Tammy Milward

IN THE SURREY CORONER’S COURT

BEFORE HIS MAJESTY’S ASSISTANT CORONER FOR SURREY

THE INQUEST TOUCHING THE DEATH OF TAMMY DENISE MILWARD

RESPONSE TO REGULATION 28 —- ESHER GREEN SURGERY

HM. Assistant Coroner Ridge for the Coroner Area of Surrey has made a Regulation 28 Report
— Action to prevent deaths dated 15 January 2025 (“the Regulation 28 Report”) concerning
the death of Tammy Denise Milward (“the Deceased”). This arises from the Inquest of 13
December 2024, adjourned and concluded on 20 December 2024 (“the Inquest”).

Esher Green Surgery (“the Practice”) respond in accordance with Regulation 29 of the
Coroners (Investigations) Regulations 2013 (“the Response”),

The numbering in the Regulation 28 Report is adopted. H.M. Assistant Coroner Ridge’s
concerns are set out in italics, with the Practice’s Response below:

“The MATTERS OF CONCERN are:

The Inquest heard evidence that Ms Milward’ case presented treatment challenges which

several agencies sought to address but there was limited coordination, in particular that:

a. The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes)
which are recorded on SystmOne and that GPimhs could not easily access the GP medical
records held on EMIS. As a result, neither the GP practice, nor GPimhs was aware that
the other had received messages from or about Ms Milward on 28 December 2023. The
coroner heard from SABP that there is ongoing work ongoing to create greater connectivity

between the various electronic record systems, but this work is not yet complete.”

General Practice Integrated Mental Health Service (“GPIMHS”) is a Surrey wide system run
by Surrey and Borders Partnership NHS Foundation Trust (“SABP”) and commissioned by
Surrey Heartlands Integrated Care Board (“ICB”).

The Practice is just one of over 100 GP practices for which SABP is the provider for GPIMHS

services.

Therefore, the development of the ability for the electronic GP medical record systems such as
SystmOne and EMIS to communicate with each other and allow sharing of clinical information,

is not within the control of any individual GP practice, including ours. This is a matter that falls

under the responsibility of the service commissioners at Surrey-wide level, specifically the ICB.
Individual practices, including ours, have no authority to determine the specifications of such
services, nor are they involved in the due diligence processes related to the Information

Management and Technology (IM&T) aspects of these systems.

However, we would welcome better connectivity between systems and therefore easier sharing

of clinical records, which would improve patient safety and clinical efficiency.

As such in respect of this Concern a., we consider we cannot proactively do anything save bring
this to the attention of the ICB as it is a commissioning issue, which we have done, and later
react to requests from SABP, subject to approval from the ICB, to facilitate integration of the
clinical IT systems which, of course we will do and would expect the other 100 plus practices

to do likewise.

b. “The evidence heard suggests that there was little personal or practical interaction between
the GP practice and GPimhs. The coroner was told that GPimhs had been recently
introduced by SABP to work alongside GPs (addressing a need in primary care to provide
mental health support) but that levels of interaction varied and was sometimes also
undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices.
The coroner is concerned that the lack of coordination and communication between

primary and secondary care providers may place patients at risk of early death,”

The majority of GPiMHS consultations for our Practice patients take place away from our
surgery building, either at other NHS estates or via remote consultations. We have consequently
not had regular in-person interactions with SABP staff, as they are not frequently on-site with

our clinicians. Communication is therefore usually via email and/or by telephone.

Clinical space in GP practices is usually fully utilised by the practices themselves and this is
the case at our Practice. We are currently working with the ICB on finding a solution to our
own estate’s challenges but are aware that there is pressure on GP space Surrey wide. As such,
we consider that in-person interactions are unlikely to be effected Surrey-wide so email and
telephone interactions should be prioritised in our view. This concern b. is not specific to the
Practice but is Surrey-wide for all practices and any action taken by the Practice alone will not

address the wider community unless SABP seek a uniform approach.

Of course, in this specific case we note the Coroner did not raise a concern with the care actually
provided by the Practice in general, or in relation to the circumstances before the death, when

the level of risk was evaluated and managed.

We welcome the ongoing work by SABP to create greater connectivity between the electronic

record systems. We are hopeful that this will significantly improve communication between

primary and secondary mental health care, in order to improve patient safety and reduce the
risk of future deaths.

Unfortunately, we as an individual practice have very limited power and no authority to
improve communication in this manner across the whole Surrey GP population of over 100
practices that GPiMHS covers. Until effective software is provided by commissioners, and

maybe beyond depending upon the nature of any IT improvements, we propose the following:

(i) We have already contacted the ICB as above;

(ii) Pending IT integration, which needs to be effected as soon as possible, we will
implement any temporary measures recommended by the ICB, alongside the other 100
plus practices. We believe it is important that any changes are effected Surrey-wide and
not on an ad hoc basis for an individual practice; and

(iii) We will continue to have timely verbal communication with GPiMHS staff when

concerns arise about a patient at risk and follow the same up by email.

The three above proposed measures are the result of a Significant Event Meeting at the Practice

on 22 January 2025 (as attached) which we hope are constructive and useful.

These measures have already been discussed as a practice with staff amongst whom we have

raised awareness, but this advice might benefit from being disseminated by SABP Surrey-wide.

4. We are copying this Response to SABP and also the CQC who have written to the Practice in
respect of the Regulation 28 Report.
5, We will implement changes as recommended by the ICB and SABP for all Surrey Practices.

Dated this 44day of Fepwmp 2025

Signed:

P| on behalf of Esher Green Surgery, Esher Green Drive, Esher, Surrey, KT10 8BX

Sharing of information between different services within the NHS has historically been very 
problematic as they have evolved in perfect silos. This is the driving force behind the setting 
up of the Surrey Care Record and whilst not fully complete, it is close to resolving the issues 
the Coroner’s report highlights. 

Currently the Surrey Care Record does share a live feed of the GP medication, all GP held 
letters and also any letters sent from an acute trust to the GP (live feed again) By mid-April 
we will have been able to implement a live feed from the GP system which will show the 
entire consultation free text, including historic consultations. This will effectively give the 
meat (all clinically relevant) GP record to the health professional treating that patient. 
Patient/pharmacy messages are stored within the GP record as an administration 
consultation and as such any messages from the pharmacist to the GP will be fully visible to 
the GPimhs team. Of note, there is embedded link (single sign on) from within the SABP 
system so that it requires only one button push from the SABP System One record, in order 
to automatically open up the Surrey Care Record for that patient. Any data is only two mouse 
clicks away. This should fully resolve the issue of the GPimhs staff not being able to see the 
GP record to the degree that is required to mitigate this risk. 

In order for GPimhs staff to communicate with the practice, each practice has a specific 
email for their reception. This email address can be provided to SABP by each practice. It is 
monitored by the practice during opening hours and any urgent emails would be forwarded 
on to the duty doctor within the practice. This would allow urgent (but not emergency) 
communication between the GPimhs team and the practice. The GPs can reply to this using 
the AccuRx email solution which writes any sent emails back into the clinical system, so that 
they are again visible to the system (SECAMB,111,OOH, and acute trust A&E). 

As long as the GPimhs’ email address is available, the GP can also email directly to raise 
non-urgent concerns. Again, the sent email is written back into the GP system and will soon 
viewable via the Surrey Care Record. This should again mitigate this highlighted risk. 

Historically there has been little personal interaction between GPihms and the practice 
though there is no reason why they cannot speak via Microsoft Teams, which is provided for 
all NHS staff. This allows both phone and video calls to take place securely. In the real world 
there are often logistical problems (different working hours/days) doing this, though it is 
possible. 

Surrey Heartlands ICB