Oscar Keenan

Care Quality Commission 
Citygate 
Gallowgate 
Newcastle upon Tyne 
NE1 4PA 
Telephone: 03000 616161 
www.cqc.org.uk 

Ms Judith Leach,  
HM Assistant Coroner for Oxfordshire  
Oxfordshire Coroner's Court 
County Hall 
New Road 
Oxford 
Sent by email to 

Car 

08 August 2025  

Our reference: 

Dear HM Assistant Coroner Ms Judith Leach,  

Re: Regulation 28 Report following the inquest into the death of Oscar Michael 
Thomas Keenan 

Thank you for raising the Regulation 28 report with us, following the inquest into the sad 
death  of  Oscar  Michael  Thomas  Keenan  on  26  June  2024  that  occurred  following  his 
admission  to  the  emergency  department  at  the  John  Radcliffe  part  of  the  Oxford 
University Hospitals NHS Foundation Trust.  

I note the legal requirement upon the CQC to respond to your report within 56 days, and 
I would like to express my gratitude for kindly providing us with two days’ extension. 

I would like to express my deepest condolences to Oscar’s parents and wider family for 
their loss.  

Following the receipt of your letter the local inspection team reviewed the risk profile of 
the service and all information we held including any other concerns received. 

We contacted Unity Health, the provider who confirmed they launched an investigation 
and  were  reviewing  how  to  improve  their  systems  to  prevent  reoccurrence.  We  also 
shared these concerns  you flagged up with the relevant Integrated Care Board for the 
area. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 You identified the following three areas of concern which I responded to below: 

The misunderstanding and miscommunication that registration with a GP cannot 
take place until a birth is registered.  

GP practices in England that offer NHS services do this through a GP contract that is held 
between  the  practice  and  the  relevant  Integrated  Care  Board  (ICB).  As  part  of  this 
contract, practices are mandated to provide emergency treatment to anyone within their 
practice area, regardless of whether they are registered with the practice or not. 

The Care Quality Commission does not regulate against the GP contract, and therefore 
the oversight of this process is better placed with the practice's ICB as the commissioner. 

Anyone can register and consult with a GP without charge, as outlined within the NHS 
Constitution,  however,  specific  points  regarding  how  the  registration  process  should 
operate, and when practices can refuse a patient's registration request are outlined within 
the GP contract. Practices should not refuse a patient's registration if they cannot provide 
proof of identity or immigration status. Therefore, practices should not typically be refusing 
a patient's registration if a birth certificate cannot be produced. However, this would again 
be for the ICB to oversee as the Care Quality Commission does not have jurisdiction over 
when practices register or do not register patients. 

We may  include  aspects  of  practices’  registration  processes  as  part of  our inspection, 
under the 'Equity in Access' quality statement. However, we would not be able to take 
enforcement action against practices, purely around the registration of new patients, as it 
is  not  within  our  regulations  to  do  so.  Where  we  comment  on  registration  concerns,  it 
could be due to a practice excluding a particular patient group such as homeless patients, 
because of a lack of ID or fixed address. In such circumstances, we may need to take 
action from an equity perspective.  

Communication between the GP surgery and the external filtering company. 

We are unable to comment on the communication between the GP surgery and the 
external filtering company, and the practice is best placed to provide this information. 

That Instructions to commence treatment can be lost in similar circumstances. 

It  is  not  in  the  Care  Quality  Commission’s  powers  to  implement  or  enforce  a  uniform 
process whereby treatment of patients is transferred from hospitals to other providers to 
avoid a similar incident occurring in the future. 

We  recognise  this  may  be  a  particular  concern  for  other  patients  who  may  not  be 
registered with GPs, such as Travellers, those with no fixed abode or people non-resident 
in the UK. Therefore, the hospital should have procedures in place to ensure aftercare 
can be provided to these patient groups.  

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Integrated  Care  Boards  and  NHS  England  will  be  better  placed  to  assist  with 
implementation  of  a  uniform  process  to  avoid  a  situation  such  as  this  occurring  in  the 
future. 

We contacted the provider in question, and they confirmed they promptly reviewed their 
processes  and  implemented  a  new  system,  when  as  soon  as  they’re  notified  about  a 
birth, they will create a new profile i.e. ‘Baby (Surname)’. The provider recognised this 
approach was not completely fail safe, as it could potentially mean there is a duplicate 
account at another provider for said child, should the parents wish to register their child 
elsewhere. 

We have already flagged this issue with the ICB for the area and will continue liaising with 
them  and  the  local  NHS  England  teams.  The  ICB  and  NHS  England  will  be  able  to 
consider  how  to  address  these  concerns  via  their  contracting  processes  and  how  to 
disseminate this to other practices. 

We will be sharing details of this incident and the associated findings with the Care Quality 
Commission’s Primary Care inspection teams at our monthly update and upskilling call. 
We will continue to monitor the intelligence about the practice in line with our regulatory 
processes. 

Yours sincerely, 

Deputy Director

Ms Judith Leach 
HM Assistant Coroner 
Oxfordshire Coroner’s Service 
The Oxford Register Office 
2nd Floor  
1 Tidmarsh Lane 
Oxford 
OX1 1NS 

Dear Ms Leach, 

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

5th August 2025  

Re: Regulation 28 Report to Prevent Future Deaths – Oscar Keenan who died 
on 26 June 2024. 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  12 
June 2025 concerning the death of Oscar Keenan on 26 June 2024. In advance of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Oscar’s parents and wider family. I was very sorry to be informed 
of the extremely sad circumstances surrounding Oscar’s death. NHS England is keen 
to assure Oscar’s parents and yourself that the concerns raised about Oscar’s care 
have been listened to and reflected upon. 

Your  report  raised  concerns  about  the  NHS  Pathways  algorithm  in  assessing 
deteriorating  newborns,  particularly  in  the  case  of  altered  breathing  and  sepsis.  In 
particular, you raised the following three concerns:  

1.  There  are  apparent  inadequacies  with  the  present  algorithm  in  assessing  ill 
newborns/infants, particularly in identifying significant respiratory problems that 
require early clinical assessment.  

2.  There is total reliance on the algorithm which does not appear to direct early 

clinical input.  

3.  There is/was a delay/lack of direction in obtaining a clinical assessment. 

Background of NHS Pathways Clinical Decision Support System 

NHS  Pathways  is  the  Clinical  Decision  Support  System  (CDSS)  used  for  remote 
clinical  assessment  (triage)  in  urgent  and  emergency  care.  In  use  since  2005,  it 
underpins  all  NHS  111  services  and  more  than  half  of  England’s  999  telephony 
systems.  The  tool  also  supports  online  triage,  in-person  and  enhanced  clinical 

                                                                                                                       
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
 assessments via modules such as the NHS Pathways Clinical Consultation Support 
(PaCCS) system. 

The safety of NHS Pathways triage outcomes - known as "dispositions" - is overseen 
by  the  National  Clinical  Assurance  Group  (NCAG),  an  independent  intercollegiate 
body  hosted  by  the  Academy  of  Medical  Royal  Colleges.  Alongside  this  external 
scrutiny, NHS Pathways aligns its content with up-to-date national clinical guidance, 
including  from  NICE  (National  Institute  for  Health  and  Care  Excellence),  the  UK 
Resuscitation Council and the UK Sepsis Trust. 

The  system  supports  over  2.5  million  triage  assessments  each  month  across 
telephone, digital, and face-to-face settings. 

NHS  Pathways  follows  a  structured  clinical  hierarchy.  Serious  and  potentially  life-
threatening  symptoms  are  assessed  first  to  ensure  rapid  escalation  -  such  as 
dispatching an ambulance or involving a clinician. The assessment then progresses 
to less urgent symptoms, identifying the most appropriate level of care. The tool is not 
diagnostic.  Instead,  it  works  by  systematically  ruling  out  more  serious  causes  of 
symptoms to ensure safe, efficient triage. Relevant history is gathered where clinically 
necessary to minimise triage time while maintaining safety. 

In  telephone  settings,  assessments  are  conducted  by  specially  trained  non-clinical 
health  advisors.  These  advisors  complete  a  rigorous  training  programme  and  are 
supported at all times by clinicians. If a case is complex or unclear, health advisors 
are required to escalate to clinical colleagues. It is therefore a condition of the NHS 
Pathways licence that clinical supervision and escalation support must be available 
24/7. 

I respond to each of your matters of concern below.  

1.  The  apparent  inadequacies  of  the  present  algorithm  in  assessing  ill 
identifying  significant  respiratory 
in 

newborns/infants,  particularly 
problems that require early clinical assessment.  

NHS England understands how critical early clinical assessment can be in cases such 
as Oscar’s. As is the usual process, the organisation has carefully reviewed this case.  

Having  sought  further  details  from  South  Central  Ambulance  Service  (SCAS)  and 
audited the call and its outcome, whilst Oscar’s symptoms did not meet the criteria for 
an  immediate  Category  1  or  2  ambulance  response,  the  system’s  safety  net  was 
activated due to his father’s report that he was not behaving normally. This led to an 
outcome of an emergency, expert clinician review – as indicated by the disposition, for 
GP assessment within an hour. 

 
 
 
 
 
 
 
 
 
 The  NHS  Pathways  system  is  designed  to  identify  signs  of  respiratory  distress  in 
infants  through  a  structured  set  of  questions,  tailored  by  age  group.  These  include 
indicators such as increased work of breathing, reduced consciousness level, changes 
in muscle tone changes, and signs of fatigue. 

We  recognize  that  the  remote  assessment  of  very  young  babies  is  inherently 
challenging,  and  we  continuously  refine  the system  based on  clinical  feedback  and 
real-world cases. In Oscar’s case – and in accordance with the investigation at SCAS 
-  the  review  concluded  that  the  algorithm  functioned  as  intended,  and  no  changes 
were  required.  However,  every  case  contributes  to  our  ongoing  learning  and 
improvement. 

We  remain  committed  to ensuring  that  NHS  Pathways  provides  the  safest possible 
guidance  for  infants  and  their  families,  and  we  welcome  continued  dialogue  to 
strengthen this further. This case is reportable to NCAG and to other oversight groups 
within NHS England, where opportunities for learning and improvement – whether in 
the algorithms themselves, or the systems they operate in - are considered. 

2.  Total  reliance  on  the  algorithm  which  does  not  appear  to  direct  early 

clinical input.  

Calls to NHS 111 or 999 are taken by specially trained health advisors. Though non-
clinical, these advisors undergo comprehensive structured training to ensure they can 
use  the  NHS  Pathways  algorithm  safely  and  effectively.  This  includes  classroom 
learning,  assessments  and  preceptorship  (a  structured  period  of  support  for  newly 
qualified  professionals).  Once  working  independently,  health  advisors  must  be 
supervised  by  clinical  staff,  to  whom  they  must  have  access  to  for  guidance  and 
support whenever there is uncertainty or complexity. Requirements relating to this are 
set out in the NHS Pathways Licence. 

A fundamental component of training is learning how to manage complex calls. The 
"complex call process" provides a clear protocol for health advisors to seek assistance 
or transfer a complex call to a clinician. This process should be followed in situations 
involving declared medications, medical procedures, or terminology that complicates 
triage, or when the advisor feels they have reached the limits of their knowledge or 
understanding. This approach is reinforced by the training motto: 

“If in doubt, shout.” 

In their audit of the call, SCAS concluded that the health advisor should have initiated 
the complex call process. This was due to the audible breathing sounds and Oscar’s 
father's description. This assessment is supported by NHS England’s NHS Pathways 
Team following their review of the call. This means that, whilst the health advisor did 
reach the system safety-net of an emergency call back from a GP, the call should have 

 
 
 
 
 
 
 
 entered a process where the immediate assistance of a clinician was sought. This is 
considered in more detail in SCAS’s response to HM Coroner, dated 22 July 2025. 

We note the development of additional training and a bespoke breathing package at 
SCAS,  alongside  reminders  of  the  processes  in  place  to  ensure  compliance  with 
training and shared learning. 

3.  A delay/lack of direction in obtaining clinical assessment   

Health advisors using the NHS Pathways system must have access to clinical support 
and supervision. They are trained to use probing questions to better understand caller 
responses.  If  a  call  is  complex,  uncertain,  or  includes  three  “not  sure”  answers, 
advisors  are  expected  to  seek  clinical  input.  This  support  should  be  available 
immediately  through  a  ‘warm  transfer’  to  a  clinician,  as  required  by  the  system’s 
Licence. To encourage this, NHS Pathways promotes the motto: “If in doubt, shout.” 
The system generates a recommended outcome (disposition), which is then matched 
to services commissioned locally. The availability of these services is managed locally. 

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 Oscar, 
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. Once again, I 
am  very  sorry  for  Oscar’s  parents’  loss  and  hope  that  this  letter  will  provide  some 
reassurance  around  the  triage  systems  used  in  initial  assessment  in  the  urgent  & 
emergency system of care. 

Yours sincerely, 

National Medical Director 
NHS England

South Central Ambulance Service NHS Trust 
Unit 7 & 8 Talisman Business Park 
Talisman Road 
Bicester, Oxon 
OX26 6HR 
Tel: 01869 365000 

PRIVATE AND CONFIDENTIAL 
Mrs Judith Leach 
HM Assistant Coroner for Oxfordshire  
Via email only (

) 

22nd July 2025 

Dear Mrs Leach, 

I am writing to you in response to the concerns that you highlighted to the Trust following the 
inquest hearing into the very sad death of baby Oscar Michael Thomas Keenan that concluded 
on 3rd May 2025. Thank you for allowing us the time to review and respond to your concerns.   

At the outset I would like to offer my personal condolences to baby Oscar’s parents.  

To  confirm,  your  Regulation  28  report  relates  to  concerns  regarding  the  adequacy  of  the 
algorithm  built  into  the  NHS  Pathways  clinical  decision  software  support  system  when 
assessing ill newborns or infants. Your report was also issued to NHS England because they 
design and manage the NHS Pathways system and will be able to consider whether a change 
to the algorithm itself is required. 

It is disappointing that the Trust were not provided with the opportunity to participate in the 
inquest hearing. I understand that the court were aware of concerns that had been raised by 
baby Oscar’s parents regarding the outcome of the 111 call in advance of the hearing. It is 
regretful that evidence was not requested from  the Trust in response to these concerns as 
would usually be the case.  

Actions taken by the Trust shortly after baby Oscar’s death. 

At the Joint Agency Response meeting held on 28th June 2024, the Chair of the meeting, D
,  questioned  whether  the response reached  at the  end  of the  111  call  was 
appropriate.  This  prompted  the  Trust  to  review  the  call  to  see  whether  it  was  managed 
appropriately. The call was audited on the same day and regrettably it was identified that there 
were missed opportunities for a higher disposition (call outcome) to have been reached. The 
audit  identified  that  the  Health  Advisor  should  have  probed  further  using  supportive 
information contained within the NHS Pathways system in relation to Oscar’s breathing. The 
auditor  determined  that  if  after  probing  a  clear  answer  had  not  been  received,  the  Health 
Advisor should have requested advice from a clinician.   

Due  to  the  comments  made  on  the  call  by  Oscar’s  parents  and  their  description  of  his 
breathing, it was determined that a Category 2 ambulance response disposition should have 
been reached at the end of the 111 call. On behalf of the Trust, I am very sorry that a lower 
outcome was reached.  

On 1st July 2024, the case was discussed at the Trust’s Daily Critical Review meeting. This 
meeting is led by our Patient Safety Team who determine whether any wider review is required 

 
 
 
 
 
 
 
 
 
 
 
 
 under  the  Patient  Safety  Incident  Response  Framework  when  a  concern  is  identified.  The 
outcome of this meeting was that the Patient Safety Team were satisfied a wider review by 
the Trust was not required.  

A meeting was held with the Health Advisor on 2nd July 2024 to feedback the results of the 
call audit and a call review plan was initiated to ensure that individual learning took place, and 
any  support  required  was  implemented.  A  call  review  plan  details  any  specific  support  / 
learning  /  development  actions required  to  address  the  area(s)  of  development  highlighted 
within the non-compliant audit. The plan is accompanied by any relevant support materials, 
for  example,  NHS  Pathways  Hot  Topics,  extracts  from  NHS  Pathways  training  materials, 
shared  learning  documents,  local  policies /  procedures.  At the  audit  feedback meeting,  the 
call  recording  was  played  to  the  Health  Advisor  and  the  issues  highlighted  within  the  non-
compliant audit were discussed with him in detail. The Health Advisor has continued to have 
regular random audits performed in line with the requirements of the NHS Pathways licence 
and their performance is in line with expected standards.  

Review undertaken after receipt of the Regulation 29 report. 

Following receipt of your report, the case was reviewed at the Trust’s Safety Review Panel 
which comprises of Assistant Directors from the clinical and medical teams, our Consultant 
Pre Hospital Care Practitioner, clinical governance leads, members of our safeguarding and 
quality improvement teams and our Patient Safety Specialist. The panel noted the speed at 
which the Trust ensured that feedback was provided to the Health Advisor following the call 
taking place and determined that the error made is not an issue that is occurring Trust wide, 
so  a  learning  response  was  not  required  under  the  Patient  Safety  Incident  Response 
Framework.  

In addition to the above, our Clinical Coordination Centre (CCC) Quality Improvement Team 
have considered points 2 and 3 of the concerns raised and they are satisfied that there is not 
an inherent or recurrent issue of staff not seeking clinical advice when appropriate to do so 
within our call centres.  

As indicated at the beginning of this letter, the Trust is a user of the NHS Pathways system, 
and we are consequently not able to alter the algorithms contained within it, only NHS England 
can  do  this.  We  have  therefore  focused  our  review  and  response  on  the  training  that  is 
provided to Emergency Call Takers and Health Advisors who use the NHS Pathways system 
and the process in place for identifying any themes or that indicate additional wider training 
may be required. 

Core NHS Pathways training is set by NHS England, and it is a condition of the NHS Pathways 
licence that their training  programme is  followed.  This  training  is  delivered within  SCAS  by 
local  trainers  who  have  attended  national  ‘train  the  trainer’  sessions  to  ensure  consistency 
across all providers. In addition to the core training, the Trust  has a dedicated CCC Quality 
Improvement team who are responsible for sharing learning with call centre staff as new and 
emerging themes and trends are  identified from a wide range of sources including, but not 
exclusively,  case  reviews  in  preparation  for  Coronial  proceedings  (See  SCAS  Shared 
Learning Processes_CCC document enclosed with this letter). Generic common themes are 
reviewed monthly by the Quality Improvement team and associated shared learning material 
is issued at least once a month. Factsheets, posters, and anonymised case studies are issued 
as  their  main  media  for  this  because  these  methods  have  been  identified  through  staff 
feedback as being an effective way of disseminating learning. The team also use podcasts 
and share links to other associated reference materials where relevant. 

Shared learning is issued via email with an embedded MS Forms acknowledgement link that 
is mandatory for colleagues to click on to acknowledge that they have read and understood 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 the content. Compliance with shared learning acknowledgement is monitored and managed 
by operational line managers. All acknowledgement forms have the option for individuals to 
flag  that  they  require  further  information  to  aid  their  understanding,  and  the  CCC  Quality 
Improvement team will then follow up with those individuals to ensure that they have a good 
understanding of the relevant topic, and they are safe to continue working in their role. 

To further gauge understanding and comprehension of the content within any shared learning 
materials issued, there is a monthly Quick Quiz for both service lines (111 and 999) comprising 
of 10 true / false and / or multiple-choice questions. The questions are drawn from any recent 
Standard  Operating  Procedure  (SOP)  Change  Notices,  shared  learning  materials,  existing 
SOPs, and general triage principles for the NHS Pathways system. The quiz is facilitated via 
MS Forms which allows staff who submit incorrect answers to see explanations of the correct 
answer  with  sign  posting  to  the  source  reference  materials.  Quick  Quizzes  have  included 
questions regarding assessing a patient’s breathing in July 2024, August 2024, September 
2024 and April 2025 and regarding when and how to pass a call to a clinician every month 
since December 2024.  

The Quality Improvement team have confirmed to me that because assessing the adequacy 
of breathing can be difficult over the telephone, a bespoke ‘breathing’ package was developed 
to  aid  the  education  of  staff.  In  this  package,  staff  select  a  sound  recording  to  play  which 
demonstrates a type of breathing pattern and they then have to confirm which type of breathing 
they have heard. This package is provided to all new starters and is available for all staff to 
access on an ongoing basis. All shared learning material is available for staff to access on a 
dedicated page on the staff intranet along with Hot Topics issued by NHS Pathways. It is the 
intention  of  the  Quality  Improvement  team  to  include  questions  specifically  related  to 
assessing breathing in children (including neonates) over the coming months.  

Having considered the robust processes and additional training that the Trust currently has in 
place, I am satisfied that these measures are sufficient to mitigate the chance of a similar error 
occurring when a call is taken by a member of our call centre team. This does not take away 
from  how  truly  tragic  baby  Oscar’s  death  was.  Should  NHS  England  decide  to  update  the 
algorithm contained within NHS Pathways, this will of course mean that SCAS staff will have 
access to this updated version upon its release.  

I hope that this letter has adequately addressed the concerns that you have raised. Should 
, Head of Legal 
you wish to discuss these matters further, please contact 
Services at the Trust who will be able to facilitate this. 

Yours sincerely, 

Chief Executive 

SCAS Shared Learning Processes CCC 

3

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 CCC SHARED LEARNING 
PROCESSES 

Contents 
Dissemination ............................................................................................................................................................... 2 

Routine Quality Assurance Audit Process ............................................................................................................ 3 

Datix Review Findings ................................................................................................................................................ 3 

Learning from Deaths Review .................................................................................................................................. 3 

Learning from Experience Forum ............................................................................................................................ 3 

Clinical Governance Reviews ................................................................................................................................... 4 

Patient Surveys ............................................................................................................................................................. 4 

Coroner Cases .............................................................................................................................................................. 4 

NHS Pathways System Issues .................................................................................................................................. 5 

NHS Pathways System Updates .............................................................................................................................. 5 

111 End to End Review Meetings ............................................................................................................................ 5 

Examples of CCC Shared Learning ......................................................................................................................... 5 

Wider Trust Communications ................................................................................................................................... 7 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Dissemination 

CCC Shared Learning is currently issued using one (or more) of the following mediums:  

•  CCC SOP Change Notices 

These are issued via CCC Operations aimed at specific service lines, e.g., 111, 999, or the 
whole CCC. 

•  CCC Memos 

These are issued via CCC Operations aimed at specific service lines, e.g., 111, 999, or the 
whole CCC. 

•  Take Note! 

A  brief  key  point  memo  highlighting  a  new  or  revised  process  based  on  a  simple 
‘Experience? Reflection? Action?’ model. 

•  CCC SCAScade 

An anonymised case study providing detailed analysis of a topic. 

•  Did You Know? 

Poster  format  with  headline  facts  and/or  informational  statements  about  a  topic,  typically 
issued alongside a more detailed Factsheet. 

•  CCC Factsheet 

Detailed  information  about  a  topic  linking  in  with  system  use  and  providing  references  for 
further reading. 

•  CCC Quick Quiz 

End-of-the-month  10  question  quiz  for  any  learning  issued  during  that  month.  Content 
covers  recent  SOP  Change  Notices  and Shared  Learning  materials  along  with existing 
SOPs  and  Pathways  triage  principles.  Quiz  answers  with  embedded  links  to  source 
reference materials are posted on the HUB.  

•  CCC Quick Quiz Spotlight 

Detailed  explanation  and  analysis  of  Quick  Quiz  questions  that  have  failed  to  receive 
responses  of  80%  or  higher  on  more  than  1  occasion  (after  potential  re-phrasing  and 
correct response explanation).   

Shared Learning materials issued for Datix learning are uploaded to the relevant Datix record. 

Specific Shared Learning actions arising from Datix reviews are logged and tracked on Datix. 

CCC  Quick  Quiz  results  are  tracked,  and  questions  receiving  responses  of  less  than  80%  are 
reviewed  and  re-quizzed  to  monitor  for  improvements.  Questions  and  training  materials  are 
reviewed as appropriate to support better understanding. 

CCC Shared Learning     July 2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 There are several streams of information that feed into potential CCC Shared Learning: 

Routine Quality Assurance Audit Process 

All NHS Pathways trained staff taking 111/999 calls from the public receive monthly routine audits 
for quality assurance purposes. The audits are conducted according to the NHS Pathways Licence 
requirements which has two audit tiers: those staff taking more than 200 calls per month receive a 
minimum of 3 random audits per month; those staff taking less than 200 calls per month (or who 
have been employed  for  less  than 6 months)  receive  a  minimum of  5  random audits  per month. 
Side-by-side audits are considered the gold standard as they facilitate immediate feedback post-
call,  and  potentially  in-call  support.  Calls  are  audited  against  defined  NHS  Pathways  Audit 
Competencies and correct adherence to local Standard Operating Procedures (SOPs). 

All audits include constructive feedback which is passed to the individual via email. Feedback from 
non-compliant  audits  is  provided  face-to-face  by  the  auditor  wherever  possible.  Where  different 
working  patterns  prevent  this,  feedback  is  provided  by  colleagues  (other  auditors,  111  Team 
Leaders or 999 Senior Emergency Call Takers). Clinicians may receive initial feedback via email 
until a face-to-face review can be arranged. 

Routine audit feedback  typically  involves  information  about  skilled  questioning,  effective  probing, 
active  listening,  and  correct  system  navigation  as  the  most  common  audit  competencies  where 
individual development areas are highlighted. 

Themes and trends identified through routine audit are communicated with CCC colleagues via a 
monthly email sent with an MS Forms acknowledgment link embedded within. 

Datix Review Findings 

Feedback  is  received  via  Datix  enquiries  logged  by  internal  colleagues  and  external  routes 
reported  by  the  Clinical  Governance  and  Patient  Experience  teams  from  concerns,  complaints, 
and  HCP  feedback.  As  part  of  the  case  review  process  any  associated  calls  are  audited,  and 
individual feedback is provided as outlined above. Identified themes and trends from case reviews 
and  complaints are  reported  to  commissioners  by  the  Trust  Clinical  Governance Leads,  and  this 
information is also shared with the Education Team so that Educators and Coaches can use real-
case  examples  to  support  their  training  scenarios.  When  the  Datix  are  completed,  feedback  is 
emailed to the reporter before it’s closed. 

Learning from Deaths Review 

Cases  are  examined  by  a  Mortality  and  Morbidity  Review  Group  and  any  concerns  about  CCC 
involvement  are  fed  back  via  the  Learning  from  Experience  forum  and  shared  with  the  Quality 
Improvement team.    

Learning from Experience Forum 

This is a SCAS-wide bi-monthly meeting to share learning across all areas of the Trust. 

CCC Shared Learning     July 2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Clinical Governance Reviews 

The Clinical Governance teams review potential cases of concern and present them as emerging 
incidents  to  a  Safety  Review  Panel  for  multi-disciplinary  discussion.  Cases  are  benchmarked 
against  the  NHS  Patient  Safety  Incident  Response  Framework  (PSIRF)  criteria  to  determine  the 
level  of  further  review  and  action.  Following  a  robust  case  review  process,  draft  reports  are 
reviewed by the specific service line Clinical Governance meetings for further discussion and any 
identified learning is fed back to the Quality Improvement team. Completed reports are returned to 
the Incident Review Panel for final approval before being submitted to the Integrated Care Board 
(ICB) commissioners. 

Patient Surveys 

These are sent out regularly by the Patient Experience Team, and a process is being developed to 
share the collated results with the Education Team, again to identify potential themes and trends 
which might be used to inform and update training materials. 

Coroner Cases 

As part of our coroner case review process any associated calls are audited. Individual feedback 
is provided as outlined above. If a case identifies a gap in internal processes these are reviewed, 
most commonly via consultation with the CCC Senior Management Team and recommendations 
shared with the service line SOPs Working Group for collective feedback.  

The  Trust  endeavours  to  internally  identify  any  needs  through  its  Datix  reporting  processes  and 
Safety  Review  Panel  meetings  so  that  measures  are  already  in  place  before  a  coroner’s  case 
inquest is held to demonstrate to the coroner that internal case review has identified learning and 
mitigation actions have already been taken. This hopefully avoids receiving a Prevention of Future 
Deaths Order (PFD – Regulation 28 report). 

Approved  amendments  to  existing  processes  usually  take  the  form  of  an  interim  EOC/111  SOP 
Change  Notice  which  is  then  adopted  into  the  next  full  version  release  of  local  SOPs.  All  such 
Notices are issued via email to relevant CCC skillset groups with an MS Forms acknowledgment 
link  embedded  in  the  email.  Colleagues  click  on  the  link  to  acknowledge  they  have  read  the 
material;  the  links  are  shared  with  CCC  Operational  Management  to  monitor  their  teams’ 
compliance. 

Any  shared  learning  identified  from  such  cases  is  disseminated  throughout  the  CCC  in  a  similar 
way, via email with embedded MS Forms acknowledgement link. A brief consolidation question set 
can be added to the acknowledgment link to demonstrate understanding of the material content. 
Again, links are shared with CCC Operations to monitor their teams’ compliance. 

Once  issued  to  CCC  staff,  all  shared  learning  materials  are  uploaded  to  a  the  SCAS  HUB 
SharePoint  page  for  the  EOC  Education  and  Development  Team  where  they  can  be  freely 
accessed at any time by all Trust colleagues, and the link to that page is provided as a reminder 
within any subsequent new issue.  

CCC Shared Learning     July 2024 

 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 NHS Pathways System Issues 

During  the  day-to-day  use  of  the  NHS  Pathways  telephone  triage  tool  colleagues  regularly 
highlight  potential  issues  with  the  system,  for  example  inconsistencies  with  how  two  related 
Pathways deal with the same symptoms. We also receive regular feedback from external partners 
and HCPs raising concerns about the Pathways system. Case details are first internally reviewed 
to ensure the issue is not a result of ‘operator error’ or a wider health system issue.   

Details of concerns are logged with NHS England for review by the national NHS Pathways clinical 
authoring  and  training  teams. We  raise  requests  for  information,  requests for  change,  and  share 
cases  of  potential  interest.  All  Patient  Safety  cases  where  there  is  a  potential  contention  about 
how the Pathways system was used are anonymously shared with NHS England in this way. 

NHS Pathways System Updates 

New Pathways software releases are issued approximately every 8 weeks; if NHS England uphold 
a logged issued and make system changes these are added to a forthcoming release and details 
of  those  changes  are  shared  with  colleagues  along  with  the  pre-release  notes  for  the  version 
training update materials (which are issued via email with embedded MS Forms acknowledgement 
link and knowledge review document). These must be completed prior to any new release go-live 
date. 
. 

111 End to End Review Meetings 

These  meetings  are  held  monthly  and  are  used  to  review  a  case  from  point  of  call  to  111 
throughout the complete patient journey, with input from GP, OOH, ambulance, and ED/Ward. The 
aim  of  this  end-to-end  process  is  to  identify  any  areas  of  learning  from  the  cases  under  review, 
and  to  implement  process/system  changes  if  required.  Any  issues  involving  the  NHS  Pathways 
system are reviewed and referred to NHS England as above.  

Examples of CCC Shared Learning  

•  an  End  to  End  Review  meeting  highlighted  a  case  of  a  30-year-old  female  8-weeks  post-
delivery complaining of sore breasts and feeling very unwell. The case was triaged to a 6-
hour  GP  timeframe,  but  the  GP  felt  this  was  too  long  as  they  were  concerned  about 
potential sepsis markers.  

There  was  one  question  within  the  assessment  algorithm  used  (Breast  Problems)  that 
asked  about  breast  feeding,  but  because  the  patient  was  expressing  her  breast  milk  and 
not actively feeding from her breast, the Health Advisor said ‘no’ to this question. If they had 
said ‘yes’, the resulting disposition would have been to speak with a GP within 1 hour.  

This case was shared with NHS Pathways with a request that they review their supporting 
information  for  this  breast-feeding  question  to  include  ‘this  also  means  expressing  breast 
milk’ and NHS Pathways acknowledged that they would improve the supporting information 
to make it clearer. 

CCC Shared Learning     July 2024 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 •  A  coroner’s  case  highlighted  the  unfortunate  death  of  a  patient  with  breathing  difficulties 
where grey lips were declared during the call. The system did not consider the abnormal lip 
colour. The non-clinical Emergency Call Taker did not understand the potential significance 
of  grey  lips  with  associated  breathlessness,  and  as  a  result  a  lower  category  ambulance 
response was dispatched.  

Following  this  event,  a  “Take  Note!”  memo  was  issued  to  all  CCC  call  taking  staff  to 
highlight  the  importance  of  declared  abnormal  lip  colour  in  the  context  of  breathing 
difficulties,  and  this  was  followed  up  with  a  more  detailed  interactive  anonymised  case 
study (CCC SCASCade).  

The case study author received subsequent emailed confirmation from an in-house clinician 
who had taken over a call passed by a non-clinical colleague specifically because abnormal 
lip colour had been declared during their call.  

Additionally,  this  the  case  was  shared  nationally  with  NHS  Pathways  who  have 
acknowledged that this case will form part of their ongoing review of their system. 

•  A coroner issued a PFD highlighting a national concern that 999 services were not aware of 
appropriate  DNACPR  exceptions.  This  linked  in  with  a  locally  identified  audit  trend  where 
999  Emergency  Call  Takers  did  not  always  exclude  the  DNACPR  exemptions  listed  in 
current local SOPs before accepting reports of a valid DNACPR form as being appropriate. 
We  also  had  a  recent  case  where  CPR  advice  was  withheld  from  a  patient  with  a  valid 
DNACPR  form  who  required  intervention  because  of  an  issue  with  their  mechanical 
ventilator.  

A “Take Note!” memo has been issued together with a detailed CCC SCAScade case study 
to share this learning, which has also identified a potential gap in our existing SOP relating 
to  DNACPR  exceptions  –  recommendations  have  been  submitted  to  the  EOC  SOPs 
Working Group to address this.  

•  A  national  case  review  was  issued by  NHSE  relating  to  the assessment  of  sub-arachnoid 
haemorrhage, arising from a tragic case of a young adult male who had multiple contacts 
with  multiple  healthcare  services  with  headache  symptoms.  This  national  case  study  was 
shared with CCC colleagues along with a Factsheet highlighting signs and symptoms. 

•  A  coroner’s  inquest  highlighted  a  case  where  an  available  defibrillator  (AED)  was  not 
offered  to  a  family  calling  999  for  a  cardiac  arrest.  The  resulting  case  review  identified 
significant learning around the 999 AED process, including national review and amendment 
of the NHS Pathways cardiac arrest algorithms.  

•  A  coroner’s  inquest  highlighted  concerns  over  the  toxicity  risks  associated  with  deliberate 
overdose  of  sodium  nitrate/nitrite.  Details  were  shared  with  all  CCC  Clinicians  within  a 
“Toxicity  Dirty  Dozen”  Factsheet,  providing  guidance  and  links  to  the  National  Poisons 
Information Service (NPIS) Toxbase reference website. 

CCC Shared Learning     July 2024 

 
 
 
 
 
 
 
 
 
 
  
 
 
 
 
 Wider Trust Communications 

All CCC staff complete and maintain statutory and mandatory e-learning and attend yearly face-to-
face  update  training.  The  agenda  for  F2F  training  is  primarily  set  by  the  regular  rotation  of  the 
UK Core Skills Training Framework (CSTF) 11 statutory training elements, e.g., Basic Life Support 
updates.  Added  to  this  are  mandatory  elements  set  by  the  Trust’s  subject  matter  experts,  e.g., 
safeguarding, sexual safety at work, learning difficulties/disabilities. Any extra time in the allowed 
F2F training provision time (usually 7.5 hours) focuses on Shared Learning topics.  

There are a variety of communication methods available to share learning across the wider Trust 
including within the CCC. Examples are: 

•  SOPs / policies / procedures 
•  Clinical and Operational Directives 
•  Clinical and Operational Memos 
•  SCAScades (anonymised case reviews) 
•  E-learning 
•  Face-to-face Education sessions 
•  Statutory and Mandatory training sessions 
•  Hot News emails 
•  Staff Matters newsletters 
•  Podcasts 
•  Twitter / Yammer feeds 
•  Apps 
•  JRCALC (Operations) 
•  Team days (Operations) 

Not  all  of  these are applicable  to  CCC  staff,  however  via  Hot  News,  Staff  Matters  and approved 
social media feeds CCC colleagues are kept abreast of wider Trust initiatives and new schemes. 

CCC Shared Learning     July 2024

Clinical Partners 

Princes Risborough Surgery 
(Main Site) 
Stratton Road 
Princes Risborough 
Bucks HP27 9AX 

Tel: 01844 344281 
Web: unity-health.co.uk 

Ms J Leach 

H.M. Assistant Coroner 

By Email:  

Dear Madam, 

Prevention of Future Deaths Report Concerning Oscar Keenan 

I am one of the GP Partners at Unity Health who operate five GP Practices, including Princes Risborough Surgery.  I 
write to provide the Practice’s response to your Prevention of Future Deaths Report dated 12 June 2025.   

You have raised concerns regarding new birth registrations at the Practice, the communication between the Practice 
and the external company we use to assist us in dealing with incoming correspondence and also that instructions to 
commence treatment could be lost in similar circumstances.  At the outset, I would again like to extend my sincere 
condolences to Oscar’s parents and wider family. 

As you are aware, nobody from the Practice was asked to attend Oscar’s Inquest and I am therefore grateful to you 
for  providing  us  with  the  opportunity  to  access  the  recording  of  the  proceedings  in  order  to  fully  understand  the 
concerns  raised.    I  hope  that  the  response  from  the  Practice  set  out  further  below  provides  yourself  and  Oscar’s 
parents with some degree of reassurance that this matter has been taken extremely seriously and that improvements 
have been made. 

New Baby Registrations at the Practice 

As  set  out  in  my  statement  of  12  March  2024,  a  baby  does  not  and  did  not  need  to  have  been  named  or  formally 
registered  with  the  Registrar  in  order  to  be  registered  as  a  patient  at  the  Practice.    Unfortunately,  it  transpired 
subsequently that Oscar’s parents had been told incorrectly by a member of the reception team that they could not 
register Oscar at the Practice until they had formally registered his birth for which I sincerely apologise.  The Practice 
conducted  a  Serious  Event  Analysis  after  this  issue  and  Oscar’s  sad  death  came  to  light.    Following  this,  a  new 
process was put in place for new baby registrations which was circulated to the Practice team on 11 December 2024.  

Brill Surgery 
22 Thame Road 
Brill 
Bucks HP18 9SA 

Chinnor Surgery 
5 Station Road 
Chinnor  
Oxon OX39 4PX 

New Chapel Surgery 
High Street 
Long Crendon 
Bucks HP18 9AF 

Thame Health Centre 
East Street 
Thame 
Oxon OX9 3JZ 

VAT Reg No 879 1204 06 

Tel: 01844 238284 
Fax: 01844 238568 

Tel:  01844 351230 
Fax: 01844 354328 

Tel: 01844 208228 
Fax: 01844 201906 

Tel: 01844 212553 
Fax: 01844 260243 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Within that email, the staff were reminded that  newborn babies do not need to be registered at the Registry Office 
before  being  registered  at  the  Practice.    When  new  staff  join  the  reception  team,  training  is  provided  and  the 
information as to the process for new baby registrations and the fact that the baby does not need to be registered 
with the Registrar is shared with them. 

The process for new baby registrations at the Practice now in force is as follows:- 

1.  All  birth  notification  letters  from  the  hospital  are  sent  to  the  Practice  via  an  electronic  filing  system  (called 
Docman).  Docman is a cloud-based platform primarily used in healthcare for managing clinical content and 
co-ordinating workloads related to the transfer of care.  It helps healthcare professionals capture, organise, 
workflow and transfer healthcare documents, both clinical and non-clinical.  Docman is used by thousands of 
GP  Practices  and  hundreds  of  thousands  of  healthcare  professionals  to  streamline  processes,  reduce 
administrative burden and improve patient care.  All electronic correspondence from hospitals are sent to the 
Practice  via  Docman.    The  correspondence  automatically  delivers  into  a  folder  within  the  “filing”  section  of 
Docman  and  is  automatically  placed  in  date  and  time  order.    The  workflow  team  at  the  Practice  then  work 
through these documents one by one filing them into the relevant patient records.  When a member of the 
workflow team identifies a birth notification/maternity discharge summary, they will register the baby with the 
Practice immediately. 

2.  Once the baby has been registered with the Practice, the birth notification will sit at the top of the electronic 
filing pile on Docman for 24 hours as Docman takes 24 hours to link the new patient into their system.  The 
birth  notification  will  then  be  filed  into  the  patient  records  the  following  day.    The  patient  will  however  be 
active on the clinical system (EMIS) as soon as they are registered and so any care required within that 24 
hour period would not be delayed. 

3.  With the new system in place, all babies will be registered with the Practice within 24 to 48 hours of the birth 
notification  letter  arriving  at  the  Practice  and  without  any  action  being  required  on  the  part  of  the  parents.  
Were  a  parent  to  seek  an  appointment  for  a  baby  within  the  very  short  window  of  time  before  the  birth 
notification letter is actioned by the Practice, the baby would be immediately registered and an appropriate 
appointment made. 

4.  A new baby welcome letter is then sent to the parents advising them that the baby has been registered with 
the Practice and asking them to complete a registration form for the baby to complete the process.  The baby 
would however already be formally registered with the Practice and so the need to complete this form would 
not delay or prevent any care being provided should it be needed in the intervening period. 

Communication between the GP Practice and the external filtering company 

Your  Prevention  of  Future  Deaths  Report  has  also  raised  concerns  in  relation  to  the  communication  between  the 
Practice and the external filtering company that we use to assist us with the correspondence received by the Practice 
in relation to patients.  Whilst the Practice in the past dealt with all incoming correspondence “in-house”, we receive 
between 1,000 and 1,200 items of electronic correspondence via Docman each week (with  some hard copy post on 
top) and this became unmanageable and unsafe for patients.  Assistance in managing this is therefore now provided 
by an external company.   

Brill Surgery 
22 Thame Road 
Brill 
Bucks HP18 9SA 

Chinnor Surgery 
5 Station Road 
Chinnor  
Oxon OX39 4PX 

New Chapel Surgery 
High Street 
Long Crendon 
Bucks HP18 9AF 

Thame Health Centre 
East Street 
Thame 
Oxon OX9 3JZ 

Practice Manager 

Tel: 01844 238284 
Fax: 01844 238568 

Tel:  01844 351230 
Fax: 01844 354328 

Tel: 01844 208228 
Fax: 01844 201906 

Tel: 01844 212553 
Fax: 01844 260243 

VAT Reg No 879 1204 06 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Any  urgent  correspondence  received  by  the  Practice  will  be  filtered  out  and  actioned  by  the  workflow  team  when 
accessing this via Docman.  The workflow team scan read every piece of correspondence and are trained to identify 
matters requiring urgent attention even if a letter is not obviously marked as “urgent”.  Any urgent correspondence 
therefore will not be sent externally as it will already have been picked up and dealt with by the workflow team based 
at the Practice.  In addition, as set out above, all new birth notification letters will be picked up and actioned by the 
Practice  team  with  the  baby  being  immediately  then  registered  with  the  Practice.    These  letters  are  therefore  no 
longer sent externally. 

All other documents are filed onto the patients’ records by the workflow team (and so are immediately available for 
clinicians  to  see)  and  are  sent  to  the  external  company  in  a  batch  every  Friday.    The  external  company  will  then 
summarise and code all relevant correspondence into patient’s records.  Any correspondence that requires action on 
the part of the Practice will be returned on a daily basis and highlighted to the Practice as requiring action.  Under the 
agreement  between  the  Practice  and  the  external  company,  they  have  5  working  days  to  deal  with  any 
correspondence which is passed to them.  As indicated above, however, anything requiring urgent action will already 
have been picked up and dealt with by the workflow team.  Anything that is returned as it requires action on the part 
of the Practice is sent to an inbox within Docman which is cleared by the Practice workflow team on a daily basis. 

Although  the  majority  of  correspondence  is  received  at  the  Practice  electronically,  some  correspondence  is  still 
received by post.  Any hard copy correspondence is scanned by the reception team on a daily basis and will be sent 
externally with the batch of documents that has been received electronically that week.  Any urgent correspondence 
would not usually be sent to the Practice via post and if it is it would be backed up by an email from the sender which 
would then be picked up and actioned by the workflow team. 

The  work  undertaken  by  the  external  company  is  audited  on  a  monthly  basis  by  our  Data  Quality  and  Compliance 
Lead  at  the  Practice  and  an  audit  on  random  letters  is  also  carried  out  on  a  daily  basis  by  the  same  person.    Any 
issues that may have been identified are fed back on a weekly basis with appropriate action then put in place to deal 
with  any  concerns.    The  Practice  intends  to  shortly  carry  out  a  review  of  the  process  in  place  concerning  how 
incoming correspondence is dealt with to ensure that matters are being dealt with as efficiently as possible. 

Concern that instructions to commence treatment could be lost in similar circumstances 

As indicated above, anything requiring urgent action will be picked up by the workflow team and dealt with internally.  
It will not therefore be sent externally.  Correspondence requiring non-urgent action would be returned to the Practice 
by the external company who are regularly audited by the Practice to ensure that they are providing an appropriate 
level  of  service.    In  Oscar’s  case,  the  letter  from  the  Trust  regarding  the  prescription  of  antibiotics  was  not  sent 
externally.  As Oscar had not been registered with the Practice, there was no patient record to attach the letter to on 
our  system.    The  “pending”  folder  that  this  letter  was  erroneously  moved  to  has  now  been  deleted  as  the  Practice 
process for new baby registrations has been amended as above and thus there is no need for this folder.  

If correspondence were to be received for a patient who had never been registered at the Practice before (e.g. likely 
sent to  us in error), this  could be rejected electronically on Docman which sends the document back to the sender 

Brill Surgery 
22 Thame Road 
Brill 
Bucks HP18 9SA 

Chinnor Surgery 
5 Station Road 
Chinnor  
Oxon OX39 4PX 

New Chapel Surgery 
High Street 
Long Crendon 
Bucks HP18 9AF 

Thame Health Centre 
East Street 
Thame 
Oxon OX9 3JZ 

Practice Manager 

Tel: 01844 238284 
Fax: 01844 238568 

Tel:  01844 351230 
Fax: 01844 354328 

Tel: 01844 208228 
Fax: 01844 201906 

Tel: 01844 212553 
Fax: 01844 260243 

VAT Reg No 879 1204 06 

 
 
 
 
 
 
 
 
 
 
 
 
 
 informing them of the reason (checks having been done by us first to ensure that they really are not registered with 
us).    If  the  patient  has  moved  surgeries  and  thus  is  no  longer  registered  at  the  Practice,  we  can  either  reject  that 
correspondence as mentioned above or if we know where the patient has registered, we can print and send it on by 
post/email to the new surgery to avoid any delay. 

Summary 

To conclude, I hope that you and Oscar’s parents are reassured that this matter has been taken extremely seriously 
by  the  Practice  and  that  our  processes  have  been  reviewed  and  improved  (and  will  continue  to  be  reviewed  and 
improved), particularly with regards to the registration of new babies at the Practice. 

Yours faithfully 

Brill Surgery 
22 Thame Road 
Brill 
Bucks HP18 9SA 

Chinnor Surgery 
5 Station Road 
Chinnor  
Oxon OX39 4PX 

New Chapel Surgery 
High Street 
Long Crendon 
Bucks HP18 9AF 

Thame Health Centre 
East Street 
Thame 
Oxon OX9 3JZ 

Practice Manager 

Tel: 01844 238284 
Fax: 01844 238568 

Tel:  01844 351230 
Fax: 01844 354328 

Tel: 01844 208228 
Fax: 01844 201906 

Tel: 01844 212553 
Fax: 01844 260243 

VAT Reg No 879 1204 06 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Brill Surgery 
22 Thame Road 
Brill 
Bucks HP18 9SA 

Chinnor Surgery 
5 Station Road 
Chinnor  
Oxon OX39 4PX 

New Chapel Surgery 
High Street 
Long Crendon 
Bucks HP18 9AF 

Thame Health Centre 
East Street 
Thame 
Oxon OX9 3JZ 

Practice Manager 

Tel: 01844 238284 
Fax: 01844 238568 

Tel:  01844 351230 
Fax: 01844 354328 

Tel: 01844 208228 
Fax: 01844 201906 

Tel: 01844 212553 
Fax: 01844 260243 

VAT Reg No 879 1204 06