Maria Simpson

From 

Minister of State for Care   

39 Victoria Street   
London   
SW1H 0EU  

3rd March 2025  

Our ref: 

HM Coroner Mr Roland Wooderson   
Gloucester Coroner’s Court,   
Corinium Avenue,   
Gloucester   
GL4 3DG  
By email: 

Dear Mr Wooderson,   

Thank you for the Regulation 28 report of 09/01/2025 sent to the Department of Health and 
Social  Care  about  the  death  of  Maria Simpson.  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 Ms Simpson’s 
death, and I offer my sincere condolences to her 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 report highlights the issues brought about by the lack of a uniform case management 
system for storing patient records and the lack of capability to store all historic documents 
relating to a patient.    

In preparing this response, Departmental officials have made enquiries with NHS England 
to ensure we adequately address your concerns.  

The first concern in the report centres on the lack of a uniform case management system for 
storing  patient  records  electronically.  The  report  highlights  that  when  transferring  patient 
records to practices that use a different system, the receiving practice must input all records 
afresh, leading to delays in the compilation of records.  

The  NHS  General  Medical  Services  (GMS) contract  regulations  stipulate  that  contractors 
must keep ‘adequate’ patient records either on forms provided by NHSE, in computerised 
records, or a combination of both. The contract also states that any computer system must 
meet the requirements set out in the GPIT Operating model and that the contractor must 
have regard for the guidance laid out in Digital Primary Care: Good Practice Guidelines for 
GP electronic patient records.  

In England, General Practices most frequently use either the EMIS web, TPP SystmOne or 
Medicus  electronic  patient  records  systems.  All  of  these  systems  can  transfer  or  make 
available a patient’s coded and structured electronic health record (including any associated 

   
   
  
  
   
  
  
 
  
  
  
   
  
  
  
 attachments) to a patient’s new practice in the event they re-register with a different general 
practice.   

The process for individual patient migrations (or deductions) to new practices is triggered by 
the patient registering at a new practice. GMS contract regulations state that for the transfer 
of any patient records, the records must be sent to the new practice within 28 days. NHS 
England guidance recommends patient record migration takes place on a weekly basis to 
ensure the new practice receives the complete record quickly.  

As per GMS contract regulations, practices must use the facility of GP2GP for the transfer 
of  any  patient  records.  GP2GP  is  the  standard  implemented  by  clinical  systems  that 
describes how a patient’s electronic record should be translated, packaged and transferred 
so that it can be understood and integrated by the clinical systems in use in the new practice.  
Where  this  happens  successfully,  a  patient’s  record  is  immediately  available  to  their  new 
practice.  This  includes  historic  paper  information  which  has  been  summarised  onto  the 
individual’s record.   

Where  an  electronic  record  transfer  fails,  practices  are  instructed  to  print  the  electronic 
health record and any attachments and make it available for collection and transportation to 
the patient’s new practice. Once received the record is then reviewed and summarised by 
the patient’s new GP into a new electronic health record.  

NHS England works closely and in collaboration with clinical system suppliers to identify and 
resolve issues related to record transfers to improve the reliability of GP2GP. The failure rate 
for GP2GP  record transfers has  improved  year on  year,  from  4.46%  in  2021  to  1.64%  in 
2024,  with  a  rate  of  0.78%  for  the  week  ending  17th  January  2025.  NHS  England  also 
publishes guidelines to help ensure a smooth transfer of patient records.   

The second concern in the report focusses on the inability of a case management system to 
store all historic documents, including referral letters from one clinician to another. This leads 
to patient information being stored in both electronic and paper form, making it difficult for 
the GP to note quickly all of the relevant information.   

The EMIS web, TPP SystmOne and Medicus records systems all have the capability to store 
attachments as part of the coded and structured electronic health record.  

Some elements of patient records continue to be stored in a paper format, called the ‘Lloyd 
George record’. Currently there are approximately 50 million Lloyd George records held by 
practices  across  England  and  approximately  15  million  held  in  archive  by  NHS  England. 
When a patient registers at a new practice the paper records must be made available by the 
patient’s previous practice, or archive, for transportation to the patient’s new practice. There 
is a system in place to deliver bar coded movement labels to each practice for any records 
that need  to be  moved  to  either the  new practice  or the  archive. These  records  are  then 
moved  through  a  dedicated  courier  network  and  tracked  until  delivery  at  the  new 
practice/archive.  

Some practices and local health systems have scanned their paper records.  In the majority 
of cases these scanned records are then attached to a patient’s electronic health record. 
The exception is for practices using TPP SystmOne, where the supplier doesn’t let practices 
upload  scanned  records  due  to  system  constraints. To  mitigate against this issue,  and to 
provide a strategic central storage facility for unstructured data for the NHS in England, NHS 
England has built and initially trialled, with Birmingham and Solihull Integrated Care Board, 

  
  
  
  
  
  
  
 a National Document Repository. The National Document Repository is supporting storage 
of and access to scanned Lloyd George records. The system is due to be rolled out nationally 
in financial year 2025/26, subject to securing funding.   

NHS  England  is  currently  designing  the  future  requirements  for  the  transfer  of  paper  GP 
patient records. The intention is to build in a new service so that where a paper record still 
exists, it will be collected from a GP practice when a patient leaves a GP practice. It will be 
scanned and uploaded into the National Document Repository for access by the new GP 
practice.  This  will  ensure  that  the  number  of  patients  having  dual  electronic  and  paper 
records steadily reduces. The intention is to introduce this as part of a new service contract 
which will take effect in 2028.  

Actions undertaken by the ICB  

The Gloucestershire ICB noted that in the case of Ms Simpson, a gap in the knowledge of 
the GP about a referral portal meant that a referral was made via ‘Choose and Book’ to the 
geographically nearest NHS trust (which was in another ICB area), rather than the NHS trust 
the patient was intending to have her baby in, within Gloucestershire. This was because the 
Gloucestershire trust did not use ‘Choose and Book’ for this service as it delayed the referral 
process.  After  the  referral  was  rejected,  the  GP  attempted  to  refer  the  patient  via 
Gynaecology ‘Advice and Guidance’ services as Obstetrics did not have  
‘Advice and Guidance’ at that time.    

Local changes have now been made by Gloucestershire ICB, with an Obstetrics ‘Advice and 
Guidance’ service running since December 2023. Pathways have also been changed and 
there is now no need to confirm the pregnancy via scan before prescribing Low Molecular 
Weight Heparin. Communications have also been sent out to all GP practices via practice 
managers, news bulletins and via the Local Medical Committee.  

Yours sincerely,