Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0073, written 24 Jan 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 24 Jan 2025 |
|---|---|
| Reference | 2025-0073 |
| Deceased | Andrew Heys |
| Coroner | John Pollard |
| Coroner area | Manchester (West) |
| Category | Suicide (from 2015) |
| Source | judiciary.uk record · original PDF |
| Responses published | 2 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
Regulation 28: REPORT TO PREVENT FUTURE DEATHS NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT DEATHS THIS REPORT IS BEING SENT TO: 1 BARDOC 2 1 CORONER , Secretary of State for Health and Social Care I am John Stanley POLLARD, Assistant Coroner for the coroner area of Manchester West 2 CORONER'S LEGAL POWERS I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. 3 INVESTIGATION and INQUEST On 21 March 2024 I commenced an investigation into the death of Andrew Dominic HEYS aged 29. The investigation concluded at the end of the inquest on 08 January 2025. The conclusion of the inquest was 'Open' and the medical cause of death was established as la) Drowning II) Post-Vaccination Auto-Immune Encephalopathy. CIRCUMSTANCES OF THE DEATH 4 In December 2021 the deceased received the vaccination against Covid 19. This was his booster. He reacted very badly to the vaccination and thereafter suffered from Auto- Immune Encephalopathy, the effects of which were devastating both physically and mentally. On the 12th March 2024 the deceased went to a bridge over the Manchester Ship Canal, climbed over the parapet and fell into the water. His body was discovered four days later. 5 CORONER'S CONCERNS During the course of the investigation my inquiries revealed matters giving rise to concern. In my opinion there is a risk that future deaths could occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows: During the course of the evidence, the GP, who was acting on behalf of BARDOC, the out of hours provider, indicated to me that she had never been trained by BARDOC, in how to follow their 'pathways'; this meant that she 'closed' the call alter speaking to the patient, rather than returning it to the Ambulance Service as should have happened. She was also confused about how she could access the patient's own GP records; again, she said she had not had any training in this regard. During the course of the evidence, I heard, yet again, the common complaint that one health professional is unable to access the health records of the patient held by another health professional. In this case, the manager of the 111 Helpline agreed that the various IT systems do not "talk to each other". It is of concern to me as to why all bona fide health professionals cannot have access to all health data held anywhere within the NHS. Regulation 28 - After Inquest Document Template Updated 30/07/2021 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe you (and/or your organisation) have the power to take such action. 7 YOUR RESPONSE You are under a duty to respond to this report within 56 days of the date of this report, namely by March 14, 2025. I, the coroner, may extend the period. Your response must contain details of action taken or proposed to be taken, setting out the timetable for action. Otherwise you must explain why no action is proposed. 8 COPIES and PUBLICATION I have sent a copy of my report to the Chief Coroner and to the following Interested Persons North West Ambulance Service r I am also under a duty to send a copy of your response to the Chief Coroner and all interested persons who in my opinion should receive it. I may also send a copy of your response to any person who I believe may find it useful or of interest. The Chief Coroner may publish either or both in a complete or redacted or summary form. He may send a copy of this report to any person who he believes may find it useful or of interest. You may make representations to me, the coroner, at the time of your response about the release or the publication of your response by the Chief Coroner. 9 Dated: 24/01/2025 John Stanley POLLARD Assistant Coroner for Manchester West Regulation 28 - After Inquest Document Template Updated 30/07/2021
2 responses published against this report on judiciary.uk. A response is a body's written reply to the coroner's concerns; publication is at the discretion of the Chief Coroner's office, so an absent response does not mean nobody replied.
Date: 12th August 2025 PRIVATE AND CONFIDENTIAL The Chief Coroner Dear Sir/Madam Re: Mr Andrew Dominic HEYS (Deceased) Moorgate Primary Care Centre 22 Derby Way Bury Lancashire BL9 0NJ www.bardoc.co.uk Official Statement from BARDOC Limited In Response to the Section 28 Regulation Issued by HM Assistant Coroner, Mr Pollard – Bolton Coroners Court, 8th January 2025 Following the inquest held at Bolton Coroners Court on 8th January 2025, BARDOC Limited acknowledges the issue of a Section 28 Regulation (Prevention of Future Deaths) by HM Assistant Coroner Mr Pollard. The regulation was issued after concerns were raised regarding the actions of a General Practitioner (GP) who was working on behalf of BARDOC as part of the Greater Manchester Clinical Assessment Service (GMCAS). During the inquest, the GP stated under oath that she had not received training on BARDOC’s clinical pathways, and expressed confusion over accessing patient’s GP records. As a result of this testimony, the Coroner concluded that a lack of training may have contributed to the incident which is under investigation. BARDOC has since conducted a thorough internal review and investigation. We have submitted to the Coroner detailed and substantial evidence that the GP did, in fact, receive the appropriate and required training prior to recommencing work within the GMCAS. This included access to current Standard Operating Procedures (SOPs), shadowing shifts, and support resources including updated pathways and processes. It is important to note that BARDOC was not requested to attend the inquest either as a witness or an interested party. As a result, we were unable to directly respond to the concerns raised during the proceedings. We believe that the testimony provided by the GP at the inquest was not factually accurate, and regret that this may have influenced the Coroner’s findings. It is our position that the issue did not arise due to any inadequacy in the training or support provided by BARDOC, but rather due to an unfortunate clinical decision made independently by the clinician involved. BARDOC takes our duty of care to patients and commitment to continuous improvement extremely seriously. We are proud of our comprehensive training programmes, operational protocols, and the robust support systems available to all clinicians within our services. We will continue to work Providing out of hours medical and dental care to our local communities collaboratively with Coroners, regulators, and NHS partners to ensure the highest standards of clinical governance and patient safety. The BARDOC board has assessed this matter and concluded that a referral to the NHS Performance team is mandated. This decision has been supported by the Coroner. As the Medical Director, I am duty bound to follow the instruction and refer the matter for further investigation due to concerns mentioned earlier in this letter We extend our sympathies to the family affected by this case, and remain committed to learning from all incidents in the interest of improving care across the healthcare system. Yours sincerely Medical Director
Minister of State for Health (Secondary Care)
39 Victoria Street
London
SW1H 0EU
HM Coroner John Stanley Pollard
First Floor,
Paderborn House,
Howell Croft North,
Bolton,
BL1 1QY
15th September 2025
Dear Mr Pollard,
Thank you for the Regulation 28 report of 24/01/2025 sent to the Department of Health and
Social Care about the death of Andrew Dominic Heys. I am replying as the Minister with
responsibility for data and technology.
Firstly, I would like to say how saddened I was to read of the circumstances of Andrew Heys’s
death, and I offer my sincere condolences to their family and loved ones. The circumstances
your report describes are concerning and I am grateful to you for bringing these matters to
my attention. Please accept my sincere apologies for the significant delay in responding to
this matter.
The report raises concerns to the Department of Health and Social Care on health
professionals being unable to access health records of patients held by another health
professional, and systems not ‘talking to each other.’
In preparing this response, my officials have made enquiries with NHS England and the Care
Quality Commission to ensure we adequately address your concerns.
I agree that ensuring health and care professionals have access to a single source of digital
information about the patients they are treating and caring for is vitally important to delivering
the best care possible. The Department of Health and Social Care, and NHS England have
programmes of work underway which should assist in preventing future deaths connected to
this issue.
Since 2022, £1.9bn has been invested in laying the foundations for digital transformation
across the health and care system, including rolling-out Electronic Patient Records to NHS
trusts that don’t have one, and supporting those with an existing one to replace, extend or
optimise it. Currently, 93% of Secondary Care Trusts have an EPR in place, we expect 96%
of trusts to have EPRs by March 2026, with the remainder to follow.
NHS England is also providing support to bring trusts up to an optimum level of digital
maturity, with all secondary care organisations completing a Digital Maturity Assessment in
May 2024, which will be run yearly to track progress and identify areas for improvement,
which will further reduce barriers to the sharing of information needed to treat patients.
Going beyond this, the Government’s 10 Year Health Plan commits to delivery of a single
patient record (SPR). This will provide a comprehensive patient record, bringing together all
of a patient’s medical records into one place. We have been engaging with the public to help
shape our plans, including what information they would like to see included in a single patient
record and we will continue to talk to the public and to health and care professionals as we
design the SPR to ensure their needs are reflected. The SPR will begin to go live from 2028
and be rolled out first in maternity care.
Introducing a single patient record will give clinicians all the data they need when treating
patients. By having access to all relevant information about a patient, frontline staff will be
able make more informed decisions and deliver the best care at the time it is needed.
I hope this response is helpful. Thank you for bringing these concerns to my attention.
Yours sincerely,
MINISTER OF STATE FOR HEALTH
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