Myles Scriven

Mr Crispin Oliver, Assistant Coroner  
West Yorkshire Western Coroner Area  
H.M. Coroner’s Court  
Cater Building  
1 Cater Street  
Bradford  
BD1 5AS 

19th September 2025 

Dear HM Coroner,  

Prevention of future death report following inquest into the death of Myles 
Edward Scriven (

Thank you for sending the Care Quality Commission (CQC) a copy of the Regulation 
28: Report to Prevent Future Deaths, which was issued following the death of Myles 
Edward Scriven, in which CQC was named as a respondent.  

Firstly, we would like to extend our condolences and sympathies to Myles’ family and 
friends. 

CQC has a process to follow whenever a Regulation 28 report is received, including 
where CQC is named within the report. 

In line with CQC’s enforcement and internal specific incident guidance, policies  
and procedures, a Decision Review Meeting (DRM) has taken place. This initial 
assessment enables CQC to consider and determine any appropriate regulatory 
response. This can include monitoring, inspection and/or civil enforcement action to 
protect service users from ongoing risks; and to assess and determine whether there 
may be reasonable grounds to suspect that a service user may have sustained 
avoidable harm or been exposed to a significant risk of avoidable harm, as a result 
of registered person failure to provide safe care and treatment. 

Specifically in relation to Calderdale and Huddersfield NHS Foundation Trust, the 
local CQC operational team have held an initial DRM where relevant information 
from stakeholders and internally held information within CQC is shared and a course 
of action is decided on. Following this we have contacted the Trust to inform them 
we have received the Regulation 28 report, and they are sending us further 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 
 information about the full circumstances surrounding this sad case and the actions 
they have taken, or are planning to take, to prevent reoccurrence.  

Calderdale and Huddersfield NHS Foundation Trust were last inspected in June 
2018 at a well led level, when it was rated as good overall and for all key lines of 
enquiry. However, given your report into the death of Myles Scriven, and the length 
of time since we last inspected, we are considering our regulatory response following 
the initial DRM which may include carrying out an inspection. Please note this is 
confidential at this stage. The DRM particularly focused on concerns in relation to 
those outlined in your report including: 

•  The impact of mental capacity assessments auditing, the nursing leadership 
walkaround of all wards auditing that LD and autism policies are applied in 
practise.  

•  How the outcomes of any audits were acted on  
•  Taking into consideration that much of the above which is now in place was 

already in place in 2022. But in Myles’s case it had no impact  

•  Specialist staff recommendations were not followed up 
•  The culture throughout the staff was not reflective of the specialist’s advice  

In response to the known challenges faced by people with a learning disability and 
autistic people when they access health care services, as well as feedback from 
people with lived experience, CQC had already begun a program of work focusing 
on the health inequalities faced by this population group. This includes taking action 
to review how we consider whether Trusts are providing safe care and treatment for 
people with a learning disability and autistic people. Specifically, we are reviewing 
and will update the guidance that we provide for our inspection teams to follow. This 
aims to prompt inspectors to carry out a more thorough assessment than currently 
takes place and gives them the necessary tools to do so. Our regulatory leadership 
teams are leading on this. Additional areas of work in this specific area focus on how 
CQC can work more closely with the Learning from Lives and Deaths -People with a 
learning disability and autistic people program ( LeDeR ) – sharing information and 
building closer links in order to do so more effectively.  

We are also taking steps to ensure our inspection teams have the right support and 
training to review how Trusts provide care and treatment for people with a learning 
disability. 

We are arranging some bespoke upskilling sessions for our secondary care 
inspection teams. This will cover pertinent issues including what people with lived 
experience have told us about issues they have faced when accessing hospital care. 
Further, it will support inspection teams to consider, understand and analyse how 
services are meeting the needs of their population. 

Since the 1st July 2022, all CQC registered health and social care providers have 
been required by the Health and Care Act 2022 to provide training for their staff in 
learning disability and autism, including how to interact appropriately with autistic 
people and people with a learning disability. This should be at a level appropriate to 
their role. 

 
 
 
 
 
 
 
 
 On the 19th June 2025, the Oliver McGowan Code of Practice was published and 
laid before parliament by the Department of Health and Social Care. The code 
commenced on 6th September 2025 and is now legal guidance. The purpose of the 
code is to explain what is meant by training that is ‘appropriate to the person’s role’ 
and to provide guidance on how to ensure all staff receive such training. 

Compliance with the standards set out in the code of practice, is expected to ensure 
that every person receives high quality learning disability and autism training that 
meets their learning needs and is appropriate to their role. Importantly, this aims to 
improve the experiences and outcomes of autistic people and people with a learning 
disability when they access CQC regulated health and social care services. This 
means that CQC registered providers must ensure that they provide each member of 
staff with training that meets the standards set out in the Code in order to deliver the 
best possible outcomes. CQC will use the Oliver McGowan Code of Practice when 
considering whether providers are meeting the requirements of the regulation. 

Throughout September, the CQC’s autistic people and people with a learning 
disability team will be running bespoke upskilling sessions on the mandatory training 
requirement and code of practice with the aim of equipping inspection teams with the 
knowledge and skills they need to regulate this requirement effectively and 
consistently. Specifically pertinent to the case of Myles Scriven, the code of practice 
enables both providers and CQC to consider the extent to which learning is put into 
practice.  

I hope this response addresses your concerns and clarifies the role and remit of 
CQC in relation to this matter. If you have any further concerns or queries, please 
contact us via email 

. 

Yours sincerely 

Operations Manager 
West Yorkshire, Network North.

Mr Crispin Oliver, Assistant Coroner  
West Yorkshire Western Coroner Area  
H.M. Coroner’s Court  
Cater Building  
1 Cater Street  
Bradford  
BD1 5AS 

17 September 2025 

Dear Mr Oliver,  

Prevention of future death report following inquest into the death of Myles 
Edward Scriven 

Thank you for sending the Care Quality Commission (CQC) a copy of the  
Regulation 28: Report to Prevent Future Deaths, which was issued following the 
death of Myles Edward Scriven, in which CQC was named as a respondent.  

Firstly, we would like to extend our condolences and sympathies to Myles’ family and 
loved ones. 

CQC has a process to follow whenever a Regulation 28 report is received, including 
where CQC is named as a respondent within the report. 

In line with CQC’s enforcement and internal specific incident guidance, policies  
and procedures, a decision review meeting (DRM) takes place. This initial meeting 
involves an assessment which enables CQC to consider and determine any 
appropriate regulatory response. This may include monitoring of relevant regulated 
services, carrying out an inspection and/or taking civil enforcement action to protect 
service users from ongoing risks. In addition, we assess and determine whether 
there may be reasonable grounds to suspect that a service user may have sustained 
avoidable harm or been exposed to a significant risk of avoidable harm, as a result 
of registered person failure to provide safe care and treatment. 

Specifically in relation to Dalton Surgery, the local CQC team held an initial DRM. 
Following this they have been in contact with the GP practice to establish the full 
circumstances surrounding this sad case and to request information about the action 
they also intend to take to prevent reoccurrence. They have received the 
information, including an action plan stating the improvements the practice intends to 

 
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
  
 
 make to prevent future deaths and improve how they deliver care and treatment for 
patients with a learning disability and autistic people. 

Dalton Surgery has been inspected once previously, in October 2016, when it was 
rated as good overall and for all key lines of enquiry. At the time of that inspection, 
we specifically reviewed how the service managed the care and treatment of specific 
population groups, this included ‘people whose circumstances may make them 
vulnerable’. The inspection report reflected that we were satisfied with the care 
provided by the practice at that time. This included ensuring that systems were in 
place to share information with other health care professionals to enable them to 
deliver safe care and treatment. However, given your report into the death of Myles 
Scriven, and the length of time since we last inspected the practice, a decision was 
taken at the DRM to carry out an inspection and we are now in the process of 
planning a full comprehensive assessment.  

In response to the known challenges faced by people with a learning disability and 
autistic people when they access primary care services, as well as feedback from 
people with lived experience, CQC had already begun a program of work focusing 
on the health inequalities faced by this population group. This includes taking action 
to review how we consider whether a GP practice is providing safe care and 
treatment for people with a learning disability and autistic people. Specifically, we are 
reviewing and will update the guidance in respect of this, that we provide for our 
inspection teams to follow. This aims to prompt inspectors to carry out a more 
thorough assessment than currently takes place and give them the necessary tools 
to do so. Our regulatory leadership teams are leading on this. Additional areas of 
work in this specific area focus on how CQC can work more closely with the LeDeR 
program – sharing information and building closer links in order to do so more 
effectively.  

We are also taking steps to ensure our inspection teams have the right support and 
training to review how GP practices provide care and treatment for people with a 
learning disability and autistic people. 

We are arranging some bespoke upskilling sessions for our primary care inspection 
teams. This will cover pertinent issues including what people with lived experience 
have told us about issues they have faced when accessing primary care. Further, it 
will support inspection teams to consider, understand and analyse how services are 
meeting the needs of their population. 

Since the 1st July 2022, all CQC registered health and social care providers have 
been required by the Health and Care Act 2022 to provide training for their staff in 
learning disability and autism, including how to interact appropriately with autistic 
people and people with a learning disability. This should be at a level appropriate to 
their role. 

On the 19th June 2025, the Oliver McGowan Code of Practice was published and 
laid before parliament by the Department of Health and Social Care. The code 
commenced on 6th September 2025 and is now legal guidance. The purpose of the 
code is to explain what is meant by training that is ‘appropriate to the person’s role’ 
and to provide guidance on how to ensure all staff receive such training. 

 
 
 
 
 
 
 
 Compliance with the standards set out in the code of practice, is expected to ensure 
that every person receives high quality learning disability and autism training that 
meets their learning needs and is appropriate to their role. Importantly, this aims to 
improve the experiences and outcomes of autistic people and people with a learning 
disability when they access CQC regulated health and social care services. This 
means that CQC registered providers must ensure they provide each member of 
staff with training that meets the standards set out in the Code in order to deliver the 
best possible outcomes. CQC will use the Oliver McGowan Code of Practice when 
considering whether providers are meeting the requirements of relevant regulations. 

Throughout September, the CQC’s autistic people and people with a learning 
disability team will be running bespoke upskilling sessions on the mandatory training 
requirement and code of practice with the aim of equipping inspection teams with the 
knowledge and skills they need to regulate this requirement effectively and 
consistently. Specifically pertinent to the case of Myles Scriven, the code of practice 
enables both providers and CQC to consider the extent to which learning is put into 
practice.  

I hope this response addresses your concerns and clarifies the role and remit of 
CQC in relation to this matter. If you have any further concerns or queries, please 
contact us via email 

Yours sincerely  

Deputy Director – West Yorkshire, South Lancashire and Cumbria

Mr Crispin Oliver  
HM Assistant Coroner  
West Yorkshire (Western) Coroner Area 
HM Coroner’s Court 
Cater Building 
1 Cater Street 
Bradford 
BD1 5AS 

Dalton Surgery  

www.DaltonSurgeryHuddersfield.com 

5 September 2025 

Dear Mr Oliver, 

Re: Regulation 28 Report to Prevent Future Deaths – Myles Edward Scriven 

We write in formal response to the Regulation 28 Report issued to Dalton Surgery on 
17 July 2025, with submission requested by 8 September 2025, concerning the 
tragic circumstances surrounding Mr Myles Edward Scriven (MS). 

Firstly, on behalf of the GP partners and all staff at Dalton Surgery, we extend our 
deepest sympathies to Mr Scriven’s family. We wish to assure you that we have 
taken the concerns raised in the Regulation 28 Report, and the family’s feedback, 
very seriously. Our priority is to ensure that such a situation does not reoccur for 
other patients. 

In this response, we address the three key areas of concern highlighted in your 
notice. To support the GP Partners in comprehensively addressing these issues, we 
have enclosed a detailed action plan. This plan outlines specific measures, assigns 
named accountable leads, includes auditable evidence, and sets clear timescales for 
monitoring through our Bimonthly Practice Protected Time (PPT) meetings. Working 
collaboratively with our ICB colleagues, progress will also be reported to the place-
based Quality Sub Committee and a full review of actions will be undertaken at a six 
month follow up meeting involving key stakeholders. 

Since receiving the Regulation 28 notice, we have implemented a range of actions to 
enhance patient safety, strengthen clinical practice, and embed learning throughout 
the practice. We also provided NHS England (
Quality, Northeast and Yorkshire) with written assurance on 29 July 2025 regarding 
progress in these areas. 

, Head of Clinical 

1.  Understanding and Supporting Patients with Learning Disabilities and 

Autism 

  
 
                                                                                                                          
                                                                                                                             
 
 
 
 
 
 
 
 
 
 
 
 We acknowledge that our practice historically did not have sufficiently 
robust systems in place to ensure consistent, proactive care for patients 
with Learning Disabilities (LD) and Autism. Specifically, there was variable 
awareness amongst staff of the additional challenges faced by these 
patients in expressing symptoms, the need for collateral history from 
carers, and the importance of reasonable adjustments in clinical practice. 

Summary of key actions undertaken: 

a)  Designated three Learning Disability (LD) and Autism champions: a GP, a 
nurse, and an administrative team member. The role of the LD Champions 
will include advocacy and support for patients, improving health outcomes 
and wider primary care engagement. 

b)  All practice staff have completed Oliver McGowan Level 1 training, with 

Level 2 training scheduled for October 15th and 28th 2025. 
c)  New administrative staff receive mandatory LD training before 

commencing duties; locum doctors are provided with LD awareness 
packs. 

d)  Implemented standard reasonable adjustments for patients, including 
extended appointment times, easy-read correspondence, health 
passports, and proactive recall systems. 

e)  Practice Manager received bespoke training on discussing reasonable 

adjustments with patients. 

f)  Engaged with Jessica Atkinson (Strategic Health Facilitator for Kirklees 
Adult Learning Disability) to jointly review the LD register and enhance 
communication aids, recall processes, and patient resources. A follow-up 
visit is planned for October 2025. 

g)  Extended appointment length for LD and Autism Health Checks from 45 

minutes to one hour. 

h)  Embedded improved safety-netting practices and clinical tools (CURB-65, 
MEWS, CHA2DS2-VASc) to ensure systematic patient assessments and 
recalls. 

i)  Added patient icons in SystmOne to flag LD and Autism status; employed 

a dedicated coder to maintain accurate records. 

j)  Scheduled Capacity and Consent training for designated GP with DAC 

Beachcroft on 8th October 2025. 

k)  Adjusted invitation scheduling for LD health checks to ensure all patients 

are invited appropriately, with staff trained on tailored invitation 
management. 

These measures reflect both training completion and practical application, 
safeguarding patients with LD and ensuring prioritised, appropriate care. 

The Practice plans to undertake bi-monthly audits of all patients on the LD 
Register to confirm its accuracy and updated care plans and hospital 
passports where necessary. The purpose of the audit is to affirm that the LD 
Register is being used with 100% accuracy and regular audits will continue to 
be carried out. Please refer to the attached action plan for audit details and 
scheduling. 

 2.  Improvement in Recording of Clinical Observations 

We fully acknowledge the Coroner’s concern that the GP consultation on 20 
March 2023 did not include adequate recording of numeric observations (e.g. 
oxygen saturation, pulse, respiratory rate). 

Reflection from GP (also stated during the Inquest) 

“I acknowledge that my consultation record was poor and lacking in important 
details – particularly quantitative values for examination findings. This is not 
usual for my way of working. I am confident that such observations were in 
fact undertaken and were satisfactory, but unfortunately, they were not 
recorded. In light of this, I have changed my practice: I now use internal 
systems and templates to prompt and facilitate proper capture of these values 
in every consultation.” 

Summary of key actions undertaken: 

a)  Reiterated the importance of thorough documentation of vital clinical 

observations during consultations, particularly for acute symptoms such as 
breathlessness, through targeted clinical safety refresher training where 
needed.  

b)  Introduced enhanced triage protocols and promoted face-to-face 

assessments when clinically indicated. 

c)  Reminded clinical staff of documentation’s role in decision-making and 

safety-netting; compliance monitored via audits and peer reviews, detailed 
in the enclosed action plan. 

d)  Implemented consultation templates, digital prompts, Ardens templates, 

and AI-supported dictation/scribing tools to improve accuracy. 

e)  Adopted a low threshold for same-day reviews or A&E referral for patients 

presenting with breathlessness. 

f)  Provided additional training for administrative staff to escalate urgent 

symptoms promptly. 

g)  Recent case reviews demonstrate effective triage and urgent management 
of patients presenting with breathlessness, including timely admissions 
and diagnoses of pulmonary embolism. 

h)  The practice has recognised the necessity of immediate same-day review 
or direct A&E referral for breathlessness presentations, now standardised 
in our clinical approach. 

The Practice plans to undertake monthly audits of 20 consultations for the 
three months to assess compliance with observation documentation. Our 
target will be 100% compliance consecutively on each occasion. 

3.  Learning from Significant Events and Internal Reviews 

We accept that, immediately after Myles’ death in April 2023, our internal 
review processes were not as rigorous or structured as they should have 
been. While reflection occurred, the depth and documentation of this initial 
review did not fully meet expected governance standards. 

 Summary of actions undertaken: 

a)  Conducted two Practice Protected Time (PPT) sessions in June and 

October 2023 focusing on clinical decision-making, triage, and prevention. 
b)  Held two further Significant Event Analyses (SEAs) in April and July 2025 

to review the case and coroner’s findings. 

c)  All clinical staff participated; 

 acknowledged 
Myles should have been referred to secondary care between 16 – 20 
March 2023 and that the failure to do so made a direct contribution to his 
death. 

d)  Enhanced policies and processes for incident reviews now include clearer 

documentation, minutes, and explicit learning outcomes. 

e)  Promoted an open culture of reporting, reflection, and continuous learning. 
f)  Updated the Practice Significant Event Policy, accessible on Microsoft 
Teams and in hard copy with signed staff acknowledgements, is being 
aligned with the NHS England Patient Safety Incident Response 
Framework (PSIRF) and the Primary Care Patient Safety Strategy for GP 
practices. 

g)  Bimonthly PPT meetings regularly incorporate SEA discussions and policy 

review to reinforce staff understanding. 

Going forward, the Practice will schedule quarterly Learning from Events 
meetings to review SEAs and share learning from both internal and external 
cases to promote shared learning. The first quarterly meeting is scheduled for 
January 2026.This will be in line with the Primary care patient safety strategy 
and Learning from Patient Safety Events (LFPSE). 

This comprehensive approach ensures thorough investigation, learning, and 
sustained improvements in patient safety. 

4.  Support from System Partners and Collaborative Networks 

As a GP practice in Kirklees we: 

a)  Benefit from the Strategic Health Facilitator for Kirklees Adult Learning 
Disability (SWYPFT), providing training and support across local GP 
practices. 

b)  Utilise Kirklees Get Checked Out resources and LD-friendly template 

letters uploaded in SystmOne for consistent communication. 

c)  Following migration to SystmOne, collaborated with the ICB Data Quality 

team to verify and ensure accurate coding of patients with LD and Autism. 

d)  Participate in the Tolson Primary Care Network’s ‘Mondays at the 

Museum’ Creative Health initiative, promoting wellbeing activities in a 
stigma-free environment, actively encouraging patients with LD and 
Autism to engage. 

Dalton Surgery has taken robust and sustained action in response to the Regulation 
28 report. We have strengthened clinical processes, embedded new policies, 
enhanced training, and fostered a culture of transparency and continuous 
improvement. 

 We trust this response and the enclosed action plan demonstrate the significant 
steps we have already taken and that you are assured of our commitment to 
delivering safe, inclusive, and accountable care. We would be happy to provide any 
further information or supporting documentation as required. 

Yours sincerely, 

GP Partners 

Enc:   Action Plan 

Cc: 

 Medical Director, NHS England (Yorkshire and the Humber) 
 Medical Director, West Yorkshire Integrated Care Board 

, Accountable Officer – Kirklees, WYICB 
, Director of Primary Care, WYICB 
, Primary and Community Care Inspector, CQC 

, Head of Clinical Quality, NHS England – NE and Yorkshire

Mr Crispin Oliver  
HM Assistant Coroner  
West Yorkshire (Western) Coroner Area 
HM Coroner’s Court 
Cater Building  
1 Cater Street 
Bradford 
BD1 5AS 

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

2 September 2025  

Dear Mr Oliver, 

Re: Regulation 28 Report to Prevent Future Deaths – Myles Edward Scriven 
who died on 16 April 2023.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 14 July 
2025 concerning the death of Myles Edward Scriven on 16 April 2023. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Myles’ family and loved ones. NHS England is keen to assure 
the family and yourself that the concerns raised about Myles’ care have been listened 
to and reflected upon.   

Your Report raises concerns that Myles’ GP surgery were ignorant of the regulatory 
requirements and reasonable adjustments required for Myles in light of his learning 
disability and autism, that they failed to record numeric observations properly, and that 
they failed to undertake a detailed and rigorous internal review for learning purposes 
following Myles’ death. 

Learning disability information 

A learning disability is defined by the Department of Health and Social Care (DHSC) 
(2001) as a significantly reduced ability to understand new or complex information, to 
learn new skills (impaired intelligence), with a reduced ability to cope independently 
(impaired social functioning), which started before adulthood. 

A learning disability is different for everyone. The degree of disability can vary greatly, 
being  classified  as  mild,  moderate,  severe,  or  profound.  In  all  cases,  a  learning 
disability is a lifelong condition and cannot be cured. 

A learning disability is different to a learning difficulty, which is a reduced ability for a 
specific form of learning and includes conditions such as dyslexia (reading), dyspraxia 
(affecting physical co-ordination), and attention deficit hyperactivity disorder (ADHD). 
A person with a learning disability may also have one or more learning difficulties. 

Training requirements  

Under  the  Health and Care  Act  2022,  since 1  July  2022,  Care  Quality  Commission 
(CQC)  registered  providers  have  been  required  to  ensure  that  their  staff,  including 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
  
 GPs, receive specific training on learning disability and autism appropriate to their role. 
On  19  June  2025,  NHS  England  published  a  Code  of  Practice  which  sets  out 
expectations for training content and delivery. This training helps to ensure that staff 
have the right knowledge and skills to provide safe and informed care. 

To support this, we have been rolling out the Oliver McGowan Mandatory Training on 
Learning  Disability  and  Autism  to  the  health  and  adult  social  care  workforce.  The 
training includes content on understanding learning disability and autism, frequently 
co-occurring conditions, reasonable adjustments, and reflection on own attitudes and 
professional behaviour. Over 3 million people have completed the e-learning package 
which is the first part of Oliver’s Training, and is freely available on the Elearning for 
Health Hub.   

Health checks and reasonable adjustments 

NHS  England  is  working  with  the  Royal  College  of  GPs  and  other  stakeholders  to 
improve the quality of annual health checks for people with a learning disability and 
will be publishing a framework for annual health checks in coming months. 

In providing the learning disability health check scheme, GP practices are encouraged 
to provide a more proactive and coordinated approach to care, improving liaison with 
carers and secondary care, and developing a health action plan with individual patients 
in response to their needs.  

The  Equality  Act  2010  places  a  legal  duty  on  health  and  care  services  to  make 
changes to their approach or provision to ensure services are as accessible for people 
with  disabilities  as  they  are  for  everyone  else.  NHS  England  has  introduced  the 
reasonable adjustment digital flag to enable health and care services to record, share 
and view details of the reasonable adjustments a person needs to support their care. 

Organisations  are  required  to  use  their  own  systems  and  processes  to  record 
reasonable adjustment needs, and staff e-learning training has been rolled out for all 
health and care staff to support this. 

Accurate recording 

The GP contract requires that accurate patient records are maintained, including for 
patients  with  a  learning  disability.  The  Learning  Disabilities  Health  Check  Scheme 
continues to be offered via the Direct Enhanced Services Directions, to encourage the 
maintenance and updating of learning disability registers and the completion of annual 
health checks and health action plans for each registered patient aged 14 years and 
over on the learning disabilities register. The Investment and Impact Fund continues 
to directly incentivise delivery of annual health checks and health action plans. 

NHS  England  has  also  produced  guidance  for  general  practice  on  Improving 
identification of people with a learning disability. 

ICB contract management of GP practices 

 Integrated  Care  Board  (ICBs)  are  responsible  for  the  commissioning  and  contract 
management  of  GP  practices. ICBs  will  undertake  intelligence  led  and  routine 
contractual  reviews  based  on  a  combination  of  national  and  local  data  sources, 
alongside other soft intelligence, and practice visits to identify practice variation and 
improvement  needs.  NHS  England  publishes  guidance  for  ICBs,  which  includes  an 
assurance framework for contractual reviews. 

As  part of  these  reviews,  NHS  England  would  expect  ICBs  to ensure  GP practices 
have  processes  in  place  for  learning  from  patient  safety  events.  The  national  GP 
contract has introduced new requirements in 2025/26 to ensure practices have regard 
to  the  primary  care  patient  safety  strategy  published  in  September  2024,  and  are 
registered with the learn from patient safety events service (LFPSE) for the purposes 
of: 

• 

recording patient safety events at the practice about the services delivered by 
the  practice,  thereby  contributing  to  the  national  NHS-wide  data  source  to 
support learning, improvement and learning culture. 

•  enabling the practice to record patient safety events occurring in other health 
care settings (for instance if a GP practice wished to record an unsafe discharge 
from hospital). 
individuals recording patient safety events being able to download a copy of the 
record for purposes of supporting appraisal and revalidation. 

• 

GP practices are now required to declare annually their compliance which, alongside 
data from the LFPSE, will support the ICB contractual review processes described. 

Regional learning and improvements 

My regional clinical quality colleagues for the North East and Yorkshire region have 
also been engaging with NHS West Yorkshire Integrated Care Board on the concerns 
raised in your Report.  

The ICB is undertaking a LeDeR review to understand what local learning can be taken 
from  this  tragic  death  and  will  implement  actions  at  a  local  level  because  of  their 
findings. 

NHS England is advised by the ICB that the GP surgery involved in Myles’ care has 
taken learnings from Myles’ death. These include:  

• 

Improved processes for the management of patients with learning disabilities 
and  autism,  to  include  all  staff  completing  the  Oliver  McGowan  training  and 
adopting  a  low  threshold  for  offering  face-to-face  reviews  for  patients  with 
learning disabilities.  

•  Reminding clinical staff of the importance of accurate documentation for clinical 
decision-making, safety netting and continuity of care, which will be monitored 
through protocols and audits.  

•  Undertaking Practice Protected Time meetings and Significant Event Analyses 
(SEAs) to discuss Myles’ care and lessons learned (early triage of breathless 
patients, same day face-to-face review of patients, etc.) 

 We refer the Coroner to the GP surgery’s response to you for further information.  

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 Myles, 
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