Stephen Stringer

Our ref: 

HM Coroner Alison Mutch  
1 Mount Tabor Street  
Stockport  
SK1 3AG  

By email: 

Dear Ms Mutch  

Minister of State for Care  

39 Victoria Street  
London  
SW1H 0EU 

13 January 2025 

Thank you for the Regulation 28 report of 15th October sent to the Department of Health and 
Social Care about the death of Mr Stephen Charles Stringer. I am replying as the Minister 
of State for Care, responsible for primary care and general practice. 

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

The department and practices must be cognizant to the recent changes made to modernise 
telephone systems, include call routing, and understand that these may not be as clear as 
they need to be for all patients. This is unacceptable and it must be very clear to all patients 
their  practice. 
what  steps  are 

to  access  care  when 

they  contact 

required 

Call routing enables patients to choose options via their keypad or voice options to enable 
direct  routing  to  the  right  person  or  team.  When  properly  configured,  these  systems  can 
divert some demand away from phones at busy times, making it easier to get through to 
someone  to  book  an  appointment.  However,  it  is  crucial  that  all  triage  and  appointment 
systems ensure patients are correctly routed - and if mistakes occur, that these are promptly 
rectified  to  connect  patients  with  the  right  team  or  person.  We  want  to  make  sure  that 
patients are able to easily access primary care, and this is not a complex system, we need 
to do better, so patients can receive the care they deserve. It is deeply upsetting that Mr 
Stringer was not able to easily access his general practice and his health tragically suffered 
due to this. 

General practices are independent businesses who are contracted by NHS commissioners 
to perform medical services, and it is the responsibility of the individual practice (provider) 
to have reliable systems in place to manage interactions with patients. It is essential that 
clinical  issues  mistakenly  categorized  as  administrative  are  identified  and  appropriately 

A10 
  
 
 
 
 
  
 
 
 
 
 
 
 
 
 managed  by  care  navigators.  If  a  practice  is  unable  to  effectively  monitor  its  systems  to 
identify and address clinical concerns, a system should be in place to manage this.  

We recognise that practices require adequate support to be able to manage these systems. 
NHS  England  produced  guidance  on  thishttps://www.england.nhs.uk/long-read/how-to-
improve-care-navigation-in-general-practice/ in May 2024. The guidance provides key rules 
to help guide practices on their role in care navigation. Firstly, clinical requests not allocated 
by a care navigator (directly over the phone) need to come into a single flow for assessment 
and  all  administrative  requests  must  have  a  clear  distribution  route  within  practice  and 
agreed turnaround times. Practices are responsible for  tailoring the exact operations and 
timeframes of this to their own requirements and patient cohorts.  

Additionally,  the  Digital  Clinical  Strategy  published  in  2021  outlines  NHS  England’s 
responsibility  and  commitment  to  improve  the  safety of  digital technologies  in health  and 
care  now  and  in  the  future,  as  well  as  identifying  and  promoting  the  use  of  digital 
technologies  as  solutions  to  patient  safety  challenges. The  Clinical  Safety  Standards 
DCB0129  and  DCB  0160  provide  the  legal  framework  and  best  practice  to  help 
organisations  manage  and  mitigate  risks  associated  with  development  and  use. NHS 
England are responsible for ensuring that the Clinical Safety Standards continue to influence 
safety, and a comprehensive review of both standards is underway and due to complete in 
2025 which will involve wide stakeholder engagement.  

Patients that are able to see the same practitioner benefit from better health outcomes. We 
expect  that  practitioners  who  have  had  prior  contact  with  a  patient,  would  recognise  the 
importance of continuity of care and proactively offer this option whenever possible. 

It is unacceptable that patients that present with red flag symptoms are consistently missed 
and misdiagnosed. NICE’s NG12 guidance: Overview | Suspected cancer: recognition and 
referral | Guidance | NICE provides guidance to practitioners on urgent suspected cancer 
referrals,  which  clearly  identifies  ‘persistent unexplained hoarseness’  as  requiring  urgent 
referral. We would expect healthcare professionals to be aware of this guidance, which is of 
long standing. 

A number of national charities highlight a hoarse voice as a potential sign of cancer on their 
websites (laryngeal or lung cancer being the most common types with this symptom) and 
there have  been  a  number  of  local campaigns  on  this as  well.  More  recently,  NHSE has 
partnered  with  ASDA  to  put  warnings  on  mouthcare  products  such  as  toothpaste  and 
mouthwash  to  highlight  the  possible  early  signs  on  head  and  neck  cancer,  including 
hoarseness. 
https://www.england.nhs.uk/2024/07/nhs-partners-with-asda-to-put-crucial-
mouth-cancer-symptoms-on-toothpaste-and-mouthwash/ 

We  understand  that  NHS  General  Practices  need  to  be  responsive  to  the  needs  of  their 
patients.  Following  contact  made  by  a  patient  the  practice  must  manage  the  presenting 
complaint  in  a  safe  and  timely  way  in  line  with  the  Health  and  Social  Care  Act  2008 
Regulations 2014: Regulation 12 Safe care and treatment. The intention of this regulation is 
to prevent people from receiving unsafe care and treatment and prevent avoidable harm or 

A11 
 
 
 
 risk of harm. CQC would also expect those working within a service to have the knowledge 
and skills to use the systems in place, and for there to be sufficient numbers of staff with the 
right skills employed to meet the needs of those using the service. This is also in accordance 
with Regulation 12 and Regulation 18: Staffing. Regulation 9 of the Health and Social Care 
Act 2008 (Regulated Activities) Regulations 2008 requires providers to provide patients with 
information  about  their  care  and  treatment  options.  CQC  would  expect  this  to  include 
information on how to access care and treatment.  Regulation 17 Good governance requires 
the provider to ensure they have systems and processes in place to ensure compliance with 
other  requirements  of  the  Health  and  Social  Care  Act  2008  (Regulated  Activities) 
Regulations 2014, including those referenced here.   

Additional  information  was  received  alongside  the  coroner’s  report  that  has  been  shared 
with the Derbyshire ICB. The NHS England Safety Team have been in contact with Derby 
and  Derbyshire  Integrated  Care  Board  to  understand  the  clinical  safety  assurance 
processes in place and have offered to support future safety training within the ICB and GP 
community if required.   

Yours sincerely, 

A12

Regulation 28 Report to Prevent Future Deaths
Derby and Derbyshire Integrated Care Board Response 

Derby and Derbyshire Integrated Care Board (DDICB) would like to extend our 
sympathies to the family of Mr Stringer. Please find below the ICBs response and future 
plans in regard to the Regulation 28 Report to Prevent Future Deaths.

If there are any areas which you feel you would like more information or to discuss in 
person this will be arranged.

On 8th April 2024 the coroner commenced an investigation into the death of Mr S C 
Stringer. The investigation concluded on the 25th of September 2024, and the conclusion 
was:

Mr Stringer died from squamous cell carcinoma of the glottis where the significance of his 
symptoms including a prolonged period of hoarse voice was not appreciated until the 
cancer had progressed to Stage4 The medical cause of death was 1a Squamous cell 
carcinoma of the glottis; II Asbestos-related interstitial lung disease, Ischaemic heart 
disease.

The following report and action plan is in response to the matters of concern revealed 
through the course of the inquest as below. Each of these areas has been reviewed 
separately with actions to prevent future deaths captured in the action plan at the end of 
the report. This will be reviewed as per the timescales included within the report.

1.  The inquest heard evidence that the GP practice had in accordance with the local 
requirements introduced an electronic patient enquiry service alongside a telephone 
service. Patients contacting the surgery had to select which stream within the practice 
their enquiry went to. It was not always clear from the headings whether the query would 
be seen by a GP or the admin team. Information that went into the admin work stream 
from a patient did not go onto the patient record and was not seen by a doctor.  
 The GPs at the practice were unaware of this and patients had no way of knowing that 
the information they had sent in was not in the patient record. The practice involved in this 
inquest had taken steps since identifying the issue to mitigate the risks. However, the 
evidence before the inquest was that the software in question was widely used by GP 
practices within Derbyshire and nationally. 

2. The evidence from the ENT consultant was that it was important that where a patient 
presented with a hoarse voice that all health professionals explored for how long it had 
been an issue and whether there was a realistic treatable cause for it. In the absence of 
any clear cause such as a throat infection or where there was no clear response to 
treatment then a hoarse voice should be seen as a red flag symptom for laryngeal cancers 
and result in a referral on the 2 weeks wait. It was clear from the evidence at the inquest 
that unlike other cancer red flags such as blood in urine the significance of a persistent 
hoarse voice was not recognised by a number of different healthcare professionals who 
saw him. The inquest was told that early detection of laryngeal cancers through early 
referrals on the 2 weeks wait significantly improves the outcomes for patients because far 
more treatment options are open to clinicians.   

3. A number of different health professionals had input into his care.  This meant that there 
was no one health professional who had a good insight into his overall deterioration and 
symptoms. Where multiple practitioners were involved one person needed to maintain 

A1 oversight or the electronic patient record needed to have easily accessible clear action 
plans and notes were required so that a patient and their symptoms could be seen 
holistically rather than a one off.  

4. There was also evidence that there is limited public awareness of how significant a 
change in voice can be and recognising it as a potential cancer symptom. Greater public 
awareness of symptoms of laryngeal cancers would ensure the public were better placed 
to seek help at an early stage.

1.  The inquest heard evidence that the GP practice had in accordance with the local 
requirements introduced an electronic patient enquiry service alongside a telephone service. 
Patients contacting the surgery had to select which stream within the practice their enquiry 
went to. It was not always clear from the headings whether the query would be seen by a GP or 
the admin team. Information that went into the admin work stream from a patient did not go 
onto the patient record and was not seen by a doctor.  
 The GPs at the practice were unaware of this and patients had no way of knowing that the 
information they had sent in was not in the patient record. The practice involved in this inquest 
had taken steps since identifying the issue to mitigate the risks. However, the evidence before 
the inquest was that the software in question was widely used by GP practices within 
Derbyshire and nationally. 

Nationally guidance issued by NHS England (NHS England » New digital and online 
services requirements: guidance for GP practices) from October 2021, Practices were 
contractually required to "offer and promote" several digital services to their patients which 
included:

•
•
•
•

An online consultation tools.
A video consultation tool.
A secure electronic communication method.
An online facility to provide and update personal or contact information.

Online consultation tools were first implemented across Derbyshire for a small number of 
practices in 2018 utilising national ETTF funding.  North of England Commissioning 
Support Unit (NECS) Projects were commissioned to undergo market research to identify 
potential suppliers, which met the ETTF criteria for digital patient-initiated requests into 
practices. A shortlist of suppliers/tools were presented to early adopter practices who 
choose and implemented an online consultation tool to pilot based on their local needs.

Demand and uptake of online consultation tools significantly increased in 2020 as part of 
the Covid-19 response with tools either being offered 'free' to GP Practices by providers or 
ultimately then rolled into national contracts. During this time practices were encouraged 
to implement online consultation tools from national teams to support remote clinical care.

While the ICB is currently the contract holder for online consultation tools in use within 
Primary Care, the choice of which online consultation to utilise resides with the GP 
Practice.

Currently, all GP Practices within Derby and Derbyshire have access to at least one online 
consultation tool, but there is some duplication with some practices having access to two, 
depending upon local need.

A2 
 Support for GP Practices is provided directly by the systems supplier who typically offer 
initial onboarding sessions to GP Practices to enable them to understand the capabilities 
of their tool along with regular workshops, demonstrations, and other online support.  
There are also online communities, Frequently Asked Questions, and resources to 
support GP Practices.

The online consultation tools are delivered nationally and at scale with the support of the 
National Procurement Hub and frameworks, with little or no capability to vary the layout, 
contents, etc on a local basis.  There is a wide range of functionality available across the 
online consultation solutions we have within our system ranging from simple forms, 
through to more complex systems which aim to direct the patient to self-care.

Across Derby and Derbyshire Integrated Care Board (DDICB) geography these systems 
began being implemented in 2018. The ICB has never mandated GP Practices to use any 
online tools and have always been guided by the GP Practices; in the early pandemic, we 
had tools such as AccuRx who made their tools available to GP Practices in a way that 
didn't need the ICB or North of England Commissioning Support Unit (NECS) to approve or 
install and hence we saw an explosion of use of these systems.  These were either 
provided for free or through a national agreement (through NHS England) – the ICB took 
on responsibility for managing the contract and finding the funding once these national 
funding agreements ceased.

The ICB holds contracts for online consultation and other tools that we have been asked 
to contract. For these tools the ICB has engaged with a general practice clinician with an 
interest in digital safety to review clinical Digital Safety on an Ad Hoc basis and have 
previously commissioned a Clinical Safety Assurance service from NECS. 

In partnership with the Digital Clinical Patient Safety Officer and Head of Digital and 
Information Governance the DDICB will develop a clinical safety service around future 
triage and online procurements as a standard rather than on an Ad Hoc basis. Until this is 
established the ICB will engage with general practice clinician to provide this service.

The DDICB holds quarterly Clinical Governance Leads meetings with general practice – a 
GP or experienced clinician attends from each general practice, the requirements for 
Digital Clinical Patient Safety will be discussed as part of overall learning, the Digital 
Clinical Safety Team at NHSE have also offered to support this session.

Prior to this the DDICB will raise awareness of the importance of digital clinical safety 
across general practice through inclusion of available training in the DDICB weekly 
General Practice bulletin and direct email communication to both General Practice and 
Primary Care Networks.

The DDICB will discuss with the Derby and Derbyshire Local Medical Council and request 
information also be included within their weekly bulletin.

The DDICB will engage with the Derby and Derbyshire General Practice Provider Board 
as a further opportunity to raise Digital Clinical Patient Safety in relation to existing tools 
and those products procured in the future via the ICB or directly from general practice.  

2. The evidence from the ENT consultant was that it was important that where a patient 
presented with a hoarse voice that all health professionals explored for how long it had been an 
issue and whether there was a realistic treatable cause for it. In the absence of any clear cause 
such as a throat infection or where there was no clear response to treatment then a hoarse 

A3 voice should be seen as a red flag symptom for laryngeal cancers and result in a referral on the 2 
weeks wait. It was clear from the evidence at the inquest that unlike other cancer red flags such 
as blood in urine the significance of a persistent hoarse voice was not recognised by a number 
of different healthcare professionals who saw him. The inquest was told that early detection of 
laryngeal cancers through early referrals on the 2 weeks wait significantly improves the 
outcomes for patients because far more treatment options are open to clinicians.   

The DDICB Clinical Lead for Cancer and Senior Commissioning Manager Cancer will.
Promote the GatewayC module for Head and Neck (education Package) through the 
following channels. 

•
•
•
•

PCN Cancer Leads 
Primary Care bulletin
The Hub plus route
LMC 

Record a webinar with Head & Neck Consultants and the DDICB Clinical Lead in a Q&A 
style to share across primary care around signs & symptoms. 
Raise awareness at the next PCN Cancer Leads meeting. 
Work with Communications to develop some public facing comms around recognising 
signs and symptoms.

To access the GatewayC training GPs can register for a free account and watch live 
webinars, recordings or do online modules, which can provide CPD evidence. This is not 
mandated but includes lots of useful training around different cancer tumour sites. The 
team will promote this education and webinar through the routes above and share the 
learning from this report. 

Please find below a summary of the Gateway C training for your review.

Head and Neck - 

Early Diagnosis - Summary.pdf

3. A number of different health professionals had input into his care.  This meant that there was 
no one health professional who had a good insight into his overall deterioration and symptoms. 
Where multiple practitioners were involved one person needed to maintain oversight or the 
electronic patient record needed to have easily accessible clear action plans and notes were 
required so that a patient and their symptoms could be seen holistically rather than a one off.  

It is now becoming the normal for a patient to not see the same GP during a course of an 
illness or when seeking care and management for an illness, this makes accurate 
consultation records even more important. The electronic patient record now acts as the 
continuity of information with regards to patients supporting direct patient care. 

At the Clinical Governance Leads meeting with general practice the below documents will 
be discussed as part of the Patient safety standard agenda item. 

NHS England » High quality patient records

A4 Good medical practice 2024 - GMC

The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being 
added to their suite of online information and support for general practice.

The DDICB recognises the importance of maintaining accurate electronic patient records 
and ensures digital solutions procured can integrate with both SystmOne and EMIS. 
Automated integration is recommended to practices during onboarding and during 
upgrades, however practices may opt out of this feature, choosing to manually extract and 
upload requests and interactions.
4. There was also evidence that there is limited public awareness of how significant a change in 
voice can be and recognising it as a potential cancer symptom. Greater public awareness of 
symptoms of laryngeal cancers would ensure the public were better placed to seek help at an 
early stage.

There isn't a national campaign covering his type of cancer so the DDICB will create our 
own messaging. To develop this the DDICB Communications Team will work with the 
Primary Care Quality and Cancer Commissioning Teams. This will then be included in the 
following internal and public facing information.

Items in the Primary Care bulletin
Items in staff and stakeholder bulletins
Item in the Joined Up Care Derbyshire newsletter
News article 
Social media
Circulate communications to our system stakeholders to include in their comms 

•
•
•
•
•
•
channels (including community groups)

A5 Action Plan

Action 
Number

1 a

1b

1c

1d

1e

Overview of DDICB actions

Action Owner

Action Updates

Digital clinical patient safety.

Digital Clinical Patient Safety Officer and Head of 
Digital and Information Governance the DDICB will 
develop a clinical safety service around future triage 
and online procurements as a standard.

Discussion and presentation at Clinical Governance 
Leads meeting. 

DDICB will raise awareness of the requirements of 
digital clinical safety across general practice through 
inclusion of available training and information in the 
DDICB weekly General Practice bulletin and direct 
email communication to both General Practice and 
Primary Care Networks.

The DDICB will discuss with the Derby and 
Derbyshire Local Medical Council and request 
information also be included within their weekly 
bulletin.
The DDICB will engage with the Derby and 
Derbyshire General Practice Provider Board as a 
further opportunity to raise Digital Clinical Patient 
Safety in relation to existing tools and those products 
procured in the future via the ICB or directly from 
general practice.  

Head of Digital 
and Information 
Governance

Asst Director 
Nursing 
&Quality 
Primary Care 

Asst Director 
N&Q PC

Head of Digital 
and Information 
Governance

Asst Director 
N&Q PC

Head of Digital 
and Information 
Governance

Proposed 
Completion 
date

01.05.2025

01.05.2025

01.02.2025

01.02.2025

01.02.2025

A6 
 Education - Head & Neck Cancer

2 a 

Record a webinar with Head & Neck Cancer 
Consultants and the DDICB Clinical Lead in a Q&A 
style to share across primary care around signs & 
symptoms. 

2b

Education session for PCN Cancer Leads

2c

2d 

2e 

Inclusion of educational information into the Primary 
Care Bulletin 

Link with Hub Plus (Derby and Derbyshire PC 
Training provider) to include links to education 

Inclusion of educational information into the Local 
Medical Council weekly newsletter

Asst Director 
N&Q PC

 DDICB 
Clinical Lead for 
Cancer 

Senior 
Commissioning 
manager 
Cancer
DDICB Clinical 
Lead for Cancer 
Senior 
Commissioning 
manager 
Cancer
DDICB Clinical 
Lead for Cancer 
Senior 
Commissioning 
manager 
Cancer
DDICB Clinical 
Lead for Cancer 
Senior 
Commissioning 
manager 
Cancer
DDICB Clinical 
Lead for Cancer 
Senior 
Commissioning 

PCN Cancer Leads verbally updated 
about the webinar scheduled for 4th 
December at 27th Nov meeting.

01.02.2025

Planning to invite H&N Consultant from 
UHDB to either January or March 
meeting for an educational slot at the 
meeting.

01.02.2025

01.02.2025

A7 2f

3a

4a 

4b

Work with Communications to develop some public 
facing comms around recognising signs and 
symptoms. 

manager 
Cancer
DDICB Clinical 
Lead for Cancer 
Senior 
Commissioning 
manager 
Cancer

Communications with staff, stakeholders and 
wider public

Work with the DDICB Cancer clinical lead and senior 
commissioning manager to re inclusion of information 
in the following. 

Campaigns 
Manager

01.01.2025 – 
01.04.2025

01.04.2025

o Primary Care bulletin
o Items in staff and stakeholder bulletins
o Item in the Joined Up Care Derbyshire 

newsletter
o News article 
o Social media
o Circulate communications to our 

system stakeholders to include in their 
comms channels (including community 
groups)

Record Keeping 
The DDICB will also liaise with HUB+ to discuss the 
possibility of Record Keeping being added to their 
suite of online information and support for general 
practice.

At the Clinical Governance Leads meeting with 
general practice the below documents will be 

Asst Director 
N&Q PC

Email sent 29.11.2024

Asst Director 
N&Q PC

01.05.2025

A8 discussed as part of the Patient safety standard 
agenda item. 

A9