Mark Simpson

Minister of State for Care 

39 Victoria Street 
London 
SW1H 0EU 

20 May 2026  

Our ref: 

HM Coroner Alan Anthony Wilson 
Blackpool and Fylde 
PO Box 1066 
Blackpool FY1 1GB  

By email:

Dear Mr Wilson,  

Thank you for the Regulation 28 report of 11 March sent to the Secretary of State about the 
death of Mark Simpson. I am replying as the Minister with responsibility for Primary Care.   

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

The  report  raises  concerns  over  the  failure  of  information  relating  to  an  NHS  111 
consultation to be relayed to a clinician or added to Mr Simpson’s medical record at his GP 
surgery.  The  information  was  considered  by  a  member  of  staff  who  was  not  medically 
qualified. 

In preparing this response, my officials have made enquiries with NHS England to ensure 
we adequately address your concerns. NHS England in turn made enquiries with Lancashire 
and South Cumbria ICB. The ICB has reported that following an in-house investigation in 
the completion of a Significant Event Analysis, the GP practice has made changes to how 
clinical information is reviewed from external providers. The practice has revised its workflow 
so that all clinical documents received from providers, including NHS 111 and out-of-hours 
services,  are now reviewed  by  a  clinician  rather than administrative  staff.  Under the  new 
process, all incoming 111 and out-of-hours documents are attached to the patient record 
and sent as a clear task directly to a clinician as part of their daily workflow to ensure that 
all relevant clinical information is reviewed by a member of staff with appropriate medical 
knowledge. The GP practice now ensures that all consultation notes and reports are added 
to the patient’s medical record. Relevant information will be coded and free-texted into the 
record  by  the  clinician,  ensuring  it  is  easily  accessible  for  review  during  future  contacts 
without the need to open attached documents. The practice will undertake an audit within 
three to six months to assess the effectiveness of this new process and learning from this 
work will be shared across GP practices within Lancashire and South Cumbria. 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
  
 The practice has also decided to review the process of practice nurses requesting ECGs 
for patients and consider whether the patient could have been asked to book a GP 
appointment for a further review, assessment and consideration of an ECG. The ICB has 
been advised that the practice will also implement a system to inform all patients by text 
about their referral. Two-week wait, urgent and routine referrals will all receive an 
appropriate electronic message to confirm their referral with additional information.  

The NHSE GP Contracts Team has outlined several relevant points on GMC Good Medical 
Practice  on  record  keeping,  as  well  as  the  GP  contract  and  underpinning  regulations  on 
record keeping, referrals, ongoing care requires and handling clinical information.  

In summary: (1) GMC Good Medical Practice requires clear, accurate and contemporaneous 
records  and  emphasises  continuity  of  care  and  information  sharing  before  referral;  (2) 
regulation  67  specifically  requires  GP  contractors  to  keep  adequate  records  and  include 
clinical reports from other services/professionals; (3) the GP contract makes referral part of 
essential  services  and  includes  explicit  requirements  to  review  NHS  111  “Post  Event 
Messages”  and  out-of-hours  clinical  details  within  specified  timescales.  These  standards 
and contractual requirements are directly relevant to the handling and incorporation of NHS 
111/out-of-hours information into the patient record and to the responsibilities that continue 
while  a  patient  is  awaiting  specialist  care.  We  expect  ICBs,  as  commissioners  of  GP 
contracts, to monitor GP practice compliance with, and performance against, the contract. 
ICBs will take appropriate action if a GP practice is in breach of its contract. 

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

Yours sincerely, 

MINISTER OF STATE FOR CARE

Vice Chair Member Standards 

Mr Alan Anthony Wilson 
Senior Coroner for Blackpool and Fylde 

10 May 2026 

Dear Mr Wilson 

Regulation 28 Report to Prevent Future Deaths - regarding the death of Mr Mark Simpson  

We are grateful for this Regulation 28 report and write to respond formally within the 
required timeframe. We offer our sincere condolences to Mr Simpson's family. The 
circumstances of his death, and the systemic failures identified at the inquest, are of the 
utmost concern to the Royal College of General Practitioners (RCGP), and we take our 
responsibility to respond constructively very seriously. 

About the RCGP 
By way of brief background, the RCGP sets professional standards and the curriculum for GP 
training and supports the career-long development of GPs. Its core purpose is to encourage, 
foster and maintain the highest possible standards in general medical practice. While the 
commissioning and regulation of individual GP practices sits with NHS England through 
Integrated Care Boards and the Care Quality Commission respectively, the RCGP has a 
significant role in shaping professional norms, guidance and education across general 
practice. 

Responding to the two areas of concern 

Concern 1: Triage of clinical correspondence by non-clinical staff 
The RCGP agrees that clinical correspondence, including reports received from NHS 111, 
must be reviewed by a clinician before any decision is made about whether it requires further 
action. The responsibility of GPs to respond to letters, test results and clinical 
correspondence in a timely manner, to maintain safe patient pathways, is reflected in our 
curriculum under ‘Being a General Practitioner and Continuity of Care’ , and in the Clinical 
Topic Guides on Cardiovascular Health and Urgent and Unscheduled Care. This principle is 
further supported by CQC guidance through GP Myth Buster 46 on managing test results 
and clinical correspondence, which makes clear that where non-clinical staff are involved in 

Royal College of General Practitioners 
30 Euston Square, London, NW1 2FB 
Tel: 020 3188 7400  |  info@rcgp.org.uk  | rcgp.org.uk 

 
 
 
 
 
 
 
 
 
 
 
 
 
 
  
  
 workflow tasks, there must be appropriate safeguards, supervision, training and audit in place 
and that the responsible clinician must take action when appropriate. 

We recognise, however, that the existence of curriculum content and regulatory guidance 
does not in itself ensure safe practice at the level of individual practices. It is clear from the 
evidence at the inquest that the systems in this practice failed to route the ‘111 report’ to the 
responsible GP at the appropriate time. The RCGP takes seriously its role in reinforcing 
professional standards through guidance and communication to its membership. 

Concern 2: 111 consultation reports not added to the patient record 
The RCGP agrees that any report received by a GP practice following an NHS 111 
consultation must be added to the patient's medical record. This is fundamental to continuity 
of care and patient safety. A GP reviewing a patient's record must be able to see the full 
clinical picture, including any recent contact with 111, in order to make appropriate clinical 
decisions. 

General practice currently holds some of the most advanced electronic health record systems 
in the NHS. Information received at a practice is ordinarily filed and coded to ensure it 
remains clinically accessible. The failure identified in this case, where a 111 report was 
neither routed to the responsible clinician nor added to Mr Simpson's record, represents a 
breakdown in what should be a routine and mandatory process. 

Action being taken 
In taking action, I shall bring these concerns around systems of workflow, coding of 
information, and the timely availability of correspondence within the clinical record as an 
agenda item to the Health Informatics Group within the next three months. The RCGP will 
ask the Group to examine why 111 consultation reports are not consistently recorded in the 
patient record, and to determine whether action is required to take this forward to the Joint 
GP IT Committee, to communicate with the wider membership, or both. 

The Joint GP IT Committee is a contractually mandated committee jointly constituted by the 
RCGP and the General Practitioners Committee of the BMA. It represents the views of GPs 
from all four nations, working with NHS England on the use and management of GP systems 
and data. Bringing these concerns through this route represents a meaningful and 
appropriate escalation with the potential to achieve systemic improvement. 

We also recognise that General Practice is currently bearing significant risk for many patients 
due to unsatisfactory and timely pathways to specialist care, and that policy changes such as 
‘Advice and Guidance’ and increasing numbers of rejected referrals by secondary care 
providers may add further pressure. The RCGP has published its policy position on the 
interface between primary and secondary care and on Advice and Guidance, and we remain 
committed to advocating for safer patient pathways. 

 
 
 
 
 
 
  
  
  
  
  
  
  
 We are committed to learning from Mr Simpson's death. The RCGP will ensure this case 
informs our guidance, our communications to members, and our engagement with system 
partners on the safe handling of clinical correspondence. We would welcome the opportunity 
to update the Coroner on the outcomes of these actions in due course. 

Yours faithfully 

Vice President Member Standards