Stephen Rhodes

Mr Zafar Siddique 
Senior Coroner for the Black Country 
The Coroner’s Court 
Jack Judge House 
Halesowen Street 
Oldbury  
B69 2AJ 

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

By Email: 

9 April 2026 

Dear Coroner, 

Re: Regulation 28 Report to Prevent Future Deaths – Stephen Martin Rhodes 
who died on 11 March 2025. 

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  6th 
February 2026 concerning the death of Stephen Martin Rhodes on 11th March 2025. 
In advance of responding to the specific concerns raised in your Report, I would like 
to express my deep condolences to Mr Rhode’s family and loved ones. NHS England 
is keen to assure the family and yourself that the concerns raised about Mr Rhode’s 
care have been listened to and reflected upon.   

Your Report raised concerns that laboratory reports don’t flag or highlight an abnormal 
blood result on the front page of the report. You advised that NHS England may wish 
to review any national guidance on how abnormal results are flagged by laboratories.  

The responsibility for the formatting, structure and presentation of pathology results 
sits primarily with:  

•  The laboratory information management system (LIMS) supplier, and  
•  The  GP  clinical  system  supplier,  who  determines  how  results  are  displayed 

once the results have been received  

NHS  England’s  role  has  been  to  set  out  a  range  of  interoperability  standards.  The 
current standard that guides how the flow of information passes between the pathology 
report laboratory and the receiving GP practice is the called the ‘Pathology Messaging 
Implementation Project - Electronic Data Interchange for Administration, Commerce 
and Transport (PMIP EDIFACT) Standard.    

If a laboratory test result falls outside the normal range, the PMIP EDIFACT pathology 
report includes a marker in most cases to show this. GP records system providers can 
use this marker to alert the receiving GP that the result is abnormal or different from 
the  expected  range.  This marker is called  the  ‘Deviating  Results Indicator.’  It  is the 
responsibility of the GP system provider to ensure this information is clearly displayed 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 and thus properly received to the GP. We note that you have indicated the supplier in 
this case has already responded to the need for greater visibility of abnormal results.  

EDIFACT is a legacy product, and NHS England is currently promoting the adoption 
of  a  new  nationally  agreed  Pathology  Messaging  Standards  using  Fast  Healthcare 
Interoperability Resources (FHIR). The new system will:   

•  Allow results to be sent in a structured way to GPs so their computer systems 
can read them more easily which reduces the risk of mistakes and helps ensure 
nothing important is missed.  

•  Enable standard clinical coding system called SNOMED CT to be used, which 
helps ensure test names and results mean the same thing everywhere and to 
every practice. This improves communication between laboratories, hospitals, 
and GP practices.  

•  Ensure  results are  sent  using  a  secure  NHS  messaging  system which  helps 

keep personal medical information safe.  

•  These  changes  will  initially  cover  common  tests  such  as  blood  counts, 
biochemistry  (like  kidney  or  liver  tests),  immunology,  and  microbiology 
(infection tests) but will widen its scope over time.  

NHS England’s Pathology FHIR Specification is one of the data products mandated 
for use in the DAPB4101: Pathology and Laboratory Medicine Reporting Information 
Standard. The Information Standards Notice (Amd 63/2023) that supports DAPB4101 
was issued on 15th April 2024. 

The  Pathology  Transformation  and  Interoperability  Programme  in  NHS  England  is 
currently undertaking the opportunity to promote:  

•  Wider standardisation of pathology result flagging conventions 
•  Strengthen  digital  clinical  safety  assurance  across  Laboratory  Information 

Management System and primary care systems  

To  help  providers  and  system  suppliers  integrate  the  Pathology  FHIR  Specification 
and  reach  conformance  with  DAPB4101,  four NHS  England  teams  (Core  Services, 
Digital  Services  for  Integrated  Care,  Diagnostic  Digital  Capability,  and  Terminology 
Design) are working together to create a roadmap for national adoption. 

A pilot is underway to establish and prove how a DAPB4101 pathology report can be 
sent from labs and ingested by GP practices safely. This will involve working with the 
GP  system  supplier,  and  the  three  pathology  middleware  suppliers  that  enable 
national  coverage  for  lab  to  GP  reporting  as  well  as  with  Berkshire  &  Surrey  NHS 
Pathology Services. Once the pilot has completed, implementing DAPB4101will then 
go  onto  NHS  England's  GP  system  suppliers’  managed  roadmap  of  development 
work, leading to national roll-out. 

GP Practice Systems and Result Handling Processes  

Your report notes that the practice handles ‘several hundred’ reports per day.  

 NHS England recognises the need for robust result review processes are needed at 
pace in busy practices and the ability to correctly assign and act on results.  

While  operational  arrangements  are  managed  at  individual  practice  level,  NHS 
England has published several resources available to support safe systems of work, 
including:  

•  Clinical messaging and test results. This guidance is part of the Data sharing 
and  interoperability  section of  the Good  practice  guidelines for  GP  electronic 
patient records.  

•  Use of clinical  decision  support NHS  England  »  Supporting  clinical  decisions 

with health information technology  

•  Digital clinical safety standards (DCB0129/DCB0160)  

All of which support safer practice.  

Auto reviewing of pathology results  

Some  GP  practices  employ  third‑party software  solutions  that use  Robotic  Process 
Automation (RPA) to support or automate the handling of both normal and abnormal 
laboratory  results.  These  RPA  tools operate  outside  of  the  digital  safety  assurance  
work  undertaken  by  NHS  England.  Some  of  the  major  GP  records  suppliers  have 
introduced  significant  robotic  automation  capabilities  for laboratory tests  within  their 
electronic patient record systems which have been specifically designed to reduce the 
administrative burden on GPs and improve patient safety. This system, often referred 
to as "auto-reviewing" or "Pathology Auto-review" automatically processes, files, and, 
in some cases, manages the follow-up of test results. Auto‑review and auto‑filing of 
pathology results in GP systems can only ever be safe if “normal” is interpreted in the 
context  of  the  individual  patient,  not  just  the  laboratory  reference  range,  so  these 
functions need stringent governance, testing, feedback, and monitoring.  

Other Guidance includes:  

•  GP mythbuster 46: Managing test results and clinical correspondence  - Care 
Quality Commission which informs practices on how they should manage test 
results and clinical correspondence and   

•  The  General  Medical  Council Good  Medical  Practice  2024 establishes the 
professional duties that underpin safe test result handling, including providing 
a good standard of care, ensuring continuity, and acting on info  

Patient safety is at the heart of NHS England’s role and the 2024 ‘Primary Care Patient 
Safety  Strategy’ describes  some  of  the  work  and  approaches  being promoted by 
NHSE. The Patient Safety Team (clinician’s) and technology teams work in step with 
one another to support patient safety related to digital systems and technology clinical 
assurance processes.  

NHS  England’s Patient  Safety  teams and Digital  Clinical  Safety  team  have  a 
programme  of  work  that  monitors  reported  clinical  incidents  via  the  Learning  From 

 Patient Safety Events (LFPSE) portal which receives incidents reported by all clinical 
organisations  funded  by  the  NHS.  This  activity  includes looking  for  any  emerging 
trends  and includes  a review  of  all  PFD reports to  ensure  that  any  lessons  learned 
from  incidents  are  discussed  and  fed  into  future  national  policy  on  patient  safety. 
via specific advice given, incorporated 
Learning may 
into training sessions or documented guidance or 
is shared 
with suppliers, technologists and Digital  Clinical Safety Officers 
line  with DCB 
standards which help ensure digital health products are safe and help to reduce harm 
events and in line with the Patient Safety Strategy.   

Learning 
in 

shared 

policy. 

be 

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  Mr 
Rhodes 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

Quarry Bank Medical Centre
High Street
Quarry Bank
Brierley Hill
West Midlands
DY5 2AE
4 April 2026

Mr Zafar Siddique
Senior Coroner
Black Country Area

Re: Regulation 28 Report to Prevent Future Deaths – Mr Stephen Martin Rhodes 
(Deceased)

Dear Mr Siddique,

We write in response to the Regulation 28 Report to Prevent Future Deaths sent to Quarry 
Bank Medical Centre (“the Practice”), dated 6 February 2026. We are pleased to confirm that 
this response is provided within the 56-day period required, by 6 April 2026.

We have taken the circumstances surrounding the death of Mr Rhodes extremely seriously. 
A formal written response has been sent to Mrs Rhodes offering condolences, setting out the 
circumstances as understood by the Practice, and detailing the system-level changes 
implemented following review. The Practice has also offered to meet with Mrs Rhodes in 
person to discuss the matter further should she wish to do so. The Practice has engaged 
openly and transparently throughout the coroner’s investigation and will continue to do so.

By way of context, laboratory blood test results are transmitted directly from ICE, the 
laboratory reporting system, into EMIS Web, the Practice’s clinical system. EMIS Web has 
an inbuilt results management filter function. When laboratory results are received, the ICE 
system assigns an abnormal alert flag to any result that falls outside the defined reference 
range. Within EMIS Web, each GP manually applies the results management filter by 
clicking within the system. This filter segregates incoming results into two distinct categories 
based on the presence or absence of a laboratory abnormal alert flag: those carrying an 
alert, which require clinical review and action, and those without an alert, which are filed as 
normal results. The purpose of applying this filter is twofold: to file normal results efficiently, 
and to identify and take prompt clinical action on abnormal results. This ensures that results 
requiring attention are not overlooked within the volume of daily pathology reports and that 
each GP can direct focused clinical review to those results that carry a laboratory abnormal 
alert. Each GP is expected to review and action their results within 24 hours of receipt.

In respect of the late Mr Rhodes, blood tests including NT-proBNP were requested on 13 
September 2024 following presentation with progressive shortness of breath. A chest X-ray 
was also requested. The blood test results were received on 17 September 2024. The 
requesting clinician did not review and file the results at the time they became available. The 
results were subsequently reviewed and filed by a different clinician. As the NT-proBNP 
result did not carry a laboratory alert flag at that time, it was not identified as requiring action 
during the manual filtering process and entered the normal results pathway, where it was 
processed and filed without the laboratory’s recommendation for urgent specialist referral 
being actioned.

 We wish to address the chest X-ray result separately. The X-ray report indicated findings in 
keeping with suspected COPD, consistent with the clinical indication on the request form. 
This result was reviewed, acted upon, and followed up: spirometry was requested to confirm 
the diagnosis and reception staff were tasked with contacting Mr Rhodes to inform him of the 
results and arrange the necessary referral. The pathway failure in this case was therefore 
specific to the NT-proBNP result not carrying a laboratory alert flag, rather than reflecting a 
general failure of results management across the Practice.

Please find enclosed a copy of the Significant Event Analysis (SEA) minutes for your 
records.

Significant Event Analysis

 The SEA was reviewed and updated on 18 February 2026 

A formal Significant Event Analysis was initiated on 30 April 2025, led by the Practice 
Manager, 
following the conclusion of the coroner’s inquest. The review involved clinical and 
administrative input and examined the systems and processes surrounding the ordering, 
receipt, filing, and actioning of the late Mr Rhodes’ blood test results. The primary cause was 
identified as failure to appropriately scrutinise and act upon a significantly abnormal NT-
proBNP result, with contributory factors including the absence of a laboratory alert flag, the 
high daily volume of pathology reports, and the absence at that time of a structured 
escalation protocol for high-risk cardiac biomarkers. All agreed actions were completed by 
18 February 2026. The SEA records the likelihood of reoccurrence as rare.

Duty of Candour

The Practice confirms that its Duty of Candour obligations under Regulation 20 of the Health 
and Social Care Act 2008 (Regulated Activities) Regulations 2014 have been discharged. 
This was completed on 18 February 2026, as recorded within the enclosed SEA. The 
Practice wishes to highlight that it was the Practice itself that first identified the issue 
following the death of the late Mr Rhodes, and proactively communicated with Mrs Rhodes 
following the conclusion of the coroner’s inquest on 29 January 2026. The written response 
sent to Mrs Rhodes acknowledges the findings of the inquest, offers condolences, and sets 
out the changes implemented by the Practice. An offer to meet in person has also been 
extended.

Actions Taken

The following changes have been implemented, all with effect from 18 February 2026 unless 
otherwise stated:

1. Laboratory Reporting (actioned 14 March 2025): On 14 March 2025, the Practice 
wrote to Russells Hall Hospital laboratory to notify them that their reports were not 
including an alert on raised NT-proBNP results. The laboratory conducted a review 
and their reports now include an alert when NT-proBNP results are raised. As these 
results now carry a laboratory red flag indicator, they are correctly identified during 
the Practice’s manual filtering process and routed into the action-required category 
for clinical review. The laboratory has also updated its report format so that all 
abnormal results are flagged on the first page of each report. This change will benefit 
all practices receiving reports from this laboratory and materially reduces the risk of a 
similar event occurring across the wider system.

2. MY Bot AI Triage System (implemented 18 February 2026): The Practice introduced 

the MY bot AI triage system on 18 February 2026 following a careful, phased 
assessment to ensure clinical accuracy and safety prior to full adoption. MY bot 
works by applying an intelligent filter to incoming blood test results, segregating them 
into two categories: results that require clinical action and results that do not require 
action. This enables each GP to focus their review directly on results requiring 

 attention, rather than manually scanning the full volume of daily pathology reports – 
which, as noted at inquest, can run to several hundred per day. The system 
underwent supervised validation to ensure that no clinically significant result was 
misclassified before it was relied upon as part of the Practice’s results management 
pathway. This directly addresses the concern raised at inquest regarding the risk of 
significant findings being overlooked within a high-volume routine workflow. MY bot 
additionally flags to the duty doctor, on the day of receipt, any urgent results 
electronically flagged as abnormal by the laboratory – including NT-proBNP, Gamma 
GT, CRP, and PSA – which must be actioned that day or tasked to the requesting 
GP. We note that, as the laboratory had not assigned an alert to NT-proBNP at the 
time of the late Mr Rhodes’ blood tests, MY bot would not have flagged his result at 
that point. However, following the laboratory’s reporting update (paragraph 1 above), 
any future raised NT-proBNP result will be electronically flagged and automatically 
segregated into the action-required category, bringing it to the duty doctor’s attention 
on the day of receipt. The laboratory alert change and MY bot together provide a 
combined safety net that did not exist at the time of the late Mr Rhodes’ presentation.

3. Revised Results Management SOP (18 February 2026): The Results Management 

Policy has been formally revised and reissued. The updated SOP explicitly mandates 
that the requesting clinician retains responsibility for the review, interpretation, 
actioning, and filing of all investigation results within 24 hours of availability. An 
automated alert is generated where results remain unfiled beyond this defined 
timeframe, with escalation to the clinical lead where defined backlog thresholds are 
exceeded.

4. Mandatory Same-Day Protocol for Raised NT-proBNP (18 February 2026): A 

mandatory same-day clinical review and documented action protocol has been 
introduced for all NT-proBNP values exceeding 400 – the threshold above which 
results are considered abnormal. The Practice has deliberately adopted this more 
conservative threshold rather than the NICE urgent referral threshold of >2000, to 
ensure that any raised NT-proBNP result, however early in its trajectory, receives 
prompt clinical attention on the day of receipt without exception.

5. High-Risk Biomarker Escalation Framework and Abnormal Alert System (18 

February 2026): The “Abnormal Alert” system has been introduced within EMIS Web 
as an additional safety check. A defined list of critical biomarkers – including NT-
proBNP, markedly abnormal potassium, CRP, and PSA – has been agreed, with 
results exceeding defined thresholds flagged for enhanced scrutiny. No result 
carrying a laboratory recommendation for onward referral may now be filed without 
documented clinician acknowledgement. Where a referral recommendation is not 
followed, a documented clinical reason must be recorded.

6. Cross-Filing Safeguard and Secondary Review (18 February 2026): Where results 

are reviewed and filed by a clinician other than the requesting GP, that clinician must 
send the requesting GP a task to review the results upon their return, ensuring a 
secondary review by the clinician with full knowledge of the clinical context. A 
secondary review safeguard has additionally been introduced for specified critical 
cardiac biomarkers to provide additional oversight where results exceed urgent 
referral criteria.

7. Clinical Documentation and Safety Netting (18 February 2026): The Practice has 

reiterated to all clinical staff the importance of recording the clinical reason for each 
investigation request in the patient’s record, so that any covering clinician reviewing 
results does so with full awareness of the clinical context. Safety netting now 
routinely includes advice to patients to contact the Practice to check their results.

8. Clinical Audit Programme (18 February 2026): The Practice has developed a 
programme of practice-level clinical audits targeting results of high clinical 
significance, designed to provide ongoing assurance that abnormal results are 
identified, actioned, and that time-bound referral recommendations are completed 
within the specified timeframe. The audit programme includes NT-proBNP and BNP, 

 PSA, and other clinically significant markers, to be expanded through ongoing clinical 
governance review. Audits are conducted on a fortnightly basis with outcomes 
reported to the monthly clinical governance meeting, at which results management is 
now a standing agenda item. A quarterly audit of NT-proBNP results and associated 
referral pathways will be conducted for a 12-month period to provide sustained 
assurance of compliance. The initial audit has confirmed that no other raised results 
have been missed.

9. Staff Training and Wider Sharing (18 February 2026): Refresher training has been 
provided to all clinical and administrative staff involved in the results management 
pathway. The findings of the SEA, the inquest, and the lessons learned have been 
shared with the wider practice team in a whole-practice learning session. The 
Practice is actively planning to share the audit framework and learning with all 
practices within the Dudley Primary Care Network. We note that the laboratory’s 
updated reporting format, which now flags all abnormal results prominently, will itself 
materially reduce the risk of a similar event across all practices using Russells Hall 
Hospital laboratory, further reducing the likelihood of recurrence beyond the 
Practice’s own boundaries.

Personal Professional Reflection

The clinician involved has reflected fully and openly on this case. The matter was brought to 
the GP’s responsible appraiser in February 2026 and has been formally documented within 
the annual appraisal and revalidation portfolio as a significant event. In addition, the clinician 
has enrolled on the Red Whale ‘Managing Blood Results’ course to support structured 
learning and reinforce safe practice in this area. The Practice considers this personal 
engagement with learning to be an important component of the overall response to this 
incident.

Notification to Relevant Authorities

The Practice confirms that the incident has been reported to and is known to Black Country 
Integrated Care Board. Upon identifying the issue, the Practice proactively notified Dudley 
Place, the ICB primary care team, and specifically raised the absence of an abnormal alert 
on NT-proBNP results within laboratory reports. The Practice requested that action be taken 
to ensure the laboratory implemented the alert, in order to protect not only patients of this 
Practice but patients across all practices receiving reports from Russells Hall Hospital 
laboratory. The Practice has maintained open communication with the ICB throughout this 
process and is pleased to confirm that the laboratory has since acted upon this. Russells 
Hall Hospital laboratory now reports NT-proBNP results with a clear abnormal alert flag, 
meaning any raised NT-proBNP result will be automatically identified during the results 
management filtering process and routed for clinical action. This change prevents any future 
instance of a raised NT-proBNP result being missed in the manner that occurred in this 
case.

Response to NHS England’s Involvement

The Practice notes that a copy of the Regulation 28 Report has been sent to NHS England 
and fully supports the Coroner’s suggestion that NHS England may wish to review national 
guidance for laboratories regarding the flagging of abnormal results. The Practice’s direct 
experience in this case demonstrates that a laboratory’s failure to flag an abnormal result at 
source can silently circumvent even well-designed electronic filtering systems at practice 
level. National standardisation of laboratory alert protocols would represent a meaningful 
and systemic patient safety improvement. The Practice would welcome any such guidance.

Ongoing Monitoring

 Ongoing compliance with the revised protocols will be monitored jointly by the Practice 
Manager and GP Partner through monthly clinical governance meetings, at which results 
management is a standing agenda item. The effectiveness of all changes will be formally 
reviewed at three and six months from the date of this response, with outcomes 
documented. Any further corrective action identified will be implemented promptly.

We hope this response, together with the enclosed SEA, demonstrates the 
comprehensiveness and seriousness with which Quarry Bank Medical Centre has 
responded to this incident. The Practice has implemented substantive, system-level changes 
that address each of the contributory factors identified, and is committed to ensuring that the 
circumstances that led to Mr Rhodes’ death are not repeated. We remain committed to the 
highest standards of patient safety.

Yours sincerely,

Practice Manager                    GP Partner
Quarry Bank Medical Centre

Enc: Significant Event Analysis – SEA 3145 (Missed Abnormal Pathology Result), Quarry 
Bank Medical Centre