Ellen Taylor

Miss Sarah Middleton 
Assistant Coroner for Northumberland 
Coroner’s Office 
Northumberland County Council 
County Hall 
Morpeth 
Northumberland 
NE61 2EF 

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

28 April 2026  

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Ellen Victoria Floyd 
Taylor who died on 1st July 2025.  

Thank  you  for your Report to  Prevent  Future  Deaths  (hereafter “Report”) dated 9th 
February 2026 concerning the death of Ms Ellen Victoria Floyd Taylor on 1st July 2025. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Ms  Floyd Taylor’s family and loved ones. NHS 
England is keen to assure the family and yourself that the concerns raised about Ms 
Floyd Taylor’s care have been listened to and reflected upon.   

I am grateful for the further time granted to respond to your Report, and I apologise for 
any anguish this delay may have caused to Ms Floyd Taylor’s family or friends. I realise 
that responses to Coroners’ Reports can form part of the important process of family 
and  friends  coming  to  terms  with  what  has  happened  to  their  loved  ones,  and  I 
appreciate this will have been an incredibly difficult time for them. 

Your Report raises concerns that previous surgery, and possible altered anatomy was 
unclear in the medical notes and thus in investigations. Additionally, previous surgery 
was not a routine consideration when inserting a nasogastric tube and is not included 
in the nasogastric tube guidelines. Whilst local guidelines have changed as a result of 
Ms Floyd Taylor’s death, you were concerned that this is a risk nationally without a 
national guideline.  

The responsibility for clinical guidance sits with the National Institute for Health and 
Care  Excellence  (NICE).  We  would  advise  the  Coroner  to  contact  NICE  directly  to 
address concerns regarding   the guidance.  

NHS England were not in attendance at the inquest and it is not clear from the Report 
if  the  clinical  team  completed  a  pH  check  after  insertion  of  the  nasogastric  tube. 
Checking the pH of liquid aspirated out of the nasogastric tube before using the tube 
is normally done to show this is acidic, as would be expected in the stomach. Usually, 
the pH in the stomach is less than around 5.5 although can be higher if patients are 

                                                                                                                       
 
 
 
 
 
 
 
  
 
 
 on acid suppressing medication. The pH in the small bowel is normally around 6 to 8. 
If  this  patient  wasn't  on  acid  suppressing  medication  and  the  pH  was  higher  than 
expected, that may have alerted the team sooner that the tip of the tube was not in the 
stomach. 

 Past medical history in patient records 

We note your concern centres around the fact that Ms Floyd Taylors’ previous surgery 
was not obvious from her notes, and you note that ‘this was not known’ to clinicians 
caring  for  her.  NHS  England  recognises  that  limited  information-sharing  within  and 
between care settings can contribute to delays in discharge, cause handovers to  be 
incomplete and create less effective continuity of care. 

NHS England has developed and led for the last 5 years a Frontline Digitisation (FD) 
Programme,  which  has  supported  provider  organisations  across  England  to  adopt 
Electronic  Patient  Record  (EPR)  systems  which  support  increased  consistency  in 
digital maturity but also improve information sharing within and between organisations. 

The  FD  Programme  enables  provider  organisations  to  procure  EPR  systems  and 
provides  guidance  on  their  implementation  to  enhance  local  digital  capability  and 
interoperability, including the ability of different digital systems to communicate more 
effectively. However, these systems are typically configured and managed locally, in 
line with agreements between provider organisations and their technology suppliers. 
As  a  result,  interoperability  often  varies  depending  on  local  infrastructure  and 
information governance arrangements. Where multiple digital systems, including EPR 
systems  and  Radiology  Information  Systems  (RIS),  are  in  use  across  a  provider 
organisation,  policies  and  procedures  should  be  in  place  to  outline  expectations, 
advice, and guidance regarding clinical record management. 

Responsibility and accountability for the sharing of information held within electronic 
records, including across different systems, rests with each organisation through its 
established digital governance processes. Information sharing across digital records 
is governed through established Information Governance.  In practice, organisations 
do not generally share the entire patient record as a single dataset. Information sharing 
is purpose-led and governed through a combination of information governance, clinical 
governance  and  clinical  safety  processes  (information  sharing  agreements,  role-
based  access,  audit  trails  and  clinical  safety  assurance),  ensuring  disclosures  are 
necessary, proportionate and safe for the stated purpose. The disclosing organisation 
determines  what  information  is  necessary  and  proportionate  for  the  intended  care 
purpose,  applies  patient  confidentiality  requirements  and  local/national  choice 
mechanisms where relevant and uses role-based access controls (RBAC) and audit 
trails  to  ensure  ‘need-to-know’  access.  Shared  information  is  therefore  typically  a 
defined subset of information such as clinical summary, which would usually contain 
information regarding medications, allergies, key problems, recent results/encounters 
and relevant documents appropriate to the clinical context.  

Northumbria  Specialist  Emergency  Care  Hospital  is  a  hospital  specialising  in 
emergency  care  for sick  and  injured patients  (managed  by  Northumbria  Healthcare 
NHS  Foundation  Trust). It  had  previously  used  a  ‘Best of Breed’ approach  towards 
achieving digital maturity. As this did not meet the FD Programme core standards it 

 received funding in 2023/24 as part of the FD Programme to support optimisation of 
their EPR through the development of a clinical noting tool for clinical teams to record 
details of patient care/treatment that would have previously been a paper process. 

The FD Programme not only enables organisations to purchase EPRs but also advises 
on  safe  and  effective  deployment.  However,  whilst  the  FD  Programme  supports 
investment  into  local  digital  capabilities,  interoperability  i.e.  how  different  digital 
systems communicate with one another, is typically configured and managed at a local 
level, based on local arrangements between provider organisations (although regional 
centres will be cognisant of the wider catchment area) and their technology suppliers. 
As such, interoperability may vary depending on local infrastructure and information 
the 
governance  arrangements.  Access  and 
Northumberland Care record is determined by local policy and procedures. 

information  contained  within 

Developing this further NHS England and the Department of Health and Social Care 
published  the  Fit  for  the  future:  10  Year  Plan  for  England,  which  sets  out  the 
government’s plan for healthcare in England over the next 10 years. It also sets out a 
commitment to give patients ‘a single, secure and authoritative account of their data – 
a  single  patient  record  –  to  enable  more  coordinated,  personalised  and  predictive 
care.’ 

NHS England is aware of the challenge in sharing medical records and results within 
the  variability  between  areas  using  different 
organisations  and  recognises 
technologies.  The  FD  programme  continues  to  work  across  the  health  and  care 
system  to  support  greater  integration  and  awareness  of  record  sharing  between 
providers. NHS England is also working with the Shared Care Records Programme 
which supports wider access to relevant patient information. 

When new EPR systems are deployed the management of historical records is one of 
the critical features of deployment and this would have been locally agreed between 
the trust and the EPR supplier. Visibility of key events of a person’s clinical history is 
a critical component.  

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 Ms 
Floyd  Taylor, are  shared  across  the  NHS  at  both  a  national  and  regional  level  and 
helps us to pay close attention to any emerging trends that may require further review 
and action.   

Thank you for bringing these important patient safety issues to my attention and please 
do not hesitate to contact me should you need any further information.  

Yours sincerely,  

 
 
  
 
  National Medical Director 
 NHS England