Suzanne Edwards

NHS
Bedfordshire Hospitals
NHS Foundation Trust

Bedford Hospital
Kempston Road
Bedford
MK42 9DJ

Mr Tom Osborne
Milton Keynes Coroner Service
Civic 1
Saxon Gate East
Milton Keynes
MK9 3EJ

3rd September 2025

Dear Mr Osborne,

Re: Suzanne Edwards -  Regulation 28 Report to Prevent Future Deaths

I am writing in response to your Regulation 28 Report to Prevent Future Deaths (hereafter "Report")
issued on 1st August 2025 following the Inquest into the death of Suzanne Edwards held on 24th July

2025.

I would like to  begin by extending my sincere condolences to the  family of Mrs Edwards for their

loss. I appreciate this will still be a very difficult time  for the family.

In response to  evidence heard at the Inquest you raised a concern in relation to  Accident and

Emergency Department clinicians not  being able to access primary health care records, in this case

GP records, upon a patient arriving at an Emergency Department. The Bedfordshire Hospitals NHS

Foundation Trust (the Trust) would like to assure both you and the family that the concern raised in

your report has been listened to and reflected upon.

This letter sets out the Trust's formal response.

Regulation 28 Concern

The matter of concern raised and responded to is as follows:

1.  Emergency Departments at hospitals in this and surrounding  jurisdictions do not have
reliable access to patients' primary care records, including recent GP consultations,
investigations or concerns. This means that clinicians are frequently treating acutely unwell
patients without full  access to their recent medical history, which can delay or misdirect
diagnosis and undermine patient safety and continuity of  care and lead to avoidable deaths.
Without access to a patients full  records further lives may be put at risk.

I understand that thankfully the care Mrs Edwards received at the Bedfordshire Hospitals NHS

Foundation Trust was not affected by the concern you raise in the report. As a prompt diagnosis of a

kidney stone was made and the clinical teams swiftly began treating the infection that  had been

caused by the  obstructed kidney; including inserting a stent to  relieve the blockage. Sadly, despite

appropriate pre-operative care, surgery and optimal post-operative treatment in our Critical Care

Complex, Mrs Edwards succumbed to septic shock.

Bedfordshire Hospitals incorporating:
Bedford Hospital, Luton and Dunstable Hospital

 I do of course recognise the risk you have identified that can result when primary and secondary

healthcare providers cannot access each other's medical records. I welcome the opportunity to

explain what access to Shared Care Records (including GP records) our A&E clinicians have at both

the Bedford and Luton & Dunstable hospital sites.  I hope this will assure you that  Bedfordshire

Hospitals NHS Foundation Trust clinicians do, as far as is possible, have access to primary care

records to assist them in the diagnosis of conditions thus reducing the overall risk to patient safety

and further mitigating the risk of future deaths.

Clinicians have access to three services:-

The Shared Care Record (ShCR)

The Shared Care Record (previously known as the Clinical Portal,) represents a collaborative effort

between Bedfordshire Hospitals NHS Foundation Trust and the Bedfordshire, Luton and Milton

Keynes Care Partnership (BLMK), originating in late 2019 and early 2020 in response to NHS

England's mandate for regional Integrated Care Boards.

This platform facilitates the exchange of data among all BLMK health providers in a "read-only"

capacity. The Shared Care Record consolidates healthcare information from various organisations

into a unified, confidential electronic record. Only relevant and accessible healthcare data is shared

on this platform for direct care purposes. Essentially, this provides a broader view of the patient's

history to support joined up care.

It is important to note that patients can, through their GP practice opt out of data sharing which

subsequently means that our clinicians will not be able to see their GP records. However, patients

are automatically opted in unless they make the conscious decision to opt out.

GP Connect

This is a national NHS service that allows authorised clinicians to view the patient's primary care

record so that they can review medications, allergies and any recent GP interactions. It also allows

for the sending and receiving of data, for example, booking appointments or sharing information

between services.

Our A and E clinicians have access to this part of the service via an internal hospital system called

Viper and the Shared Care Record.

Summary Care Record (SCR)

This is a national NHS service which is automatically created from GP records. It contains key patient

information such as medications, allergies and any previous adverse reactions a patient may have

had. The SCR is primarily used in urgent or emergency care when GP records are not accessible. It is

important to note that the patient has the option to opt out of their data being put on to the SCR.

These services have clear benefits for both the patients attending our hospital sites and the clinicians

working within the Emergency Medicine setting.

Benefits of the three system to our patients include:-

(cid:127) 

There are fewer steps for patients, this reduces the repetition of relaying information

multiple times to  different clinicians with the attached risk of missing something vital.

Bedfordshire Hospitals incorporating:
Bedford Hospital, Luton and Dunstable Hospital

 (cid:127)  Medication safety improvements; patients do not need to remember their full list of

medication which may be extensive.

(cid:127) 

(cid:127) 

Improved communication between referrers and service providers.

Improved healthcare outcomes for patients, including patient experience.

Benefits to our Clinicians include:-

(cid:127)  Clinicians are able to make a better informed decision with more extensive information

available at their fingertips.

(cid:127) 

Increased productivity and efficiency as clinicians may not  need to contact other sources,
departments or services.

(cid:127)  An improved user experience and clinical satisfaction; our clinicians are able to do their job

with the right information available to them resulting in positive interactions with patients.

It is not  within the Trust's control to expand upon what patient information is shared on the services

outlined above as the record is taken from the Summary Care Record and GP Connect. The extent of

what is contained in the Summary Care Record is regulated by NHS Digital which forms part of NHS

England.

There are unfortunately certain limitations to  what can be accessed and shared without a single

system for medical records which could be used nationally by all NHS Care providers; but we strive

to ensure that what is available is easily accessible to our treating clinicians.

Thank you for  bringing this important patient safety concern to my attention. As a Trust we are

committed to  working closely with our healthcare partners to ensure that data sharing happens, we

all recognise the vital information sharing that is needed to effectively treat our patients.

Yours sincerely

Chief Executive Officer

Bedfordshire Hospitals incorporating:
Bedford Hospital, Luton and Dunstable Hospital

Mr Tom Osborne 
Senior Coroner for Milton Keynes 

Stoke Mandeville Hospital
Mandeville Road
Aylesbury
Buckinghamshire
HP21 8AL

Friday 8 August 2025 

Dear Mr Osborne 

REF: Regulation 28 Report to Prevent Future Deaths 

Thank you very much for your Report dated 1 August 2025 and for your request regarding visibility of 
primary care records. 

In Buckinghamshire we are fortunate to have a Summary Care Record which contains a record of 
encounters with all health services. This includes primary care diagnosis codes and lists, medication 
lists and brief summaries of primary care appointment outcomes. The Summary Care Record is visible 
to all hospital colleagues and access will be linked into our Acute Electronic Patient Record front 
screen when this launches in September / October 2025. This visibility would I believe mitigate against 
the issues noted in the Report although at the moment some patients have opted out across the 
system as a matter of personal choice. 

In addition, many of our colleagues have access to the full GP record in EMIS if they are working in 
our Trust community services. 

Yours sincerely, 

Chief Executive 
Buckinghamshire Healthcare NHS Trust 

Providing a range of acute and community services across Buckinghamshire

Mr Tom Osborne 
HM Senior Coroner  
Milton Keynes Council 

23 September 2025 

Dear Mr Osborne 

Regulation 28 Report following Inquest into the death of Mrs Suzanne Edwards 

I am writing following receipt of a Regulation 28 report dated 01 August, relating to the 
Inquest concluded on 24 July 2025. Mrs Edwards died from septic shock secondary 
to pneumonia and urosepsis, the latter associated with a calculus. I was sorry to learn 
of Mrs Edwards’ death. I understand that MKUH was not named as an interested party 
prior to the Inquest, the Trust was not legally represented, and Trust witnesses were 
not  called  to  provide  oral  testimony.  Over  a  period  of  48  hours,  Mrs  Edwards  had 
contacts  with  her  GP  and  the  MKUH  Emergency  Department  and  had  then  been 
admitted to Bedford Hospital under urology where she subsequently died. MKUH and 
Bedford Hospital operate a shared urology ‘out of hours’ service at Consultant level.    

Whilst the Record of Inquest suggests that you were satisfied that management was 
appropriate at each specific step, you were concerned that there had been a failure to   
recognise signs of urinary tract obstruction resulting in a lost opportunity to treat this 
prior to the onset of sepsis.  

The  Regulation 28  report  (sent  to  MKUH  and  separately  to  neighbouring  hospitals) 
articulates a concern that staff in Emergency Departments do not have reliable access 
to patients’ primary care records. You expressed the view that this lack of access can 
delay or misdirect diagnosis and undermine patient safety and continuity of care and 
lead to avoidable deaths.    

Whilst challenging to provide a comprehensive response having not been party to the 
Inquest, I shall outline the issues in this area as seen by MKUH and the actions we 
have taken and continue to take on this issue.  

It is perhaps useful to consider the historic position of paper-based notes where all 
different care providers maintained a physically separate clinical record. Primary Care 
and  some  hospitals  have  moved  decisively  towards  electronic  records.  Electronic 
records have many benefits including the potential to share content across providers 
(at least in a ‘read-only’ manner). Concerns do naturally persist in relation to the legal 
status of the record (and a reluctance therefore to have ‘third parties’ edit or write into 
the  record)  and  information  governance  (in  terms  of  ensuring  that  access  to 
confidential  personal  data  is  appropriate  and  has  a  legal  basis).  MKUH  is  relatively 
advanced  in  terms  of  its  digital  infrastructure  and  has  rolled  out  Oracle  Health’s 
Millennium  product  incrementally  since  2018  (known  locally  as  eCare).  Our  tertiary 

 
 
 
 
 
 
 
 
 
 
 
 
 provider (Oxford University Hospitals) uses a separate instance of the same product. 
Neighbouring providers use other systems including SystmOne (Primary Care, CNWL 
community  and  Buckinghamshire  Hospitals),  Nerve  Centre  (Bedfordshire  Hospitals 
NHS  Foundation  Trust)  and  EMIS  /  System  C  (Primary  Care  in  Oxfordshire  and 
Buckinghamshire).  

One important element of Oracle Health’s product is the Health Information Exchange 
(HIE). The HIE acts as an interface between the MKUH instance of Oracle Health’s 
Millennium and other instances, or third-party products (including SystmOne, System 
C and Nerve Centre). In some cases (specifically Nerve Centre), some ‘middleware’ 
known  as  Intersystems  is  required  for  this  connection.  The  HIE  acts  as  a  ‘window’ 
through which selected content of one record system can be seen from within another 
system. This works in both directions: for example, selected content from SystmOne 
can be seen from within Millennium, and selected content from Millennium can be seen 
from within SystmOne. The entire record is not typically visible through HIE, rather a 
selected  subset  of  documents  and  data  items  within  the  record.  The  range  of 
documents and data items that can be seen through HIE is determined by the owner 
of  the  clinical  record:  in  other  words,  MKUH  determines  what  information  to  render 
visible to others through the HIE window. Only a subset of the record is shared for 
several  reasons:  the  volume  of  data  which  is  collected  during  a  relatively  short 
secondary  care  inpatient  episode  is  very  large  (as  you  are  aware  from  records 
provided to assist in your coronial inquiries); some parts of the record would be of no 
discernible  use  to  those  outside  the  hospital;  some  of  the  data  are  such  that 
interpretation  is  required  in  order  to generate  usable  information;  and,  the  ability  to 
structure  records  within  HIE  is  very  limited  (such  that  there  is  limited  ‘search 
functionality’, and it can be difficult to find the desired information within ‘background 
noise’). 

The information shared by Primary Care through HIE is variable but can offer a more 
complete  view  of  the  primary  care  record.  The  patient  can  have  limited  input  into 
determining  how  much  of  their  Primary  Care  record  is  visible  through  HIE.  There 
remain  challenges  as  to  how  HIE  users  locate  important  and  pertinent  information 
within the view that they are afforded. The way in which information is arranged is not 
intuitive.  Whilst  key  information  may  be  accessible  in  theory,  it  can  be  less  so  in 
practice.   

MKUH has developed HIE linkages with many other providers.  

Specific challenges in the MKUH footprint include: 

1.  Variable maturity of digital records (meaning that in some instances there is still 
relatively  little  digital  information  to  share).  Bedfordshire  Hospitals  NHS 
Foundation  Trust  is  still  in  the  implementation  phase  of  its  electronic  record 
(Nerve Centre).  

2.  Variable willingness of other providers to establish HIE links. This is a particular 
challenge  with  Primary  Care  in  Oxfordshire  and  Buckinghamshire  (including 

 
 
 
 
 
 
 
 
 
 Aylesbury Vale / Buckingham from where patients frequently access urgent and 
emergency  care  at  MKUH).  Leaders  in  the  Thames  Valley  have  a  strategic 
preference  for  sharing  the  content  of  care  records  via  the  Thames  Valley 
Shared Care Record. Whilst this is rational (from the perspective of wanting to 
drive real patient benefits from this shared care record), it does lead to gaps in 
the HIE environment described above. Discussions are ongoing.  

At MKUH, we continue to:  

  optimise our eCare record for sharing via HIE;  
  establish HIE links with all providers with whom we have a significant number 

of common patients; 

  educate clinicians internally and externally about the benefits and possibilities 

of HIE; and, 

  encourage other providers to share more pertinent content from their records 

with us via HIE.    

I append several illustrations to demonstrate our activity and energy in this area.  

Fig. 1   

HIE Connections to other provider record systems set up by MKUH  

MKUH Health Information Exchange (HIE) Connections  
Connection 
BLMK GP Practices 
Willen Hospice 
MK Urgent Care 
CNWL Community 
One London 
Oxford University Hospitals 
Bedfordshire Hospitals  
MKCC – Adult Social Care 
MKCC – Children’s Services 
Connection available but not activated 
Swan and North Bucks PCNs 
Thames Valley Shared Care Record 

Type 
Primary Care 
Community 
Urgent Care 
Community 
Various 
Tertiary 
Acute 
Social Care 
Social Care 

Primacy Care 
Primary Care / Various 

 
 
 
   
 
 
 
 
 
 
 
 
 Fig. 2a 

HIE Interface as seen in MKUH’s eCare (Oracle Health’s Millenium)  

 
 
 
 
 
 
 
 
 Fig. 2b 

HIE Interface as seen in Primary Care’s SystmOne 

Fig. 3a 

Upsurge in HIE usage by sector, 2020-23 

 
 
 
 
 
 
 
 
 
 Fig. 3b 

Items accessed through HIE, 2020-23  

Sections most commonly viewed
by GPs / MKUH

(data 1 -31 Jan 2020 – 2023)

I trust that this response is helpful.  

Yours sincerely, 

Chief Executive Officer 

Copies 

CEO, Bedfordshire Hospitals NHS Foundation trust  
, Interim CEO, Buckinghamshire Healthcare NHS Trust