meant  that  she  did  not  receive  the  community  crisis  support  alternative  to  hospital 
admission  that  she  required.    Consideration  should  be  given  to  ensuring  that  the 
pathway for urgent/crisis referrals from private practitioners to the NHS are clear to all 
(both  for  this  area  and  throughout  the  country)  and,  if  it  is  not  already  the  case,  to 
ensuring a process that allows private practitioners to arrange crisis support through the 
NHS directly. 

The Trust notes the Coroner’s desire that this aspect of the PFDR is reviewed from a 
national perspective and considers that the DH and NHSE will  be able to address this 
within their response. 

However, the Trust would like to assure the Coroner that private providers can refer their 
patients to the Trust’s crisis services when required.  Private providers can telephone or 
make  a  referral  about  someone  they  are  concerned  for  to  our  crisis  services  via  the 
Trust’s Mental Health Crisis Line in the same way as a GP or other non-Trust health 
professional.  If a private provider contacts the Mental Health Crisis Line, advice will be 
provided, and their patient will be directed into the correct care pathway dependent upon 
the patient’s presentation and risk factors. In an emergency scenario, private providers 
can also call 999 or 111 and patients are able to attend A&E to access the pathway for 
crisis services.  

At the time Mrs Obholzer accessed Trust services, there was clear information available 
on  the  Trust’s  website  regarding  how  to  access  Trust  crisis  services  via  the  Mental 
Health Crisis Line and what to do in a mental health emergency. This could be accessed 
from a prominent orange link (button) on the homepage marked ‘I need help now’. It is 
unclear if the private psychiatrist who gave evidence at the Inquest attempted to access 
the Trust’s website. 

In response to the PFDR, the Trust has reviewed and further improved the information 
available for all healthcare professionals on the Trust website to ensure it is more easily 
accessible. The link (button) on the front page of the website is now red to make it even 
more prominent and marked ‘Urgent Help’ (Home - Website (swlstg.nhs.uk). 

To aid, I have provided some screenshots of our website, with the below first showing 
the new red ‘Urgent Help’ button.  

Chief Executive,

  Chairman, 

 
 
 
 
 
 
 
 
 There  is  also  a  second  button  marked  ‘urgent  help’  on  the  front  page  which  states 
‘healthcare  professionals  making  referrals  can  call  our  24/7  crisis  line  on  0800  028 
8000’. People can access  further information by clicking this button  – see screenshot 
below. 

When either of these two buttons are clicked, they go to information about services that 
can be accessed in an emergency (https://swlstg.nhs.uk/urgent-help).  This includes the 
specific information in bold type that says ‘Any healthcare professional can also contact 
the  mental  health  crisis  line  if  making  a  referral  for  someone  experiencing  a  mental 
health crisis’. 

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
 
 
 
 
 
 
     
 In  addition,  you  will  see  below,  the  Trust  has  included  an  amber  header  on  the 
GPs/Professionals page with the telephone number of the Mental Health Crisis Line so 
it is clear how a ‘GP, partner agency or private provider’ can make a referral in a crisis. 
(Referring to our services - Website (swlstg.nhs.uk) 

Additionally,  we  have  again  shared  our  crisis  information  externally,  which  we  do  at 
regular  intervals.  This  includes  on  social  media  and  in  extra  places  on  our  website 
including news articles and in information about our campaigns. 

(3) In the course of the evidence it was confirmed that the private consultant psychiatrist 
was unable to send the urgent letter to Mrs Obholzer’s GP in part because their details 

Chief Executive, Vanessa Ford 

  Chairman, Ann Beasley 

 
 
 
 
 
 
 
 
 
 
 
 
 
 had  not  been  provided.    Consideration  should  be  given  to  ensuring  that  all  medical 
practitioners (private and NHS) can access GP registration details for patients and GP 
contact details to avoid delays where there is an urgent need to contact a person’s GP. 

The Trust does not feel able to provide a response to this aspect of the PFDR as access 
to GP registration details is a national issue.  We understand that the response to this 
concern will come from the DH or NHSE response.  

(4) In the course of the evidence it was confirmed that there is no sharing of medical 
notes between private practitioners and NHS providers.  This (along with other factors) 
led to delays in a treatment plan being set by Wandsworth SPA as they had to obtain 
further details regarding Mrs Obholzer’s CBT from Mrs Obholzer rather than being able 
to access the notes through a shared system. Consideration should be given to ensuring 
a system is in place to allow sharing of medical information between practitioners across 
Trusts and also between NHS and private providers. 

Systems and processes for information sharing between NHS and private providers is 
principally  a  consideration  for  NHSE  and  the  DH  who  are  best  placed  to  provide 
guidance around the GDPR and confidentiality considerations. 

However, locally the Trust is reviewing its approach to how information can be shared 
in line with consent and the confidentiality policy. Naturally, the Trust is not able to share 
clinical  information  with  a  private  practitioner  (and  vice  versa)  without  the  explicit 
consent of the patient, except in rare cases where risk considerations mean information 
sharing is essential.  

The  Trust  is  exploring  ways  to  obtain  advanced  consent  to  share  information  can be 
captured in the clinical record when patients are also accessing private services, as part 
of the assessment and on-going care planning process and this will be recorded in their 
clinical records.  The Trust is currently reviewing the best way to collect this information 
and operationalise the process.   

The Trust will remind all staff of the ‘Urgent Care Pathway’ in a Monthly Learning Bulletin 
article (to be published by October 2024).  Staff will also be reminded to regularly check 
if service users are receiving private treatment and discuss consent to share information.  
Staff will also be signposted to the Trust’s ‘Private Providers Shared Care Policy’, so 
they are aware of the process if they are contacted by a private provider regarding a 
patient in crisis.  This policy will also be shared through our local GP networks.  

The Trust remains committed to continuous learning and improvement and we are very 
grateful  for  all  those  involved  in  the  Inquest.  This  PFDR  and  the  response  will  be 
reviewed  and  monitored  at  the  Trust’s  Mortality  and  Suicide  Prevention  Committee, 
which is attended by senior representatives from all the Trust’s service lines.   

Chief Executive, 

  Chairman, 

 
 
 
 
 
 
 
  
   
 
 
 Finally,  the  Trust  is  ready  to  respond  to  future  guidance  issued  by  NHSE  or  the  DH 
regarding information sharing between NHS organisations and private practitioners.  

Yours sincerely, 

Chief Executive  

i Guidance on NHS patients who wish to pay for additional private care 
(publishing.service.gov.uk) 

Cc:  

▪  Department of Health & Social Care (DHSC) 
▪  NHS England 

As advised by NHS England (London Regional Team), NHS England have been 
commissioned by DHSC to coordinate their response to the PFDR on behalf of both 
NHSE and DHSC, as such the Trust should copy the response to NHSE London 
Patient Safety Team - england.londonpatientsafety@nhs.net 

Chief Executive, 

  Chairman,