Isaac Ingle-Gillis

Caroline Saunders 
Senior Coroner (Gwent) 

Dear Ms Saunders 

15th September 2025 

Re: Regulation 28 Report received by Aneurin Bevan University Health Board 
further to the inquest touching on the death of Isaac Arlan Ingle-Gillis which 
concluded on 18 July 2025 

Thank you for your Regulation 28 Report dated 22 July 25 and received by the Health 
Board on 24 July 25. I am writing to provide you with the Health Board’s response to 
the Regulation 28 Report, which was issued following the inquest into the death of Isaac 
Arlan Ingle-Gillis. 

As requested, the information presented below is intended to describe the actions which 
have been taken/are being taken by Aneurin Bevan University Health Board to mitigate 
the risk of future deaths.  

During the inquest you heard evidence that the Crisis Resolution and Home Treatment 
Team (CRHTT) do not have access to the GP records. Though you could not determine 
on balance of probabilities that access to additional information recorded by the GP in 
their consultation with Isaac on 9/2/2025 would have changed the assessment made 
by  the  CRHTT  on  this  occasion.  However,  you  are  concerned  that  in  future  this 
information (or lack of it) may be vital. 

You require the Health Board to provide you with the following information: 

You have asked the Health Board to confirm whether there are plans to allow secondary 
care practitioners access to GP records. 

I would support the view that it is desirable for clinicians working across boundaries to 
have  as  much  access  to  the  patients  wider  medical  records  as  possible  in  order  to 
ensure that relevant clinical information is available. 

A  summary/precis  version  of  the  GP  record  is  available  to  clinicians  working  in 
secondary  care  via  the  Welsh  Clinical  Portal,  until  now  that  availability  has  been 
restricted  to  the  medical  staff  in  the  Mental  Health  and  Learning  Disability  Division. 
Work has commenced to broaden that access to other clinicians including those who 
work in the CRHTT. This information is a summary/precis record and it is a high-level 
summary  of  key  diagnoses,  medications,  allergies  and  other  selected  coded 
information. It may not convey all of the information that could be potentially useful to 
clinicians from outside the practice.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 It is important that clinicians in secondary care continue to liaise directly with a patients 
GP  if  they  require  supplementary  information.  Ordinarily  a  significant  information  is 
included  in  referral  letters  generated  by  the  GP  system  when  patients  are  referred 
electively. As you will appreciate emergency referrals may be by telephone as opposed 
to the electronic letter. 

Notwithstanding that the Health Board has made the summary GP record available to 
all clinicians working in secondary care in the Health Board. Training will be provided 
to staff, with initial priority given to those in the Mental Health and Learning Disability 
Division who work in crisis and emergency clinics.  

The availability of the summary GP record cannot substitute for the full detail available 
in the GP record. Unfortunately, there are barriers to making this routinely available for 
clinicians working outside a GP practice. These include legal and practical barriers. 

The  integration  of  records  across  the  architecture  of  clinical  IT  systems  in  Wales, 
including the scope of shared data, is centrally co-ordinated by Digital Health and Care 
Wales.  We  are  not  aware  of  any  immediate  plans  to  allow  full  access  to  systems  to 
users  across  different  agencies  with  the  emphasis  being  on  ensuring  that  key 
information  can  be  shared  without  the  need  for  all  clinicians  to  have  individual  user 
access  across  multiple  platforms.  The  scope  of  which  data  is  shared  via  the  Welsh 
Clinical Portal is also determined nationally. 

The key hurdle to overcome is that each practice (other than those directly managed 
by  the  Health  Board) is  an independent data  controller.  Consequently,  each  practice 
would have to authorise individual users to access the system remotely. Nationally the 
GP community is resistant to less restricted access to the data for which they are legally 
responsible.   There are also logistical barriers in so much as the records are currently 
configured  such  that  external  users  would  require  a  unique  log-in  and  password  for 
multiple  GP  practice  systems  and  each  practice  could  potentially  be  responsible  for 
thousands of users of its system over whom they have no direct control. 

Nonetheless it is accepted nationally that we need to overcome these barriers.  Welsh 
Government and Digital Health and Care Wales (who are commissioned to manage the 
systems  utilised  by  GP  Practices)  are  working  to  overcome  the  legal  and  logistical 
barriers to wider access to the fuller information held in the GP system. There is also 
ongoing work to allow patients fuller access to the medical information held by their GP 
via the rollout and access to increased functionality of the NHS App. The pace of change 
in respect of such developments is outside the direct control of the Heath Board but is 
something which we fully support and embrace. 

These  actions  are  underpinned  by  a  recommendation  in  the  report  of  the  Ministerial 
Advisory Group on NHS Wales Performance and Productivity, published earlier this year 
and the positive response from Welsh Government  

 
 
 
 
 
 
 Recommendation 26  

The Cabinet Secretary should work with ministerial colleagues to prioritise the need to 
address Wales’s data sharing policy and associated framework position with a view to 
accelerating the incorporation of datasets into the National Data Resource. Timescale 
– within 12 months.  

Welsh Government Response: Accept  

A plan has been developed with the activities and actions required to provide the 
required clarity to the system through a combination of legislative and policy 
proposals. 

(See NHS Wales performance and productivity: independent review | GOV.WALES) 

There  is  a  clear  strategy  to  store  all  healthcare  information  in  the  National  Data 
Resource and make this available to applications so that healthcare professionals have 
access  to  the  information  they  need.   This  would  be  supported  by  an  Information 
Governance  framework  so  we  can  be  assured  that  Caldicott  principles  in  relation  to 
information governance are being followed. 

In the meantime, we remain committed to ensuring staff in secondary care are aware 
of  the  availability  of  the  summary  GP  record  whilst  understanding  that  it  may  be 
necessary  to  contact  the  patients  registered  GP  practice  if  further  information  is 
required. 

I trust that this information reassures you with regard to the matters raised, however, 
if you require any further information or assurance, please do not hesitate to contact 
me. 

Yours sincerely  

Chief Executive