Akhona Moyo

Regulation 28: REPORT TO PREVENT FUTURE DEATHS

NOTE: This form is to be used after an inquest.

REGULATION 28 REPORT TO PREVENT DEATHS

THIS REPORT IS BEING SENT TO:

1 Secretary of State for Health and Social Care
2 Northampton General Hospital
3 NHS ENGLAND

1

CORONER

I am Hassan SHAH, Assistant Coroner for the coroner area of Northamptonshire

2

CORONER’S LEGAL POWERS

I make this report under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009
and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.

3

INVESTIGATION and INQUEST

On 20 December 2022 I commenced an investigation into the death of Akhona MOYO aged
4. The investigation concluded at the end of the inquest on 27 January 2026. The
conclusion of the inquest was that:

Akhona Moyo died 26 November 2022 at Queens Medical Centre, Nottingham as a result of
a brain tumour. Had he been admitted to hospital on 23rd November 2022, scanned earlier
in the day on 24 November 2022 and received earlier intervention directed at reducing
intracranial pressure, he probably would have survived.

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CIRCUMSTANCES OF THE DEATH

Akhona Moyo died 26 November 2022 at Queens Medical Centre, Nottingham as a result of
a brain tumour. Had he been admitted to hospital on 23rd November 2022, scanned earlier
in the day on 24 November 2022 and received earlier intervention directed at reducing
intracranial pressure, he probably would have survived.

The medical cause of death was: -

1a. Acute obstructive hydrocephalus
1b. Posterior fossa ependymoma

A narrative conclusion was given as above.

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CORONER’S CONCERNS

During the course of the investigation my inquiries revealed matters giving rise to concern.
In my opinion there is a risk that future deaths could occur unless action is taken. In the
circumstances it is my statutory duty to report to you.

The MATTERS OF CONCERN are as follows:
(brief summary of matters of concern)

Hospital doctors, including in the Emergency Department and Paediatrics, do not have
electronic access to primary care medical notes e.g. GP notes, community mental health
notes etc. At Northampton General Hospital, a new electronic system known as “Nerve

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

 Centre” contains only hospital notes. Hospital doctors also have access to the
“Northamptonshire Care Record” which contains basic lists of GP visits and medication, but
no detailed entries.

All the doctors that gave evidence to the Inquest stated that access to primary care records
would undoubtedly assist them in delivering better patient treatment and care. It was felt
that access to such information was particularly important in cases such as the present
when a patient is autistic and non-verbal. There may be a multitude of other reasons why a
patient or their family may not be able to relay to doctors a full and accurate medical
history. Access may also enable doctors to have a more global view of a patient’s medical
condition rather than, as it was put at Inquest, “working in silos”.

6

ACTION SHOULD BE TAKEN

In my opinion action should be taken to prevent future deaths and I believe you (and/or
your organisation) have the power to take such action.

7

YOUR RESPONSE

You are under a duty to respond to this report within 56 days of the date of this report,
namely by March 24, 2026. I, the coroner, may extend the period.

Your response must contain details of action taken or proposed to be taken, setting out the
timetable for action. Otherwise you must explain why no action is proposed.
COPIES and PUBLICATION

8

I have sent a copy of my report to the Chief Coroner and to the following Interested
Persons

Northampton General Hospital
Delapre Medical Centre

I am also under a duty to send a copy of your response to the Chief Coroner and all
interested persons who in my opinion should receive it.

I may also send a copy of your response to any person who I believe may find it useful or
of interest.

The Chief Coroner may publish either or both in a complete or redacted or summary form.
He may send a copy of this report to any person who he believes may find it useful or of
interest.

You may make representations to me, the coroner, at the time of your response about the
release or the publication of your response by the Chief Coroner.

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Dated: 28/01/2026

Hassan SHAH
Assistant Coroner for
Northamptonshire

Regulation 28 – After Inquest
Document Template Updated 30/07/2021

Parliamentary Under-Secretary of State for 
Health Innovation and Safety 

39 Victoria Street 
London 
SW1H 0EU 

06 March 2026 

Our Ref: 

HM Assistant Coroner Hassan Shah 
Northamptonshire 

By email: 

Dear Mr Shah,  

Thank you for the Regulation 28 report of 28/01/2026 sent to the Secretary of State for Health 
and Social Care about the death of Akhona Moyo. I am replying as the Parliamentary Under-
Secretary of State with responsibility for data and technology.       

Firstly, I would like to say how saddened I was to read of the circumstances of Akhona Moyo’s 
death and I offer my sincere condolences to their family and loved ones. The circumstances 
your report describes are concerning and I am grateful to you for bringing these matters to 
my attention. 

The report raises concerns over (1) A lack of electronic access to primary care medical notes 
(2) A lack of detailed entries in the Northamptonshire Care Record. 

I agree that ensuring health and care professionals have access to a single source of digital 
information about the patients they are treating and caring for is vitally important to 
delivering the best care possible. The Department of Health and Social Care, and NHS 
England have programmes of work underway which should assist in preventing future 
deaths connected to this issue. 

The Single Patient Record (SPR) will unify patient data from multiple sources into one easy-
to-access platform for patients and clinicians. The SPR will bring together fragmented 
pieces of information, creating a single source of truth which improves care quality, reduces 
administrative burden, empowers patients and enables more effective use of health data for 
both care delivery and research. A single source of patient information will ensure that 
clinicians are able to view a patient’s test results and diagnostic activity among other patient 
alerts, which will prevent important patient information from being missed by clinicians. 

The SPR is designed to harmonise with existing data systems being used by healthcare 
professionals which will allow them to access the SPR through their existing clinical 
systems. Seamless data sharing through the SPR will significantly reduce administrative 
burden for clinicians. The Government’s 10 Year Health Plan specifically commits to saving 
NHS staff an estimated 140,000 hours annually. This will free up valuable clinical time for 
clinicians to focus on direct patient care.  

 
 
 
 
 
 
 
 
 
 
  
  
   
 
 
  
 I hope this response is helpful. Thank you for bringing these concerns to my attention.   

Yours sincerely, 

Parliamentary Under-Secretary of State  
for Health Innovation and Safety

Mr H Shah 
Assistant Coroner for Northamptonshire 
The Guild Hall 
St Giles Square 
Northampton 
NN1 1DE 

Kettering General Hospital 

Rothwell Road 

Kettering NN16 8UZ 

Northampton General Hospital 
Cliftonville 
Northampton NN1 5BD  

Main Switchboard: 0153

18th February 2026 

Dear Mr Shah 

Regulation 28: Report to prevent future deaths: Akhona Moyo 

I write in response to the above reported issued on 28th January 2026 to 
Northampton General Hospital (NGH), which is part of University Hospitals of 
Northamptonshire NHS Group. 

I would like to firstly express my sincere condolences to the family of Akhona and to 
acknowledge and apologise for the concerns identified at inquest in relation to our 
clinicians’ access to electronic primary care records. 

This response details the position in November 2022, when Akhona was in our care 
and the progress made to date on improving access to healthcare records held by 
primary care providers. 

The Position in November 2022 

Clinicians at NGH had access to the following primary care healthcare information: 

•  The Spine Summary Care Record (SCR), containing medications, allergies 

and adverse reactions; 

•  The Medical Interoperability Gateway (MIG), which required a separate login 

to access GP data; 

Unfortunately, the Northamptonshire Care Record (NCR) and GP Connect were not 
available at NGH at that time. 

1 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 Progress since November 2022 

As a Hospital Group, we have made significant progress in improving clinicians' 
access to primary care information: 

•  Northamptonshire Care Record (NCR) 

This is now available at NGH, providing clinicians with access to GP data 
including medications, allergies, diagnoses, and lists of GP consultations.   
This has single sign-on integration from our clinical system (Nervecentre) into 
NCR and this element is currently in final testing and expected to be available 
within weeks, removing the need for separate logins. 

•  GP Connect  

This is now available at NGH, providing structured data from GP records 
including medications and allergies. 

•  Summary Care Record  

Was available at the time but only contained basic demographic and allergy 
information. All the information in the SCR has been moved into the NCR and 
it has been suprceeded by it.    

These improvements mean that clinicians now have significantly better access to 
primary care information than was available in November 2022. 

Limitations and the national context  

We are working within the national boundaries of what is currently achievable in 
terms of being able to access general practitioner consultation notes and free text 
entries within primary care.  We share the views of our clinicians that such access 
would benefit patient care, but there are currently significant national barriers to 
overcome before this is possible: 

•  The national roadmap 

Unfortunately, full GP free text consultation notes are not currently within the 
scope of national programmes for shared care records (including the National 
Record Locator and Shared Patient Record workstreams). The data currently 
shared comprises structured fields rather than narrative clinical entries. 

• 

Information governance 
Direct read access to GP clinical systems (EMIS and SystmOne) has been 
explored previously in Northamptonshire. This requires individual data sharing 
agreements with each of the 66 GP practices in the county, plus consideration 
of practices across county boundaries whose patients attend our hospitals. 
Previous attempts to negotiate these agreements did not progress. 
Additionally, 20% of Northamptonshire patients are registered with practices 
using EMIS rather than SystmOne, and any solution would need to ensure 
equitable access for all patients. 

2 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 In working within the above constraints, we are committed to maximising the 
information available to clinicians and our ongoing work includes: 

•  We aim to complete by the end of February 2026, single sign on integration 
from Nervecentre to the National Care Record (NCR), enabling seamless 
access; 

•  By the end of March 2026, we will raise the requirement for GP free text 
access with the National Record Locator and Shared Patient Record 
Programme Boards; 

•  We are continuing to work with Northamptonshire Integrated Care Board to 

explore options for enhanced data sharing within primary care; 

•  We are ensuring that Accident and Emergency Department attendance 

summaries and discharge notifications from NGH are shared with the NCR to 
improve information available in other care settings.  We will review progress 
during June 2026; 

We note that whilst digital solutions can significantly improve information availability, 
they cannot entirely replace clinical communication.  The option for clinicians to 
contact a patient’s GP directly for information remains available and is standard 
practice where there are concerns about incomplete information.  This is also the 
business continuity process when digital systems are unavailable, when a patient 
has opted out of data sharing or when a patient may be unable to communicate 
clearly. 

I trust that the above information and progress to date demonstrates the substantial 
improvements to primary care information access since November 2022.  I 
acknowledge that full GP consultation notes remain unavailable and that achieving 
this would require national actions on data standards and information governance 
frameworks.  I can provide assurance that we will continue to advocate this through 
the appropriate national forums. 

We remain committed to doing everything within our power to ensure clinicians have 
the information they need to deliver safe, effective care. 

Yours sincerely 

UHN Deputy Medical Director  

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