Thomas Mallinson

CumbnaHealth

20 th August 2025

To 

Or Nicholas Shaw

Dear Dr Shaw

Coroners Regulation 28 Report
Patient: TM
DOB: 05/03/1945
Date of Death: 23/11/2024

I am responding to the Regulation 28 Report to prevent future deaths as outlined in your letter
of the 30/6/25

The Regulation 28 relates to the case of the late Thomas Mallinson who died on the 23/11/24.

The summary of matters of concern as documented is below:

To Cumbria Health (CH) - Thomas's case was sent electronically to the service, marked for 2-
hour attention. I  appreciate why  this did  not  take place as  it  was  impossible for clinicians on
night  duty  to  triage a  large  number  of  calls  waiting while  actually visiting and  treating their
caseload. I  note  a  new  "OPEL” system has  since been  instituted to  try  to  escalate and  get
extra help as the number of  calls waiting increases, but where will these extra resources come
from overnight? I am also concerned that the referral from NWAS came as a result of  a 999-
emergency phone call but  there  seemed to  be  no way  of  telling NWAS  that  the  call had  not
been dealt with and (presumably) passing responsibility back to them. As  referred to above
where does responsibility lie?

I have responded taking each concern separately

1.  At inquest and in my  statement, I outlined a new updated escalation policy (attached)
Within this policy there are steps to be taken to request extra clinical triage assistance
The Control Room will send a text out to Clinicians but there is no requirement for any
of the receiving Clinicians to respond to the request  There are no financial constraints
(within reason) to this part of the escalation policy  Getting Clinicians to work extra over
night shifts is understandably challenging, but we do find that some evening Clinicians
are  able  to  extend their  shifts into  the  early  hours  We  therefore do  our  best  to  add
extra resources where  we  can  at  times  such  as  those  in  November 2024  where we
know  there  was  pressure  on  all  system  partners  (particularly  NWAS  and  the
Emergency  Departments)  due  to  the  high  number  of  respiratory  cases  in  the
community  It is  also important to note  that  at  that  time there  was  no  winter pressure

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CumbriaHealth

funding available to support the system which in previous years has come in the form
of  funding  for  additional  Out  of  Hours  staffing  and/or  the  setting  up  of  community
Respiratory  Infection  hubs  to  reduce  pressure  in  the  daytime  for  North  Cumbria
practices and ourselves. These were commenced but not in the period in question.

In terms of the updated policy, we have put in place a clear process for managing calls
that we cannot deal with overnight to reduce the risk of simply handing them all back
to the daytime GP practices (page 13 in Clinical Operational Policy).
We now provide a  welfare call to patients in the overnight period in whom we have
breached their response times. If there are concerns of deterioration  then the case is
escalated to  a  Clinician as priority. As discussed at  inquest we  will be  adopting  an
automated  text  system  to  do  the  welfare  checks  with Adastra  (our  patient  record
software provider) when it becomes available which we understand will be by the end
of the year.

2.  The responsibility  for  the  case  of  TM lay  with  CH  after  it  had  been passed  to  our
organisation  We held a joint case review with NWAS, and they stated that they can
get over 200 such calls daily across their area (999 triage that come directly to CH with
no allocation of an ambulance) and policing such calls would not be possible  Once
the case comes into the CH system it sits  with us  as responsible organisations. As
documented in my  statement and at inquest I acknowledged that the triage volume
made it challenging to manage ail the cases that came into CH that period. CH has no
cap on its capacity and if the demand outstrips the capacity our actions are focussed
on risk mitigation which the updated policy addresses.

In other case types we receive from NWAS (those cases that have been allocated a
Category 3 or 4 ambulance that requires revalidating to see if the case can be dealt
with by primary care and not need an ambulance) there is a robust system for safety
netting. The case remains visible to NWAS. If the time response from CH breaches (a
Category 3 response from CH is 30 minutes and a Category 4 is 60 mins), then the
CH Control Supervisor will automatically hand these cases back to NWAS. There is an
additional  safety  net  which  involves  NWAS  checking  that  the  case  has  also been
addressed within those timelines and they will see if CH has not managed the case
(which may include handing back to them). NWAS would in such cases contact CH to
get an update on the situation.

Other actions taken so far
1.  CQC have been informed of the receipt of the Regulation 28 and discussions have

taken place

2.  The  ICB  have  been  informed  of  the  receipt  of  the  Regulation  28.  I  have had
meetings with their quality team looking at how we manage the “shoulder time" at
the  daytime  practice/Out  of  Hours  interface  These discussions  are  ongoing as
currently  there is no  formal agreement on how cases are managed  and I have
raised  the  possibility  with the  ICB  about  an  MOU  with  all practices  that  would

4 W&vell Dr, R o s e M l  industrial Estate. CerirsleCAI 2SE

01228 514830  on rofl ice@cumtjneheanh.nhs.uk
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 CumbriaHealth

enable both parties to manage the risk of handing over cases to each  other.  Part
of this was a meeting with the Chair of the LMC on the 13/8/25

3  The  ICB  have  arranged  a  SUI  meeting  with  the  daytime  practice  in  question

leading  This has not happened as yet but is planned for September 2025.

In  summary, the  systems involved in dunng the period of time  for  TM did function in that  the
case was sent correctly to CH, but our workload outstripped our capacity to deal with the case
in the response time required. We did attempt to contact the patient's wife at approximately 6
am but the Clinician was called way to what  was deemed a more urgent case

Our actions have centred on mitigating this risk to prevent such events happening again and
we  continue to work  collaboratively with the  ICS on  managing the  challenges of the winter’s
clinical pressures.

I would be happy to provide any  clarification if needed.

Yours sincerely

Medical Director

4 Wavell Dr, RosehiU Industrrai Esiere. Carlisle CAI  2SE
01 228 514830  cn.olfice@cunwianefllth nhs uk

AeciitjUiC nEnfUicMJ S Wftiet 

r pan,  01  1117

Department
of Health &
Social Care

Dr Nicholas Shaw
HM Coroner s Office
Fairfield
Station Road
Cockermouth
Cumbria
CA13 9PT

Dear Dr Shaw,

Minister of  State for Health (Secondary Care)

39 Victoria Street
London
SW1H OEU

12th September 2025

Thank you for the Regulation 28 report of 30 June sent to the Secretary of State for Health
and Social Care regarding the death of Thomas Raymond Mallinson.  I am replying as the
Minister with responsibility for urgent and emergency care

Firstly, I would like to say how saddened I was to read of the circumstances of Mr Mallinson
death, and I offer my sincere condolences to his family and loved ones.  The circumstances
your report describes are concerning and I am grateful to you for bringing these matters to
my attention,

Your report raises concerns of initial GP handling of the incident, high demand and
communication issues between GP and 999 services, and information transfers between
NHS111 and 999 in the North West.  I understand that the SSP Health, Cumbria Health,
and North West Ambulance Service should be responding to these respective concerns in
due course.  You also notified this case to the Secretary State in the context of an
’overcomplex system’ and the development of the 10-Year Health Plan. This response
provides you an update in relation to this Plan and our work to improve urgent and
emergency care (UEC) services

The Government is clear that patients should expect and receive the highest standard of
service and care from the NHS.  The Government also accepts that the NHS's urgent and
emergency care performance has been below the high standards that patients should
expect in recent years.  We have been honest about the challenges facing the NHS and we
are serious about tackling the issues; however, we must be clear that there are no quick
fixes.

Building an NHS fit for the future is one of the Government’s five missions.  I would like to
assure you we are committed to continuing to improve NHS performance, to ensure all
patients can access the right care first time, and in a timely manner.

In June 2025, we published our 10-Year Health Plan which sets out how we will reform the
system, including UEC care services, with a key focus on shifting urgent care into the
community through new Neighbourhood Health Services.  The 10-Year Health Plan

 focusses on ensuring three big reform shifts in the way our health services deliver care.
First, from  hospital to community' to bring care closer to where people live.  Second, from
'analogue to digital’ with new  technologies and digital approaches to modernise the NHS,
and third, from ‘sickness to prevention’ so people spend less time with ill-health by
preventing illnesses before they happen.

The plan also commits to a  whole-system reform by creating a new NHS  operating model,
ouicomebased funding, integrated digital records, and personalised care plans, ensuring
services work together rather than in isolation. It aims to reduce overcomplexity through
system-wide working and joined-up pathways. With respect to clinical neglect, the plan
outlines a  commitment to a new era of transparency, improved quality of care for all, and
stronger inclusion of patient and staff voices. This effort aims to address and prevent
unnecessary suffering caused by healthcare failures and broader issues within the NHS.

Regarding UEC  services, we  published our 
on 6  June 2025  which sets out a fundamental shift in delivery, driving collaboration across
the system to deliver improvements that will see  the biggest impact on UEC  performance.
The Plan will:

.<  to

, 

]■ 

■ ■ ■ >:(cid:127)' 

(cid:127)  Commit to  implement the  recommendations from  the  NHS  111  review  to make  the

service quicker and simpler to navigate.

(cid:127)  Undertake  and  implement  the  findings  of  an  evidence -based  clinical  review  of
categorisation, with the aim of improving the clinical triage of 999 calls, by expanding
overnight support for 999 call handlers and clinicians to provide urgent in-home care
for clinically assessed patients  with follow-up services available the next day.

>  Provide almost  £450  million  of  capital investment  for  Same  Day  Emergency  Care,
Mental  Health  Crisis  Assessment  Centres  and  new  ambulances,  avoiding
unnecessary  admissions  to  hospital  and  supporting  the  diagnosis,  treatment  and
discharge on the same day for patients.

(cid:127)  Reduce ambulance handovers to a maximum of 45 minutes, helping get ambulances
back  on  the  road  quicker for patients, and  reduce Category 2  ambulance response
time to 30  minutes on average.
Improve  patient  flow  through  hospitals,  ensuring  at  least  78%  of  patients  in  A&E
departments are seen within 4 hours and reduce the number of patients waiting over
1 2 hours for admission or discharge from an emergency department.

(cid:127) 

The reforms will support putting the NHS  on a sustainable footing so it can tackle the
problems of today and the future.

I hope this response is helpful.  Thank you once again for bringing these concerns to my
attention.

Yours sincerely,

MINISTER OF  STATE FOR  HEALTH

Regulation 28 Response

NHS
Providing NHS services

Carlisle Central Practice
65 Warwick Road

Carlisle
CA1 1EB

Date: 27/07/2024

To Dr Nicholas Shaw
HM Assistant Coroner for Cumbria
Fairfield Station Road

Cockermouth
Cumbria CA13 9PT

Re: Regulation 28 Report -  Prevention of Future Deaths -  Mr Thomas Raymond
Mallonson (Deceased)

Dear Dr Shaw,

Please find below our response to the Regulation 28 report dated 20 June 2025 following
the inquest into the death of Mr Thomas Raymond Mallinson.

Firstly, on behalf of Carlisle Central Practice, I would like to extend our sincere
condolences to Mr Mallinson’s family.

We recognise  the concerns raised as we are fully committed to delivering high-quality,

safe, and compassionate care to all our patients. As discussed during the inquest, while
this tragic case involved multiple services including 111, 999 and the Out-of-Hours, we

would like to assure you that our systems and staff are operating to the highest
standards and clearly demonstrate below that they effective.

As part of the inquest, we conducted a full investigation detailed as follows:

(cid:127)  Monday 18 November 2024: Mr Mallinson's wife called the surgery in the

afternoon requesting an appointment for diarrhoea. This started the previous day
(Sunday 17 November 2024). Reception advised that we had no available

appointments and to call 111 should the symptoms worsen.

 Providing NHS services

(cid:127)  Monday 18 November 2023: According to EMIS records, Mr Mallinson’s wife

called 111 in the evening  Mr Mallinson was eventually seen by the paramedics
who deduced he was not clinically dehydrated  His observations including his
blood pressure, pulse, temperature and oxygen saturations were all normal. Mr

Mallmson 's wife was advised to contact the GP if he was no better.

(cid:127)  Tuesday 19 November 2024: Mr Mattison’s wife called the GP surgery and was

put through to the doctor on the same day. She spoke to 

(GP). At this point Mr Mallinson had been suffering with a two-day history of
diarrhoea, and the GP was advised by Mr Madison’s wife that his vomiting and
abdominal pain were settling. During the inquest it was suggested that 

 should have carried out a home visit  It would not be conventional to

perform a home visit on a patient with such a short history of and improving
symptoms. This is unless there were major concerns about sepsis or hydration,
which there were not. Considering the information to hand, I believe 

followed the correct protocol.

(cid:127)  Wednesday 20 November 2024: Call to 111 was made by Mr Mallinson’s wife,

this was booked on the self-booking system for a GP call back. 111 booked this
into a 17:45 telephone slot at 17:42. The incoming 111 callback requests are

manually monitored by the GP practice throughout the day. Due to the short
timeframe of three minutes between booking and slot time the practice actioned
the query as quickly as practically possible. Unfortunately, no follow up call was
received from 111 to alert the practice to the short notice booking and, from a
practice perspective, 111 should have not booked a slot on such short notice

(cid:127)  Thursday 21 November 2024: Reception staff arranged an outbound triage call
with the GP as per 111*s request. The GP spoke to Mr Mallinson's wife at 15:36

and was advised that he had been admitted to hospital.

(cid:127)  Saturday 23 November 2024: Mr Mallinson sadly passed away on the Intensive

Care Unit at Cumberland Infirmary Carlisle.

Actions taken by me:

(cid:127) 

I reviewed the care navigation process of this case. Considering the symptoms

and their duration, the call handler and GP acted appropriately.

(cid:127) 

I conducted an audit of all cases of diarrhoea, vomiting and gastroenteritis in the
months of May and June 2025. It was ascertained that no missed opportunities

were identified, and every case concluded with the best possible outcome.

 The GP practice have taken the following actions as part of our continuous training:

(cid:127)  Continue to reinforce training for reception and call navigation teams.

(cid:127)  Continue to do monthly significant event analysis review meetings to team

reflection and learning.

Providing NHS services

Additionally, as is usual, their formal training is recorded as part of our ongoing

competence framework, with refresher sessions delivered regularly. Our regular

telephone audit confirms our staff handle calls in an appropriate manner and direct

patients to alternative services where necessary. For example, the telephone audit was

carried out on calls taken between 1 May 2025 and 1 July 2025. The results show that

96% of calls taken were appropriately triaged with only 1 call failing to refer to other

services.

For further support, a structured mentorship system exists within the team to help less

experienced reception staff. Doctors are accessible for same-day clinical triage where

concerns are raised by reception.

 (GP) spoke to Mr Mallinson’s wife on the third day of his illness.

At the time he was reported to be eating and drinking, with settled abdominal

symptoms. You felt that there may be an element of wellness bias and that a face-to-

face appointment or a home visit would have been more appropriate. 

has

reflected in detail on the case, participated in a formal Significant Event Analysis,

engaged in one-to-one clinical supervision with me and undertaken additional learning

in the assessment for gastroenteritis, dehydration and frailty. Considering the indication

from Mr Madison’s wife that they symptoms were improving and the number of patients

that would present with similar symptoms, respectfully, our views differ from yours and

we feel that 

 acted appropriately in this case.

To evaluate current standards of care, I conducted a focused audit on patients with

Gastroenteritis, diarrhoea and vomiting at Carlisle Central Practice between 1 May 2025

and 1 July 2025. Fifty-five patients were reviewed to see whether appropriate clinical

decisions, safety-netting, and escalation pathways were followed. Of the patients

reviewed, 73% were seen face-to-face, with the remainder assessed remotely based on

clinical appropriateness. Notably, high risk patients including those aged over 75,

immunocompromised individuals and children under 5 were managed safely in every

case. The audit clearly demonstrates that the practice has robust and safe systems in

place for managing patients presenting with gastroenteritis. The tragic circumstances of

Mr Matlinson's case are not due to any actions or in-actions of the surgery and  there is

no evidence of a wider pattern of unsafe care at the surgery. We have committed to

repeating this audit annually to ensure continued assurance.

 NHS
Providing NHS services

We also recognise your wider concerns about fragmented care across the NHS
services. During the inquest, we noted that Mr Mallinson's case involved repeated

transfers between 111, 999, Out-of-Hours and the GP surgery. In our view, this case
exemplifies the complexity and lack of clarity that can occur when multiple providers
share responsibility without a single clear point of accountability. We therefore support
your decision to address this Regulation 28 to national stakeholders and would

welcome further national guidance and structural changes to reduce these risks for
vulnerable patients in future.

In summary, when Mr Mallinson’s wife spoke to 
days, his vomiting and abdominal pain had settled and he was eating and drinking.
Considering his symptoms, it would be common practice to manage this case as 

, he had diarrhoea for two

did.

My Mallinson’s family asked for medical help from the Northwest Ambulance Service

who did not arrive, they re-directed the call to 111 instead. The call then sat in the third
party Out-of-Hours GP system for seven hours without any action. At this point if an
ambulance had gone out to Mr Mallinson, it would have significantly increased his
chances of survival.

We are deeply saddened by Mr Mallinson’s death and take this case as a serious
opportunity for reflection and improvement where necessary.

Should you require any additional documentation or evidence please let us know.

Yours sincerely.

Director of Clinical Operations

SSP Health

NHS
North West
Ambulance Service

399 Chorley New Road

Bolton
8L1 5DD

nwas.nhs.uk

Dr Nicholas Shaw

His Majesty's Assistant Coroner

Cumbria Coroners Court

By Email Only

8 September 2025

Dear Dr Shaw

l  write  further to  your  Prevention of Future  Deaths Report dated  30 June 2025, which was issued to  North  West
Ambulance Service ("NWAS") following the conclusion of the inquest touching the death of Mr  Mallinson.

I  am  aware  that  you  will  share  my  response  with  Mr  Mallinson's family, and  I  firstly  wish  to  express my  sincere

condolences to  them. NWAS' core purpose is to save lives, prevent harm and provide services which optimise the
likelihood of positive patient outcomes.

Through the  Regulation  28  report, you  have  requested that  NWAS considers your  matters of  concern  and  have

suggested that  action is taken  to  prevent  future deaths occurring in the  future  By this letter I  will address those

concerns as far as I am able.

1.  There were multiple calls to 111 and 999 in this case. I was told that  there was no alert to a call handler

to Indicate recent contacts for the  same patient with the  same condition which might highlight a need

for more decisive action.

When a call handler receives a call from someone who has been attended by NWAS, either face to face or over the

telephone, within the previous 24 hours, an alert is automatically generated on our Computer Aided Dispatch (CAD)

system. Once the patient's location is confiimed, a 'pop-up box' appears to inform the call handler that a previous

call has been made to that address. If the earlier call remains open in the CAD system, a banner is also displayed to

allow the call handler to view the details of that previous call  Where a call is no longer active, for example following

cancellation, attendance, or onward referral (such as in Mallinson's case), the Emergency Medical Advisors (EMAs)

can view the associated records for that location in the 'previous call' tab on their screen.  The EMAs are empowered

to escalate any concerns regarding a patient to a supervisor and/or a clinician if they have any concerns

I  understand this process was described in oral evidence by  the  NWAS witness, 

 (Clinical Delivery

Manager)  at  the  inquest  hearing,  who  explained  how  the  system  functions  in  practice.  I  can  further  confirm

Delivering the

at the

in the

every time.

 clinicians also have  the  ability to  review  such incidents and can access patient details when this is  necessary  to

support decision making

It  would  not, however, be expected that  call handlers review  all previous calls while managing a new  emergency

call. The call details remain accessible in the  system but, given the time-critical nature of emergency calls and the

structured algorithm  that  must  be  followed, 999  call handlers  would  not  have  the  capacity  to  explore historic

records during live calls.

With regards to  the 111 service, I can confirm whilst there is no  automated alert, our  experience is that  that  the

caller will inform the Health Advisor (HA) that they have previously called, and at this point the HA is able to review

the previous calls and consider escalation, just as their 999 call handler colleagues are empowered to do

i can  provide assurance  that  our  call  handling process  follows the  nationally recognised algorithm of  questions

within NHS Pathways, which is a highly regarded safe and reliable system  Where symptoms indicate a greater level

of  need, this  will  be appropriately flagged, ensuring that  the  patient is assessed and managed according to  their

presenting risk, so any changes in  the patient's condition can be captured by the repeated triage that  would take

place on subsequent calls.

2. 

I  am also concerned that  there is no system that  alerts your control to the  fact that  a 999 (emergency)

case you have passed to another agency has not in fact been dealt with.

In Mr  Mallinson's case NWAS handed over  the episode of care to Cumbria Health on Call (CHOC) in line  with the

established clinical pathway. It is not possible for NWAS to follow up on every call once care has been transferred,

and  the  service  relies  on  the  contractual arrangements  that  are  in  place  with  partner  organisations  to  ensure

appropriate continuity of care.

In this case, Mr Mallinson was referred to community-based care and CHOC accepted responsibility for the referral.

I understand this  was confirmed by CHOC during the  inquest, and there  was no dispute regarding the  transfer of

care.  Once  a  referral has  been  accepted, the  duty  of  care  then  rests  with  the  receiving provider, and  NWAS'

responsibility appropriately ends at that point

There  was  no  subsequent  pass  back  to  NWAS in  Mr  Mallinson's case,  but  if  there  had  been  NWAS also  have

established pathways for these circumstances

3.  A further concern refers specifically to the 111 service. At inquest it  was questioned whether for out  of

hours GP services Cumbria had been better served when calls went to a local control room in Carlisle.

NWAS 111 operates as an advice service, providing guidance and signposting patients to the most appropriate point

of care based on their symptoms and needs.  Any calls that are received into the NWAS 111 service, regardless of

which of our four contacts centres it is received into, would be managed in the same manner  Therefore, a contact

centre in Carlisle would process the calls in the same way we do now and there would be no notable difference.

All calls are handled in the same structured manner, and the outcomes for patients are unaffected by the location

of  the  control centre. Each call  is dealt  with  equitably, ensuring that  all  patients  receive the  same standard of

assessment and advice.

I am  grateful to  you  for  bringing this  matter  to  my  attention and I am  sorry  that  you  felt  it  necessary to  issue a
Prevention of Future Deaths Report to NWAS. If you require any further clarification or information, please do not
hesitate to contact me or the Trust's Deputy Director of Corporate Affairs, Emma Shiner.

 Yours sincerely

Chief Executive