Neil Yates

Ms Anita Bhardwaj 
Area Coroner  
Liverpool and the Wirral Coroner’s Service 
Gerard Majella Courthouse 
Boundary Street  
Liverpool  
L5 2QD 

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

9 January 2025 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Neil Michael Yates who 
died on 25 April 2023  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  4 
November  2024  concerning  the  death  of  Neil  Michael  Yates  on  25  April  2023.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Neil’s family and loved ones. NHS England are keen 
to assure the family and the Coroner that the concerns raised about Neil’s care have 
been listened to and reflected upon.   

Your Report raises concerns over delays to prescribing information for patients being 
sent to GP surgeries by voluntary and NHS organisations.  

There is a National Care Records Service (NCRS), also referred to as the Summary 
Care Record (SCR), which is often used by care providers as a source of information 
for a patient’s current medication. The medications displayed on this record are driven 
by the patient’s GP record as opposed to other sources. This means that there remains 
a  need  for  medications  supplied  from  sources  other  than  the  patient’s  GP  to  be 
recorded on the GP record before the information can then be made available on the 
National Care Records Service.  

The limitation of medication information within patient clinical records is a known one, 
and a series of initiatives and work are being undertaken to address this across NHS 
England, local systems and IT vendors. These include the following: 

•  A core set of fully “interoperable medicine standards” (IMS) have been defined 

and tested by early adopters and are available to IT system suppliers.   

•  An Information Standards Notice (ISN) for Trusts is supporting wider adoption 
of  IMS  which  have  been  incorporated  into  national  digital  medicines 
programmes.  

•  National adoption of IMS to underpin the transfer of medication information at 

the time of hospital admission and discharge is underway.  

•  The first NHS Trust has used the IMS as part of the local shared care record.  

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
 
  
 •  GP IT suppliers are now required to deliver the requirements set out in the IMS 

by June 2025.  

•  The GP Connect interface, where prescription only medication supplies made 
from  specific  settings  (e.g.  community  pharmacies)  without  being  prescribed 
directly by the GP, can now be electronically recorded into the GP record by 
the supplying professional. 

•  Guidance on consolidated patient medication records has been published by 
the  Faculty  of  Clinical  Informatics,  as  follows:  professional-consolidated-
medication-record-rendering-guidance-v20-sep-23.pdf  

•  The Professional Record Standards Body (PRSB) have updated their 

discharge summary standards:  
https://theprsb.org/standards/edischargesummary/ 

•  Work  is  currently  underway  to  update  the  medicines  specification  of  the 
Transfer  of  Care  initiative,  i.e.  the  mechanism  to  send  information  from 
secondary care to primary care.  

•  NHS England have worked with local Integrated Care Boards (ICBs) to support 
the development of “local shared care records.” This provides the opportunity 
for local systems to present medication information across multiple providers.  
•  This programme of work is seen as a priority by NHS England, and timelines 
are currently being reviewed but implementation must be managed in line with 
the differing levels of digital maturity within ICBs. 

The  full  national  adoption  and  implementation  of  these  pieces  of  work  would  allow 
permitted clinicians to have an up-to-date record available along with medicines supply 
information to aid safe clinical decision making.  

Work is underway on all these projects, but adoption is required by multiple vendors 
which makes it difficult to give a specific completion end date. These projects will likely 
be rolled out over the coming two to five years.   

Regarding prison screening processes specifically, the reception screening process 
for those arriving at prison asks the patient about their current medicines, in line with 
the  National  Institute  for  Health  and  Care  Excellence  (NICE)  guideline  NG57: 
Recommendations | Physical health of people in prison | Guidance | NICE. This is the 
basis  by  which  the  current  medicines  are  initially  recorded  and  reviewed.  A  patient 
receiving  treatment  in  the  community  under  the  Substance  Misuse  Service  (SMS) 
would be referred to the prison’s SMS team for review and a care plan.  

It should be noted that morphine sulphate tablets (MST) are not used for substance 
misuse treatment but are used as an opioid for pain.  

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 Neil, 
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