Hailey Thompson

NHS
Greater Manchester
Integrated Care

Date: 17 September 2025

Private & Confidential
Mr Michal James Pemberton
HM Assistant Coroner for the area of Manchester
(West)
Manchester City Coroner's Office & Court
Exchange Floor
The Royal Exchange Building
Cross Street
Manchester M2 7EF

Dear Mr. Pemberton

Re: Regulation 28 Report to Prevent Future Deaths -  Hailey Anne Thompson

Thank you for your Regulation 28 Report dated 7 April 2025 regarding the sad death of Hailey Anne
Thompson. On behalf of NHS Greater Manchester Integrated Care (NHS GM), We would like to begin by
offering our sincere condolences to Hailey’s family for their loss.

Thank you for highlighting your concerns during the inquest which concluded on the 3 April 2025. Please
accept my apologies for the delay in this response. We recognise it is very important to ensure we make
the necessary improvements to the quality and safety of future services.

During the inquest you identified the following cause for concern:

1.  During the course of evidence, an issue was explored regarding Hailey’s mother
attempting to obtain an appointment or advice with the GP surgery following an
apparent allergic reaction to prescribed antibiotics. These had been prescribed on 7
December for tonsilitis but stopped after three days due to an apparent allergic
reaction. Regulation 28 -  After Inquest Document Template Updated 30/07/2021

2.  During a call to the GP surgery, Hailey’s mother spoke with an administrative member
of staff (who at the inquest was referred to as a care navigator at a call centre). The
staff member referred an appointment to a pharmacist working with the practice to call
her.

3.  The pharmacist to whom this was assigned was not competent to deal with a

paediatric medication enquiry and sent a message back advising of this, albeit not on
the medical records system where an auditable trail would exist. On the evidence, the
pharmacist was not provided with feedback directly on the need to use the medical
records system or involved in the lessons learned process as they were not directly
employed by the practice.

Part of Greater Manchester
Integrated Care Partnership

4th Floor, Piccadilly Place, Manchester  M1 3BN
Tel: 0161 6257791  www.gmintegratedcare.org.uk

 NHS
Greater Manchester
Integrated Care

4.  A further concern arose during the course of evidence from the primary care practice

manager that a care navigator may not have a clear pathway
action to, or triage tool to recognise that a reported allergic reaction to a medication
may require urgent consideration by a doctor to assess any risk of anaphylactic shock.

5.  No evidence was provided to:

a. explain how a patient telephoning the practice and being answered by the call centre
would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre
which is not located within the doctor surgery.

6.  These issues are important as I had no reassurance that an administrative member of

staff who spoke with a patient contacting the practice, had a clear pathway or guidance
on whom the required task should be referred to.

7.  Instead, the task could be allocated using judgement (although as above, guidance to
apply this was not clear) to a clinician who could not in fact assist, which occurred in
this case. The jury who heard the inquest found that there was a missed opportunity to
review the antibiotics, which was not causative in this case. In my opinion, there is a
risk that an urgent need for appropriate clinical referral may not occur in the above
circumstances.

I note that SSP Health have provided a response to you, and this directly addresses the issues in your
report from the perspective of the provider responsible for the direct care and treatment for Hailey Anne.
My response on behalf of NHS GM will refer in parts to the SSP response and outline further action and
assurance that NHS GM will take.

I have addressed the causes of concern in turn below:

1.  During the course of evidence, an issue was explored regarding Hailey’s mother
attempting to obtain an appointment or advice with the GP surgery following an
apparent allergic reaction to prescribed antibiotics. These had been prescribed on 7
December for tonsilitis but stopped after three days due to an apparent allergic
reaction. Regulation 28 -  After Inquest Document Template Updated 30/07/2021

2.  During a call to the GP surgery, Hailey’s mother spoke with an administrative member
of staff (who at the inquest was referred to as a care navigator at a call centre). The
staff member referred an appointment to a pharmacist working with the practice to call
her.

SSP Health have explained how they managed the request for medication at that time. NHS
GM does recognise that administrative staff across all our practices in Greater Manchester
receive training on care navigation, signposting and advising patients on the best avenues to
treatment. This could be with a GP or other allied health professionals. Whilst the nature of
the training and roles can be particular to different practices. The aim is consistently to
provide the best care, in the best and most efficient way for patients.

3.  The pharmacist to whom this was assigned was not competent to deal with a

paediatric medication enquiry and sent a message back advising of this, albeit not on
the medical records system where an auditable trail would exist. On the evidence, the
pharmacist was not provided with feedback directly on the need to use the medical

Part of Greater Manchester
Integrated Care Partnership

4th Floor, Piccadilly Place, Manchester  M1 3BN
Tel: 0161 6257791  www.gmintegratedcare.org.uk

 NHS
Greater Manchester
Integrated Care

records system or involved in the lessons learned process as they were not directly
employed by the practice.

I have reviewed the response from SSP Health to this part of your report and think there is
some learning for primary care providers around ensuring efficient and effective access to the
right clinician to treat them and the requirement to ensure accurate, detailed and timely record
keeping. To this aim, I will ensure that:

(cid:127)  Working with NHS GM clinical leadership and the NHS GM primary care team, a
learning document is developed to cover responsibilities for safe and effective
referrals to treating clinicians, be that between practice administrative staff or clinician
to clinician.

(cid:127)  Working with the NHS GM Information Governance (IG) team, a reminder is shared
through the NHS GM Primary Care Newsletter on the requirements under GDPR of
record keeping.

4.  A further concern arose during the course of evidence from the primary care practice

manager that a care navigator may not have a clear pathway on whom to refer a task or
action to, or triage tool to recognise that a reported allergic reaction to a medication
may require urgent consideration by a doctor to assess any risk of anaphylactic shock.

I note that SSP Health have provided assurance that they do have referral pathways in place.
The learning document described above will cover this and be shared with GM practices.

5.  No evidence was provided to:

a. explain how a patient telephoning the practice and being answered by the call centre
would be referred to the urgent triage doctor on duty at the practice,
b. whether a list of clinician competencies and whom to refer tasks to was held
c. Care Navigator training
d. Algorithms or policies that apply to assist care navigator / call handlers at a centre
which is not located within the doctor surgery.

6.  These issues are important as I had no reassurance that an administrative member of

staff who spoke with a patient contacting the practice, had a clear pathway or guidance
on whom the required task should be referred to.

7.  Instead, the task could be allocated using judgement (although as above, guidance to
apply this was not clear) to a clinician who could not in fact assist, which occurred in
this case. The jury who heard the inquest found that there was a missed opportunity to
review the antibiotics, which was not causative in this case. In my opinion, there is a
risk that an urgent need for appropriate clinical referral may not occur in the above
circumstances.

I note that SSP Health have addressed this part of your report and explained how calls are
managed by them and provided you with evidence to support this. Although your concerns
were addressed specifically to SSP Health, there is a wider opportunity for reflection and
learning, and this will come through the learning document I have described above.

NHS GM recognises the importance of staff training in all our primary care practices to ensure
that patients are navigated correctly and in a timely way as appropriate for the symptoms they
are presenting with, including providing appropriate and timely treatment. NHS GM will

Part of Greater Manchester
Integrated Care Partnership

4th Floor, Piccadilly Place, Manchester  M1 3BN
Tel: 0161 6257791  www.gmintegratedcare.org.uk

 NHS
Greater Manchester
Integrated Care

ensure that the practice carries out a Significant Event Analysis (SEA) and key learning is
implemented, within the provider and SSP Health as a multiple
the SEA and any learning with you.

On a more general note, we are also working with the GM locality leads where SSP Health
has contracts to agree a more collective approach to contract and quality management,
including the review of Regulation 28 Reports and the associated learning.

I hope that my response, along with the detailed response to you provided by SSP Health, has
addressed your concerns. Please do contact me if I can be of further help.

Best wishes

Interim Deputy Chief Executive Officer and Chief Nursing Officer
NHS Greater Manchester

Part of Greater Manchester
Integrated Care Partnership

4th Floor, Piccadilly Place, Manchester  M1 3BN
Tel: 0161 6257791  www.gmintegratedcare.org.uk

Date: 28th April 2025 

Michael James Pemberton 
HM Assistant Coroner for Manchester West 
Paderborn House 
Howell Croft North 
Bolton, BL1 1QY 

Re:  Regulation  28  Report  –  Prevention  of  Future  Deaths  –  Hailey Anne  Thompson 
(Deceased)  

Ref: 

Dear Mr Pemberton, 

Thank you for your Regulation 28 report dated  4 April 2025 following the inquest into the 
death  of Hailey  Anne Thompson. On behalf of SSP  Health and Ashton Medical Centre, I 
wish to express our deepest sympathies to Hailey’s family and our sincere  thanks for the 
opportunity to reflect  on this tragic event. We consider safety and quality of care to be of 
upmost importance and paramount in our ethos and culture. 

We  acknowledge  the  concerns  raised  regarding  care  navigation,  governance,  and 
communication processes, and would like to take this opportunity to provide assurances 
of the  processes that  are embedded  into the  practice.  We note  that  you state that  you 
concluded  that the  concerns  you raised did not contribute  to the  death and would also 
point out that the structures and operating procedures which are used at the surgery are 
consistent with those used in the vast majority of doctors surgeries in the UK. As a result, 
we  would  ask  you  to  consider  if  a  Regulation  28  Report  is  appropriate  in  these 
circumstances. 

Below is our response structured around the key issues raised. 

1.  During  the  course  of  evidence,  an  issue  was  explored  regarding  Hailey’s  mother 
attempting  to  obtain  an  appointment  or  advice  with  the  GP  surgery  following  an 
apparent allergic reaction to prescribed  antibiotics. These had been prescribed  on 7 
December  for  tonsilitis but  stopped  after  three  days  due  to  an  apparent  allergic 
reaction.  

2.  During a call to the GP surgery, Hailey’s mother spoke with an administrative member 
of staff (who at the inquest was referred to as a care navigator at a call centre). The 
staff member  referred  an appointment to a pharmacist working with the  practice  to 
call her.  

 
 
 
 
 
 
 Practice Response: 

•  Our pharmacists do not prescribe for children. This has been further reinforced within 
our teams and further formalised in a policy, preventing  pharmacists who work with 
the  practice  from issuing or  altering  antibiotics or  medications  for  children,  except 
when stated explicitly in consultant letters.  

•  Our  receptionists,  who  are  also known as  care  navigators, receive  care  navigation 
training  during  their  induction.  They  take  calls  across  several  of  our  practices  for 
standardisation.   

•  The  nature  and  skills  of  our  receptionists  are  consistent  with  the  vast  majority  of 
doctors surgeries in the UK and in line with regulation and contract requirements. 

Action: 

•  Our centralised competencies  register  is under  review for all clinical staff, including 
pharmacists,  which  will  be  distributed  to  care  navigation  teams  and  reviewed 
biannually. 

• 

In  addition to  regular  training and  updates,  pharmacists  employed  by  the  practice 
have further support from our Director  of Clinical Operations. 

3.  The  pharmacist  to  whom  this  was  assigned  was  not  competent  to  deal  with  a 
paediatric medication enquiry and sent a message back advising of this, albeit not on 
the medical records system where an auditable trail would exist. On the evidence,  the 
pharmacist was not provided with feedback directly on the need to use the medical 
records  system or involved  in the lessons learned process  as they  were  not directly 
employed by the practice.  

Practice Response: 

• 

 (Pharmacist) was not  known to be  involved  at  the  first  SEA  (Significant 
Event Analysis) but has since participated  in reflective  supervision discussions with 
the  Lead  Pharmacist,  where  she  reaffirmed  her  position  on  not  prescribing  for 
children. 

•  Supervision records provided by 

 (Lead Pharmacist) confirm multiple group 
and individual reviews  between  2021 and 2025, which will now explicitly  include any 
involvement in significant events. 

•  The  policy  further  ensures  that  administrative  staff  follow  standard  processes  to 

reduce  error.  

 
 
 
 
 
 • 

Instant  messaging  is  not  permitted  for  clinical  communication  by  regulation.  All 
communication must be  logged through auditable systems, as per our Queries  and 
Task  SOP.    A  clause  is  visible  on  the  screen  message  stating  this  to  serve  as  a 
reminder.  

Action Taken: 

•  We  have  conducted  a review  of  our Clinical Correspondence  Management SOP 

and Queries and Task SOP (Attachment 1 & Attachment 2).  

•  We  have  reinforced  the  requirement  for  auditable  documentation  across  all 

communication channels. 

4.  A further concern  arose during the course of evidence  from the primary care practice 
manager that a care  navigator may not have a clear  pathway on whom to refer  a task 
or action to, or triage tool to recognise that a reported allergic reaction to a medication 
may  require  urgent  consideration  by  a  doctor  to  assess  any  risk  of  anaphylactic 
shock.  

Practice Response: 

•  Ashton Medical Centre  have  a clear  pathway  of whom to refer  a task to, action and 
triage  tools  that  would  recognise  an allergic  reaction  or  ‘red  flag’ symptom. These 
tools are in the form of guidance sheets which are available to all admin staff at their 
desks, SOPs which are  available  in paper format  and electronic  copies  held on  the 
practices drive. All staff are trained on these at induction and regularly reminded.   

•  Clarification:   Phenoxymethylpenicillin  was  prescribed  on  Wednesday  7th 
December  2022, and the medication was stopped on Saturday 10th December 2022. 
Contact was made by telephone  with the practice  on Monday 12th December  2022, 
approximately two days after  the  last dose  and five  days after  initiation. Given  that 
anaphylaxis typically  occurs  within  minutes  to  hours  of  exposure,  it  is  extremely 
unlikely  that a reaction  requiring emergency  escalation could have  occurred  at this 
point. Delayed onset anaphylaxis is exceedingly  rare and would not typically present 
more than 24 hours after the last exposure to the allergen.  

•  All  clinical tasks must be completed  same day  where  possible, with oversight  from 

the Practice Manager and Assistant Practice Manager. 

5.  No evidence  to explain: 

a.  how a patient telephoning the practice and being answered by the call centre 

would be referred  to the urgent triage doctor on duty at the practice. 
b.  whether  a list  of clinician competencies  and whom to refer  tasks to was 

held  

c.  Care Navigator training  
d.  Algorithms or policies that apply to assist care navigator / call handlers at 

a centre  which is not located within the doctor surgery.  

 
 
 
 Practice Response:  

•  All  staff  working in  the  contact  centre  receive  the  same induction  and  training  as 
those based within our practices. They are very  much part of our team. This includes 
training  in  care  navigation, immediate  and  emergency  procedures,  and  other  key 
operational protocols.  

•  The  nature  and  skills  of  our  care  navigator  is  consistent  with  the  vast  majority  of 

doctors surgeries in the UK, regulations and contract requirements. 

• 

•  Contact  centre  staff  have  access  to  real-time  information via  OneNote,  a  visible 
system which contains essential details specific to each practice they support - such 
as the availability and competencies of clinicians. 
In  addition,  all  call  handlers  are  provided  with  relevant  policies  and  procedures, 
including  those  for  care  navigation,  our  children’s  access  policy,  protocols  for 
identifying  and  managing  immediate  and  emergency  conditions,  and  emergency 
escalation processes. 
If an urgent call  is received  and no appointments remain available, the  call handler 
will contact the practice  directly to seek a suitable solution. 

• 

•  Please find attached evidence  to support the processes followed including:  

Care Navigation Training & Information (Attachment 3) 
Practice  crib sheet (Attachment 4) 
Call Handler Induction (Attachment 5) 
Conditions & Exclusions for referral to pharmacists (Attachment 6) 
Chest Pain Protocol (attachment 7) 
Emergency Handling Flowchart (Attachment 8) 
Immediate & Life Threatening Conditions Protocol (Attachment 9) 

Action Taken: 

•  We  have  a quarterly  audit, reviewing  care  navigator  decisions and task completion 

checks.  

•  SEA reviews will include retrospective  involvement for newly identified staff. 

6. These issues are important as I had no reassurance that an administrative member of 
staff who spoke with a patient contacting the practice, had a clear pathway or guidance 
on whom the required task should be referred  to.  

Practice Response:  

•  SSP Health has a Clinical Correspondence Management SOP and a Queries and Task 

SOP (Attachments 1 & 2) 

•  All  staff members  have  a  yearly  appraisal with their  line  managers. The  appraisals 
allow the line managers to identify any areas which the staff member or manager feel 
additional training may be required and therefore to implement a plan/performance 
review. 

 
 
 
 •  We have checked  the individual’s training record and it was up to date, but we have 

actioned a further update of the training for them. 

SSP Health and Ashton Medical Centre are committed to patient safety and will 
reinforce the following ongoing actions: 

•  We  reviewed  the  clinicians’ capabilities  matrix  accessible  by  all  staff, this  will  be 

further reviewed  by June 2025. 

•  Audit  trail  reinforcement:  All  communication  involving  clinical  requests  must  use 
auditable  systems  (e.g.  EMIS  tasks)  —  screen  messages  have  been  categorically 
banned for clinical referrals. 

7. Instead, the task could be allocated using judgement (although as above, guidance to 
apply this was not clear) to a clinician who could not in fact assist, which occurred  in 
this case. The jury who heard the inquest found that there was a missed opportunity to 
review  the antibiotics, which was not causative in this case. In my opinion, there  is a 
risk  that  an urgent  need  for  appropriate  clinical  referral  may  not  occur  in the  above 
circumstances.  

Practice Response: 

•  Our well-embedded  organisational policies suggest that the request was likely made 
to  obtain  an  alternative  medication  following  an  adverse  reaction  to  the  original 
antibiotics. 

•  Based on  the  notes  recorded  at  the  time, it  appears  that  the  nature  of  the  patient 
request was specifically for an alternative antibiotic, rather than for an appointment.  
•  The pharmacists manage prescription requests  changes for adults not  children, on 
this occasion the call-handler  sent it through to the pharmacist.  All staff have been 
reminded of the process to follow with training reinforced. 

•  Our Access  for Children  Policy is designed  to ensure  that  all appointment requests 
for children are handled promptly and appropriately. In this case, we don’t believe that 
there was a request for an appointment.  

•  All  care  navigators  and call handlers  receive  thorough training on this policy  during 
their induction and at regular intervals throughout the year to support consistent and 
safe practice. 

Conclusion 

We  acknowledge  the  deeply  tragic  circumstances  of  Hailey’s  death  and  note  the 
concerns raised about missed opportunities for earlier review and intervention. We hope 
that  our  responses  to  each  concern  have  provided  reassurance  —  both  that  systems 
were  in place at the time and that they have since been reviewed  and strengthened. 

 
 
 We also note that you concluded  that  the areas of concern  that you highlighted did not 
contribute  to  the  death  in this case. As such, we  would  ask you to consider  whether  a 
Regulation 28 Report is appropriate in these circumstances. 

We remain committed to ongoing quality improvement and have already implemented a 
number  of  actions  to  strengthen  oversight,  clarify  clinical  responsibilities, and  ensure 
clear, safe pathways for all staff involved in patient care. 

Should further  clarification  be  required  or  additional documentation  be  requested,  we 
would be pleased to provide it. 

Yours sincerely, 

Director of Clinical Operations 
SSP Health