John Kirkman

Professor Paul Marks 
Senior Coroner 
East Riding & Hull Coroner’s Service  
The Guildhall 
Alfred Gelder Street 
Hull  
HU1 2AA 

National Medical Director  
NHS England  
Wellington House 
133-155 Waterloo Road  
London 
SE1 8UG 

22nd September 2025  

Dear Professor Marks,  

Re: Regulation 28 Report to Prevent Future Deaths – John Michael Kirkman 
who died on 27 December 2023.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 8 July 
2025  concerning  the  death  of  John  Michael  Kirkman  on  27  December  2023.  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 is keen 
to assure the family and yourself that the concerns raised about John’s care have been 
listened to and reflected upon.   

Your Report raised the concern that the use of different IT systems across different 
healthcare institutions means that the results of a mental health screening assessment 
carried  out  in  one  part  of  the  country  may  not  be  available  in  another  part  of  the 
country, and that this could adversely influence subsequent assessments. This is not 
unique  to  mental  health  records  and  fragmentation  of  IT  systems  remains  a  risk  to 
patient safety.  

The NHS in England has made significant strides in improving the sharing of clinical 
information across systems, with the National Care Records Service (NCRS) playing 
a  central  role.  This  includes  access  to  the Summary  Care  Record  (SCR)  -  which 
provides  vital  information  such  as  current  medications,  allergies,  and  adverse 
reactions - and the National Record Locator (NRL) - which helps to locate care plans 
and other key documents. These tools are designed to support clinicians in delivering 
safe and informed care, particularly in unscheduled or urgent scenarios. 

The SCR is a national database derived from GP records and is updated automatically 
whenever a GP record changes. It is accessible to authorised staff across the health 
and  care  system  who  are  involved  in  a  patient’s  direct  care,  offering  a  concise 
summary  without  exposing  the  full  record.  This  is  especially  valuable  during 
emergency or out-of-hours care. 

The NRL complements  this  by  indexing  the  location  of  digital  and  paper  records 
across  the  NHS,  allowing  health  and  social  care  professionals  to  securely  retrieve 
information from the source. It reduces duplication and ensures access to the most 
up-to-date  data.  Importantly,  it  also  provides  visibility  into  which  organisations  are 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
  
 currently involved in a patient’s care, enabling timely coordination - particularly in crisis 
situations. 

In  the  context  of  mental  health,  the  NRL  is  especially  impactful.  It  does  not  store 
sensitive data, but instead points users to where documents such as Mental Health 
Crisis Plans can be found. This allows professionals, such as Care Coordinators, to 
gain a longitudinal view of a patient’s treatment history at the point of need. NRL data 
can  be  accessed  via  the  NCRS,  and  users  can  sort  multiple  document  pointers  by 
creation date to find the most relevant information.  

The NRL functionality allows any previous health assessment to be both located and 
seen, however only 17 out of 54 mental health trusts can currently share data via the 
NRL, mainly due to the need for system suppliers to implement technical pointers, but 
also as there is currently limited funding for this development work. Some suppliers 
have  not  participated  in  using  the  NRL  due  to  their  preferences  for  structured  data 
formats. 

NHS  England  cannot  currently  mandate  that  suppliers  undertake  this  work,  but 
significant progress is being made with the Shared Care Records services across the 
country  in  adopting the  NRL,  which  will  increase accessibility  substantially over  the 
next few months. 

Beyond  these  national  services,  NHS  England  is  committed  to  supporting  broader 
clinical record sharing across organisational boundaries. Since 2021, all primary and 
secondary care organisations have been able to share a subset of patient information 
within Integrated Care Board footprints via their local Shared Care Record. The Core 
Information  Standard defines  the  typical  content  of  these  records  and  provides  a 
consistent framework for data sharing. 

Recognising the clinical need for greater interoperability, NHS England has launched 
a national initiative to connect Shared Care Records across England. This investment 
aims to ensure that authorised professionals can access safe, reliable, and accurate 
records,  regardless  of  where  care  is  delivered.  Local  organisations,  including 
participating  NHS  Trusts,  determine  what  additional  information  beyond  the  core 
standard is shared, and individual Trusts are responsible for negotiating data-sharing 
protocols to support enhanced local collaboration. 

We acknowledge the ongoing challenges posed by disparate IT systems, particularly 
in mental health services, where timely access to information can significantly affect 
assessment  and  referral  decisions.  This  is  a  recognised  patient  safety  and  clinical 
quality  issue.  NHS  England  continues  to  develop  solutions  to  address  these 
challenges, including the proposed creation of a Single Patient Record as part of the 
NHS 10 Year Health Plan. It is intended that this record will bring a patient’s medical 
records into once place and will build on existing foundations to support clinicians and 
patients in accessing the information needed to aid clinical decision-making, subject 
to appropriate permissions and privacy safeguards. 

We remain committed to working collaboratively with partners across the health and 
social care system to improve data sharing, enhance interoperability, and ensure that 
patient care is supported by the best possible access to information. 

 Whilst NHS England does not have many details of this case, we have sought to obtain 
further information to support a further review of John’s case. We hope the information 
in  this  response  clarifies  the  existing  systems,  and  confirms  our  intention  to  deliver 
improvements in this area to support clinical outcomes for patients such as John.   

NHS England is also developing a specific framework for delivering personalised care 
and  support  to  adults  and  older  adults  with  severe  mental  health  problems.  The 
framework  will  set  out  the  core  aspects  of  care  for  people  who  require  help  from 
secondary or integrated primary, voluntary, community and social enterprise (VCSE) 
and secondary care mental health services. The framework outlines that all required 
information relating to a person’s mental health assessment and their care and support 
plan  should  be  available  to  all  staff  who  need  it.  This  includes  where  people  move 
between different services across different geographical areas.  

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,  

National Medical Director  
NHS England