Prevention of Future Deaths reports · 2025
Regulation 28 report to prevent future deaths, reference 2025-0232, written 19 May 2025. A coroner writes one of these when an inquest reveals a risk that could cause further deaths unless something changes.
| Date of report | 19 May 2025 |
|---|---|
| Reference | 2025-0232 |
| Deceased | John Charles Spencer |
| Coroner | Edward Steele |
| Coroner area | East Riding of Yorkshire and City of Kingston Upon Hull |
| Category | Community health care and emergency services related deaths |
| Source | judiciary.uk record · original PDF |
| Responses published | 4 |
Text extracted from the PDF text layer. Reproduced verbatim, including the scan's own layout.
ANNEX A REGULATION 28: REPORT TO PREVENT FUTURE DEATHS (1) NOTE: This form is to be used after an inquest. REGULATION 28 REPORT TO PREVENT FUTURE DEATHS THIS REPORT IS BEING SENT TO: 1. Holderness Health, Hedon Group Practice. 2. Care Quality Commission. 3. Royal College of General Practitioners. 4. NHS England. 1 CORONER I am Mr Edward Steele, assistant coroner, for the coroner area of East Riding of Yorkshire and City of Kingston Upon Hull. 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 18 June 2024, I commenced an investigation into the death of John Charles Spencer (“Mr Spencer”), aged 82 years. The investigation concluded at the end of the inquest on 12 May 2025. The conclusion of the inquest was Natural Causes. Box 3 of the Record of Inquest read: John Charles Spencer died on 21 May 2024. Mr Spencer had become unwell on 17 May 2024, insofar as having diarrhoea and vomiting, after eating fish and chips. On 20 May 2024, he had a telephone and a subsequent an in-person consultation with a GP out of hours surgery. Mr Spencer’s past medical history included a right inguinal hernia repair in December 2010. That information was not available on the computer system being used by the GP out of hours surgery and it was not mentioned by Mr Spencer in consultation. The clinical diagnosis, consistent with his presentation, was gastroenteritis and safety net advice was given. Mr Spencer was discharged and found deceased at his home address, circumstances and there was no third party involvement. , the next day. There were no suspicious His medical cause of death was recorded as: 1a Diffuse purulent peritonitis. 1b Small intestine perforation. 1c Recurrent inguinal hernia with obstruction. 4 CIRCUMSTANCES OF THE DEATH Mr Spencer became unwell four days before his death, on 17 May 2024. He was suffering symptoms that were later diagnosed, after a telephone and an in-person consultation on 20 May 2024, as gastroenteritis. When Mr Spencer was assessed by the GP out of hours surgery, including an examination of his abdomen, he had made no complaint in relation to hernia issues. The examination of his abdomen was considered 1 to be consistent with the diagnosis given. In 2010, some 13 and a half years earlier, Mr Spencer had suffered from a right inguinal hernia. This was recorded in his GP medical history. The GP medical history was not available to the GP out of hours surgery. The post-mortem examination report stated that, in the opinion of the Consultant Histopathologist, Mr Spencer died due to a purulent peritonitis (inflammation of the abdominal cavity) secondary to a bowel perforation (rupture). That was caused by a section of the small bowel getting stuck and becoming obstructed within a right inguinal hernia, increasing the pressure within the bowel. Mr Spencer sadly died the day after the consultation, on 21 May 2024. 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 will occur unless action is taken. In the circumstances it is my statutory duty to report to you. The MATTERS OF CONCERN are as follows. – (1) The GP medical history summary, populated by the GP that a patient is registered to, is not always accessible to a GP out of hours surgery. Evidence was given that there are various reasons for this, including the patient not providing consent for the exchange of this information. However, on some occasions, even when a patient has consented, the patient record systems utilised by the GP registered practice and the GP out of hours surgery, insofar as being different computer systems or for whatever other technological reason, prevented the exchange of information into the GP out of hours surgery. In this case, evidence was heard that the GP practice was using the EMIS system and that the urgent treatment centre (GP out of hours surgery) was using SystmOne. That fact caused the GP out of hours surgery to not be able to access Mr Spencer’s GP medical summary. This situation generates a concern that, providing the patient has consented, key medical information may not be conveyed to the GP out of hours surgery which should be accessible to allow the appropriate exchange of medical information to inform what examinations should take place in an out of hours setting. This concern is particularly significant in circumstances where the patient does not say and/or present with the points in the medical history relevant to the GPs determination about what further examinations should occur flowing from the medical history of the patient. 6 ACTION SHOULD BE TAKEN In my opinion action should be taken to prevent future deaths and I believe your organisation has 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 14 July 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: the family of John Charles Spencer, City Health Care Partnership, . 2 I am also under a duty to send the Chief Coroner a copy of your response. The Chief Coroner may publish either or both in a complete or redacted or summary form. She may send a copy of this report to any person who she 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 [DATE] [SIGNED BY CORONER] 19 May 2025 HM Assistant Coroner Edward Steele 3
4 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.
Mr Edward Steele, Assistant Coroner East Riding of Yorkshire & City of Kingston Upon Hull Coroners Service The Guildhall Alfred Gelder Street Hull HU1 2AA 8 July 2025 Dear HM Coroner, Prevention of future death report following inquest into the death of John Charles Spencer Thank you for sending Care Quality Commission a copy of the prevention of future death report issued following the death of John Charles Spencer in which CQC was named as a respondent. Following receipt of your report CQC has been in contact with both the GP practice (Holderness Health) and Out of Hours provider (City Health Care Partnership) to establish the full circumstance surrounding this sad case and action the providers intend to take to prevent recurrence. We have been assured by Holderness Health Centre that Mr Spencer’s hernia repair procedure was correctly coded in his medical record on 30 December 2010. The practice informed us that the usual practice is for a coded procedure to default to 'inactive' after a specified period of time (usually between 3-12 months, but this can be individually set) in circumstances where: a surgical procedure has been a planned procedure, the postoperative recovery period has been completed with no ongoing problems, and the procedure does not relate to another ongoing condition that the patient remains under treatment or surveillance for (for example a cancer, ongoing cardiac treatment). Unfortunately, details of the hernia repair procedure did not appear on Mr Spencer’s summary care record that was accessed by the out of hours service as it was recorded as an inactive problem due to the passage of time since his hernia repair procedure was undertaken. The practice advised that if Mr Spencer had presented to the practice with symptoms relating to the hernia procedure subsequently, the relevant code would have been reactivated as an 'ongoing' episode which would have ensured the information was included in the summary care record which would have been visible to out of hours clinicians via the NHS Spine. Mr Spencer had no attendances at his GP practice relating to his hernia surgery since it was performed in 2010, and other than routine vaccinations, was last by the practice in 2019 for symptoms relating to earwax. The Out of Hours service clinician did access the NHS Spine and Mr. Spencer’s summary care record during his consultation with Mr. Spencer. Unfortunately, due to the reasons listed above this did not include details of the hernia repair procedure and this was not mentioned by Mr. Spencer during the consultation. It is not within the CQC’s role or remit to dictate the computer systems that providers operate or the IT infrastructure in use as this is a commissioning matter and not something we have any direct control over. As CQC is aware that computer systems across healthcare providers are often unable to communicate with each other we have taken steps to mitigate this issue. For example, we ensure that we look closely at how providers deal with incoming correspondence (e.g. letters from secondary care or other health and social care providers), coding, sharing of information with other healthcare providers and patient pathways during our inspection and monitoring activity. We also look closely at how they identify, record and learn from significant events such as this one and were satisfied with the significant event analysis undertaken by City Health Care Partnership in relation to this matter. Holderness Health Centre was last inspected in October 2022 when it was rated as good overall and for all key lines of enquiry. The inspection report reflects that we were satisfied with the systems and processes they had in place to assess, monitor and manage risks to patient safety. This included ensuring that systems were in place to share information with other agencies to enable them to deliver safe care and treatment. At present we have no concerns about the practice. We have not yet inspected the out of hours service provided by City Health Care Partnership as they only registered with CQC under this provider in December 2024. At present we have no known concerns about this service which will be inspected in line with our current inspection priorities. In the meantime, we will continue to monitor the service. I hope this response addresses your concerns and clarifies the role and remit of CQC in relation to this matter but if you have any further concerns or queries please contact the CQC via email at CQCInquestsandCoroners1@cqc.org.uk quoting reference Yours sincerely Operations Manager – SYB1
Head Office Church View Surgery 5 Market Hill Hedon HU12 8JE Tel: 0333 332 4242 Chief Executive Officer Partners Our Ref: 27 May 2025 Hull and East Riding Coroner Officer The Guildhall Alfred Gelder Street Hull HU1 2AA Dear Mr Steele Re: Mr John Spencer Thank you for your report regarding the death of Mr John Spencer, date of birth 19/05/1942. I am writing in my capacity as a GP partner and clinical director at Holderness Health having reviewed Mr Spencer’s clinical records in relation to your concerns. Relating to the matters of concern raised in your report, I can confirm that Holderness Health had a planned clinical IT system migration from EMIS to TPP SystmOne on 13th May 2024, with GP Connect enabled. Management One of the key reasons for choosing to migrate clinical systems was the interoperability with local community systems, where the patient consents to this. GP Connect allows limited access to the medical summary for all healthcare professionals where consent is provided by the patient or in emergency setting. This generally only includes significant active problems, allergies and medication. In this case I note Mr Spencer’s surgery was carried out 14 years ago with no subsequent contacts or symptoms relating to this, so this would not generally be considered as a significant or currently active problem. I hope this information provides the necessary reassurance. Should you provide any further information please do not hesitate to contact me. Yours sincerely GP
Mr Edward Steele
HM Assistant Coroner
East Riding and Hull Coroners Service
The Guildhall
Aldred Gelder Street
Hull
HU1 2AA
Co-National Medical Director
NHS England
Wellington House
133-155 Waterloo Road
London
SE1 8UG
11 July 2025
Dear Mr Steele,
Re: Regulation 28 Report to Prevent Future Deaths – John Charles Spencer
who died on 21 May 2024.
Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 19 May
2025 concerning the death of John Charles Spencer on 21 May 2024. In advance of
responding to the specific concerns raised in your Report, I would like to express my
deep condolences to John’s family and loved ones. NHS England are keen to assure
the family and yourself that the concerns raised about John’s care have been listened
to and reflected upon.
Your Report raises concerns over the interoperability of different computer systems
used in the health system, in this case EMIS and SystmOne, which led to key medical
information not being shared between the registered GP Practice and the urgent out-
of-hours (OOH) treatment centre attended by John.
I am advised by my digital clinical governance colleagues at NHS England that the
SystmOne out-of-hours system, provided by TPP, can be configured to enable access
to the EMIS system. This feature is enabled in many areas in England and is
dependent on local configuration and set up.
The National Care Records Service (NCRS) enables access to the patient’s Summary
Care Record (SCR) which can also be accessed out of hours. In the event that the
patient is not able to provide ‘Permission to View’ their SCR, an emergency access
option is available to clinicians.
The local OOH service would have access to a patient’s SCR either via TPP’s
SystmOne, which includes an integrated SCR viewer, or via the NCRS, which is
internet based, accessible via a web browser, as a standalone service. As a minimum,
the SCR contains important information from the patient’s GP record about their
current medications, allergies and details of any previous reactions to medicines. In
addition, the SCR may also contain ‘additional information’ which includes significant
medical history (past and present), reason for medication, anticipatory care
information (such as information about the management of long-term conditions) and
any end-of-life care information recorded there.
As of 19 May 2025, 88% of the population of England (approximately 59 million
patients) have a SCR with additional Information. It is not known to NHS England
whether the SCR or NCRS was accessed in John’s case, nor what the content of his
SCR was, so we are unable to provide further comment on this matter.
However, in addition to the SCR, there are many different mechanisms that enable the
sharing of GP records which include:
• GP Connect Direct Care Application Programming InterAPIs
• Medical Interoperability Gateway (MiG)
• Shared Care Records (ShCR)
• Local mechanisms for sharing records directly between out of hours and
registered GPs.
NHS England is aware of the challenge in sharing medical records between providers
during the in-hours and out-of-hours period and the variability between areas using
different technologies. We are also aware that use of the NCRS is variable across
different care settings.
We are therefore working across the health system to support greater integration and
awareness of record sharing between in-hours and OOH providers. We are also
working with the ShCR Programme to support wider access to relevant patient
information.
At present, Integrated Care Boards (ICBs) are responsible for commissioning,
implementation and integration of in-hours and out-of-hours primary care solutions.
The newly published Fit for the future: 10 Year Plan for England, which sets out the
government’s plan for healthcare in England over the next 10 years, also sets out a
commitment to give patients ‘a single, secure and authoritative account of their data –
a single patient record – to enable more coordinated, personalised and predictive
care.’
My Regulation 28 Leads for the North East & Yorkshire region have engaged with
Holderness Health on the concerns raised in your Report. We note that their practices,
included the Hedon Group Practice where John was registered, have now migrated
from EMIS to TPP SystmOne, with GP Connect enabled, and that a key reason for
doing so was interoperability between local community systems.
I would also like to provide further assurances on the national NHS England work
taking place around the Reports to Prevent Future Deaths. All reports received are
discussed by the Regulation 28 Working Group, comprising Regional Medical
Directors, and other clinical and quality colleagues from across the regions. This
ensures that key learnings and insights around events, such as the sad death of John,
are shared across the NHS at both a national and regional level and helps us to pay
close attention to any emerging trends that may require further review and action.
Thank you for bringing these important patient safety issues to my attention and please
do not hesitate to contact me should you need any further information.
Yours sincerely,
Co-National Medical Director
(Primary Care)
Mr Edward Steele HM Assistant Coroner East Riding of Yorkshire and City of Kingston Upon Hull Sent by email to: Dear Mr Steele 09 July 2025 Regulation 28 Report to Prevent Future Deaths - touching on the death of Mr John Charles Spencer on the 21 May 2024 I was sorry to hear of the tragic death of Mr Spencer and our condolences go to his family. You have asked us to comment on the matter of concern relating to access of the GP record during the out of hours period, the different computer systems and the technological reasons which prevented the exchange of information into the GP Out of Hours Urgent Care Setting. The Royal College of General Practitioners works to improve patient care by encouraging the highest possible standards in general medical practice by supporting members, setting standards, providing education and training promoting research and advocating and representing the College. We recognise that in this individual case that the standards of care fell short, in part relating to the lack of interoperability between General Practice IT systems. In this case there were two different clinical EPR (electronic patient record) systems, the system used to record the patients GP record (EMIS) including the GP medical summary and the system used to record Out of Hours record (System One). We recognise that the GP Practice ‘Holderness Health’ have written to you confirming that they had a planned clinical IT system migration from EMIS to TPP System One on the 13 May 2024 (see letter dated 27 May 2025). This planned migration, had it occurred, could have enabled the sharing of records through GP Connect and avoided the tragic circumstances. GP IT systems have existed since the 1970s, however since 1990 there was an exponential growth in the number of practices using computerised systems leading to 100% of practices being computerised by the end of the century. General Practice has a role in coding and summarising information from other parts of the health system including hospitals who often still share paper records rather than an electronic records. The GP summary held by in hours General Practice contains one of the most comprehensive health records in the world. Royal College of General Practitioners 30 Euston Square, London, NW1 2FB Tel: 020 3188 7400 | info@rcgp.org.uk | rcgp.org.uk Registered Charity Number 223106 | Patron: His Majesty King Charles III The innovation in General Practice IT systems has been led partly by a government strategy to create a Plurality of GP IT Providers by increasing the diversity in the marketplace through NHS frameworks like the GP IT Futures Framework and more recently the Tech Innovation Framework. The new Tech Innovation framework has even brought in a new provider into the marketplace in the last few weeks called Medicus Health. It is therefore not possible for all GP IT systems across both the in and out of hours period to be the same. Recognising that there would be patient benefit to other areas of the health system such as the Hospital Emergency Departments for access to the GP Summary work has been carried out to provide interoperability. This work currently falls under NHS England who own the dedicated Interoperability strategy as well as GP Connect which is a new national service which enables healthcare staff to view GP patient records significantly improving data sharing between General Practice and other parts of the NHS. It is recognised that as technology progresses the sharing of records improves but within a robust information governance structure and data sharing agreements. The RCGP is aware of the issues of Interoperability and has a Health Informatics group which acts as an advisory group but also works together with the British Medical Association to form the Joint GP IT Committee (JGPITC). This committee represents the view of GPs from across the four nations and influences negotiations and discussions with NHS England and other national bodies. Although the EPR records for out of hours services have improved leading to improved safety through the continuity of the GP record by individual providers (originally highlighted by the case of Penny Campbell 20 yrs ago), there is still more progress needed by the whole health system to share records more widely. As a College our action shall be to highlight this tragic case to our health informatics group so they can use it to influence discussions with NHS England. It is important that the area of Health informatics is not lost with the reorganisation of NHS and that the government both prioritise and progress action in this work. We shall also highlight your concerns to The Professional Record Standards Body (PRSB) who are dedicated to the development and implementation of health and care information standards and for whom this area on interoperability is relevant. Yours sincerely Honorary Secretary
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