Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0206, written 25 Apr 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 25 Apr 2025 |
|---|---|
| Reference | 2025-0206 |
| Deceased | Richard Moss |
| Coroner | Jonathan Heath |
| Coroner area | North Yorkshire and York |
| Category | Community health care and emergency services related deaths |
| 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 (1) REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Townhead Surgery 1 CORONER I am Jonathan Heath, Senior Coroner for the coroner area of North Yorkshire and York. 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 04 June 2024 I commenced an investigation into the death of Richard James MOSS aged 72. The investigation concluded at the end of the inquest on 09 April 2025.The cause of his death was 1 a) Myocardial Infarction 1b) Coronary Artery Thrombosis. The conclusion of the inquest was Natural Causes. 4 CIRCUMSTANCES OF THE DEATH On 15 March 2024, Richard James Moss attended his General Practitioner with intermittent chest discomfort. He was properly treated, and the intention was to refer him to the Rapid Access Chest Pain Clinic. He was found deceased on 29 May 2024. The cause of his death was 1a) Myocardial Infarction 1b) Coronary Artery Thrombosis. At the time of his death the referral had not been actioned, but it cannot be determined that the outcome for Mr Moss would have been different. 5 CORONER’S CONCERNS During the course of the inquest the evidence 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 MATTER OF CONCERN is as follows: When a referral document is completed by a medical practitioner at this practice, an alert to colleagues to action the referral will only be sent if the practitioner manually selects the option to do so rather than every referral document completion automatically generating an alert. OFFICIAL - SENSITIVE 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 20 June 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: (Family) (Family) (Medical Protection) 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 other 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. 9 25 April 2025 Jonathan Heath OFFICIAL - SENSITIVE
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.
From: Sent: 13 June 2025 20:11 To: Coroners Admin Subject: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss Jonathan Heath O(cid:431)ice of HM Senior Coroner for North Yorkshire and York The Coroner’s Court 3 Racecourse Lane Northallerton DL7 8QZ Dear Sir, I am writing in response to your Report to Prevent Future Deaths issued 25 April 2025 in relation to the inquest hearing for the late Richard James Moss. You expressed concern that when a GP completes a “Rapid Access Chest Pain Clinic” referral form, that there is no automatic alert to colleagues to complete the referral process. When the referral was done for Mr Moss, the GP was required to manually trigger an alert to the secretarial team, and in Mr Moss’s case this was not done. It is important to note that the Rapid Access Chest Pain referral form and the clinical IT system in which it sits are not owned or controlled by the GP surgery. The cardiology department at Airedale hospital, together with the IT department are responsible for the form content and referral process. We held a significant event meeting 23.07.24 for the GPs and Practice Manager. The purpose of the meeting was to determine whether anything had gone wrong with our referral process, and if so, could we prevent a recurrence. We determined that the Rapid Access Chest Pain referral form sits within an IT software system called “GP Assist.” GP Assist is used by all local GP surgeries to generate referrals to secondary care. In this case “GP Assist” gives the referring GP the option to either 1) Open the document and send a task (to secretaries) at the same time, or 2) Open the document only (no task generated unless done so manually). Dr Kerry used option 2) and once the referral form had been completed there was no automatic reminder to alert the secretarial team. Following the significant event meeting we approached GP Assist to ask that they remove option 2) from the clinical system. We felt this would be safer, as it would force GPs to consider sending an alert. At the time GP Assist said this was not possible. Their reason was that some GP practices prefer a system without automatic alerts. We have had to develop our own internal safety system. This consists of a reporting system that searches all our patients for any unsent Rapid Access Chest Pain Referral. We run the report every two weeks. We have been using this since last year. So far, we have not detected any other missed referrals. We have raised this matter at a meeting held between the practice and representatives from NHS West Yorkshire Integrated Care Board on 06 June 2025. The outcome from this meeting is that we are escalating the matter to ICB level in the hope that other practices are made aware of the potential problem, but also that the referral process can be made safer by the IT team. I enclose a copy of the letter that I have sent the ICB. Yours sincerely GP Partner Townhead Surgery Settle North Yorkshire BD24 9JA T: 01729 822611 ********************************************************************************** This message may contain confidential information. If you are not the intended recipient please: i) inform the sender that you have received the message in error before deleting it; and ii) do not disclose, copy or distribute information in this e-mail or take any action in relation to its content (to do so is strictly prohibited and may be unlawful). Thank you for your co-operation. NHSmail is the secure email, collaboration and directory service available for all NHS sta(cid:431) in England. NHSmail is approved for exchanging patient data and other sensitive information with NHSmail and other accredited email services.
Subject: FW: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss Sent: From: Coroners Admin 14/07/2025, 10:44:20 From: Coroners Admin Sent: 14 July 2025 10:39 To: ' Subject: RE: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss (TOWNHEAD SURGERY)' Good Morning Thank you for the update received on the 1st July, which the Coroner has acknowledged. Kind Regards Support Officer to Senior Coroner (TOWNHEAD SURGERY) From: Sent: 01 July 2025 09:58 To: Coroners Admin < Subject: Re: HM Coroner Prevention of future Deaths Reg 28-Richard James Moss > Please can I provide a further update regards preventing future deaths. We raised the IT issue with our ICB, and they have confirmed that changes have been made to the chest pain referral pathway for all GPs in the area. It is now no longer possible to complete a referral without simultaneously sending a message to secretaries to ensure the referral is completed. GP Partner Townhead Surgery Settle North Yorkshire BD24 9JA
See every Prevention of Future Deaths report matching Community health care and emergency services related deaths, and how often a new one appears.
What would an alert for this have sent me? Search the full text
Free to try — the preview shows the real matches and how many arrived in the last 12 months. Your first email alert is free.
These reports are published by the Chief Coroner's office at judiciary.uk and are © Crown copyright. The text here is reproduced from the published PDF so it can be searched. If something on this page is wrong, or you are a person named in it and want it reviewed, email drcjar@gmail.com and we will act promptly.