Theresa Lydon

Minister of State for Health (Secondary Care) 

39 Victoria Street 
London 
SW1H 0EU 

James Thompson 
HM Assistant Coroner, Gateshead & South Tyneside

15 June 2026 

Dear Mr Thompson, 

Thank you for the Regulation 28 report of 21 April 2026 sent to the Secretary of State about 
the  death  of  Mrs  Theresa  Lydon.  I  am  replying  as  the  Minister  with  responsibility  for 
Secondary Care.    

Firstly, I would like to say how saddened I was to read of the circumstances of Mrs Lydon’s 
death and I offer my sincere condolences to their family and loved ones. The circumstances 
your  report  describes  are  very  concerning,  and  your  finding  that  Mrs  Lydon’s  death  was 
contributed  to  by  neglect  is  particularly  troubling.  I  am  grateful  to  you  for  bringing  these 
matters to my attention. 

The  report  raises  concerns  across  several  issues:  the  formatting  of  letters  sent  from 
diagnosing  consultants  to  GPs;  the  ability  for  secondary  care  specialists  to  issue  a 
prescription  at  the  point  of  diagnosis;  and  the  sharing  of  medical  records  between  NHS 
trusts.  

In  preparing  this  response,  my  officials  have  made  enquiries  with  the  Care  Quality 
Commission (CQC). I understand that you have shared this report with NHS England who 
are  responding  separately.  I  hope  this  ensures  that  we  are  adequately  addressing  your 
concerns. 

Whilst there is no national mandating of letter templates that diagnosing consultants should 
use  when  sharing  a  patient’s  treatment  plan  with  GPs,  I  echo  your  concerns  around  the 
importance of clear formatting in ensuring that all necessary courses of action for a patient 
can be easily interpreted with no room for confusion. To support this, there should also be 
an  open  dialogue  between  primary  and  secondary  care  to  enable  swift  resolution  to  any 
possible misunderstanding. 

In  July  2025,  NHS  England  published  the  Getting  It  Right  First  Time  (GIRFT)  guidance 
‘Bridging the interface between primary and secondary care, mental health and community 
services’. This suggests that:  

“ICBs should work with Trusts to design and use a standardised discharge letter template 
to enable consistency and aid GP practices to clearly see diagnosis and actions required”. 

 https://gettingitrightfirsttime.co.uk/wp-content/uploads/2025/07/GIRFT-Bridging-the-interface-July-2025-
FINAL-1-1.pdf  

The department and the CQC generally expect registered providers to have awareness of 
and act in line with statutory and best practice guidance, and that registered providers take 
note of statutory and best practice guidance when providing care and treatment. 

I am informed by the CQC that in their next planned engagement with both South Tyneside 
& Sunderland NHS Foundation Trust and Gateshead Health NHS Foundation Trust, they 
will discuss the concerns raised in your report. 

With regard to the ability for secondary care specialists to issue a prescription at the point 
of  diagnosis,  when  a  patient  is  discharged  from  inpatient  or  day  case  care  in  hospital, 
sufficient medication must be supplied by the hospital pharmacy for a minimum period of 7 
days after discharge. This is unless a shorter period is more clinically appropriate, or the 
patient  has  an  adequate  supply,  or will  receive  such a  supply through an existing  repeat 
prescription.  The minimum period  of  time covered  by  the  prescription  should take  into 
account bank holidays and weekends, to allow patients sufficient time to contact staff at their 
general practice.  

The  GP  to  whose  care  the  patient  is  being  transferred  should  receive  notification,  via  a 
Discharge Summary, within 24 hours of discharge of the patient's diagnosis and medication, 
so that any necessary ongoing treatment can be maintained.   

Where a patient has an immediate clinical need for medication as a result of attending an 
outpatient  clinic,  the  secondary  care  provider  must  supply medication  sufficient  to  last  at 
least until the point at which the outpatient clinic’s letter can reasonably be expected to have 
reached  the  patient’s  GP,  and  when  the  GP  can  therefore  accept  responsibility  for 
subsequent prescribing. Consideration should be given to providing a minimum of 7 days’ 
supply to allow patients sufficient time to contact staff at their general practice (or shorter if 
medicines are not required for that length of time).  

Prescribing of medicines can also be transferred from specialist to a GP through a process 
called  shared  care.  Shared  care within  the  NHS  refers  to  an  arrangement  whereby  a 
specialist  doctor formally  transfers  responsibility  for  all  or  some  aspects  of  their  patient’s 
care, such as prescription of medication, over to the patient’s general practitioner (GP).    

Shared care arrangements between a specialist service and the patient’s GP can cover a 
number of clinical areas. In proposing shared care agreements, a specialist should advise 
which medicines to prescribe, what monitoring will need to take place in primary care, how 
often  medicines  should  be  reviewed,  and  what  actions  should  be  taken in  the  event 
of difficulties. The specialist clinician must follow General Medical Council (GMC) guidance 
that if continuation of the treatment is dependent on shared care, then an agreement with 
the GP must be in place before the treatment is started.   

At an individual patient level, patients themselves and/or carers must be centrally involved 
in any decision-making process. They should be supported by good quality information that 

 helps  them  to  both  come  to  an  informed  decision  about  engagement  in  a  shared  care 
arrangement and sets out the practical arrangements for ongoing supplies of medicines.   
When clinical responsibility for prescribing is transferred to general practice, it is important 
that  the  GP,  or  other  primary  care  prescriber,  is  confident  to  prescribe  the  necessary 
medicines. Shared care agreements play a key role in enabling primary care prescribers to 
prescribe medicines with which they may not initially be familiar.   

Prescribers are  responsible  for the  prescriptions  they sign, and  they  must  be  prepared  to 
explain and justify their decisions and actions.  

I would like to highlight action we are taking at a national level which will radically improve 
data sharing between NHS service providers, whether they are neighbouring hospitals as 
was in Mrs Lydon’s case, or at opposite ends of the country. 

There  is  a  national  programme  of  work  to  introduce  a  Single  Patient  Record  across 
England from 2028. This will allow patient information to be shared with patients and their 
relevant  health  and  social  care  providers  (such  as  GPs,  hospital  doctors,  social  care 
workers  and  others  involved  in  their  direct  care).  Our  aim  is  that  for  the  first  time,  the 
NHS  will  have  a  single  record  of  patient  needs  and  history,  consistently  across  health 
services and social care in England. 

There are already some excellent local Shared Care Records which offer a similar service. 
The  Single  Patient  Record  will  mean  everyone  across  England  gets  the  same  benefits 
from having  their  data  in  the  same  place  for  professionals  to  see  when  delivering 
care. 

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

Yours sincerely, 

MINISTER OF STATE FOR HEALTH

Mr James Thompson 
Assistant Coroner for  
Gateshead & South Tyneside 
Coroner’s Service 
Town Hall and Civic Offices 
Westoe Road, South Shields 
Tyne and Wear  
NE33 2RL 

Dear Mr Thompson, 

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

15 June 2026  

Re: Regulation 28 Report to Prevent Future Deaths – Theresa Lydon who died 
on 18th September 2022.  

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 21st 
April  2026  concerning  the  death  of  Theresa  Lydon  on  18th  September  2022.  In 
advance of responding to the specific concerns raised in your Report, I would like to 
express my deep condolences to Mrs Lydon’s family and loved ones. NHS England is 
keen  to  assure  the  family  and  yourself  that  the  concerns  raised  about  Mrs Lydon’s 
care have been listened to and reflected upon.   

Your Report raised the following concerns: 

1.  That there is no uniform format for use by consultants when they are informing 
a patient’s GP what the treatment plan is and what action needs to be taken for 
the patient. This can mean that the treatment plan is not clearly communicated 
to those implementing it. 

2.  Current practice does not allow for a specialist in a secondary care setting to 
issue a prescription for the required drugs at the point of diagnosis and then 
instruct the patient's GP to continue the process. 

3.  There  is  a  national  issue  with  different  trusts  being  able  to  promptly  access 
medical  records  of  patients  in  their  care,  for  example,  regarding  recent 
admissions at other trusts.  

Effective communication of treatment plans 

It is indeed vital that secondary care clinicians communicate treatment plans as clearly 
as possible, both for patients and for the primary care team also involved in their care. 
Many trusts now have an electronic patient record, with locally agreed standardised 
clinic letter templates to facilitate this.  

As that is not  yet universal, nationally, the Getting it Right First Time (GIRFT) Team 
produced  a  Clinically  Led  Speciality  Outpatient  Guide  document  in  July  2023 
highlighting the importance of clear, concise clinic letters and offering guidance on the 
best  ways  to  do  this.  This  states  that  outpatient  clinic  letters  have  at  least  three 
different audiences, each of which will have different requirements for what they need 
to be able to take from the contents. In view of this, clinic letters must be clear, concise, 

                                                                                                                       
 
 
 
 
 
 
  
 
 
 
 
  
 in plain English and be structured with headings to allow quick and easy reference for 
all concerned. It details a specific section for Primary Care which outlines: 

“In view of the high volume of letters these are primarily dealt with by admin, coders 
and pharmacy. Need to easily understand and identify information on any changes to 
the patient’s diagnosis or management and any actions required by primary care.  

Summary of the key information that is structured and in plain English:  

•  Diagnoses (highlight any new ones)  
•  Changes to medication  
•  Planned Investigations  
•  Management Plan (who is responsible)  
•  Actions for Primary Care to arrange 
•  Any follow up or escalation plan  
•  Contact details for queries / escalation” 

It is not clear from the Report whether or not the patient and GP had been told how to 
escalate any issues and whether they had been given contact details for any queries 
or escalation, for example for the local Inflammatory Bowel Disease (IBD) specialist 
nurse or the IBD helpline. Almost every hospital will or should have an IBD helpline or 
an IBD specialist nurse. Patients with known Ulcerative Colitis should be given these 
contact details when they are diagnosed.  

More recently GIRFT have also recently produce an 'IBD handbook' to help to optimise 
care  for  patients  with  IBD,  outlining  these  expectations  in  more  detail.  This  was 
published in November 2025.  

Specialists issuing prescriptions 

When a diagnosis made by a specialist in secondary care, the specialist, assuming 
they are a registered medical practitioner, is permitted to prescribe medicines for the 
patient without having to ask a GP to do this on their behalf. This has been standard 
practice  in  the  NHS  since  its  inception,  and  was  confirmed  in  guidance  from  NHS 
England  in  2018.The  North-East  and  North  Cumbria  Area  Prescribing  Committee 
formulary, lists balsalazide (the drug prescribed to Mrs Lydon to treat her ulcerative 
colitis) as a GREEN+ drug. The definition of a GREEN+ drug from the formulary is:    

“GREEN+ DRUGS: 

Drugs normally recommended or initiated by a hospital specialist who is a prescriber, 
a GP with an extended role [GPwER]), or a specialist within primary care which can 
be safely maintained in primary care and monitored in primary care. In some cases, a 
further restriction for use may be defined. The primary care prescriber must be familiar 
with  the  drug  to  take  on  prescribing  responsibility  or  must  obtain  the  required 
information  from  the  specialist.  Therefore,  provision  of  additional  information,  or  an 

 
 
 
 information leaflet, may be appropriate in some cases to facilitate continuing treatment 
by primary care prescriber or provide information re stopping criteria.  

These  are  considered  suitable  for  primary  care  prescribing  following  specialist 
assessment and recommendation of therapy, with ongoing communication between 
the primary care prescriber and specialist, if necessary.  

In  some  case  these  drugs  require  specialist  initiation  and  short  to  medium  term 
monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist 
review the patient may be transferred to primary care for ongoing prescribing. Ongoing 
prescribing  by  primary  care  can  include,  if  required,  additional  dose  titrations  and 
assessment  of  efficacy,  with  ongoing  communication  between  the  primary  care 
prescriber and specialist, if necessary.  

If the drug requires urgent initiation, it is expected that the specialist provides the first 
prescription  from  the  inpatient/outpatient  setting,  of  sufficient  supply  for  a  patient’s 
immediate needs. The quantity provided should cover at least up to the point where 
the discharge/clinic letter has reached the GP, plus reasonable time for the practice to 
manage  the  document  and  issue  further  supplies.  A  GREEN+  drug  can  only  be 
recommended to primary care for initiation if it does not need to be initiated urgently, 
taking into account clinical need.  

GREEN+ status will be assigned if the following conditions apply:  

1.  The  medicine  is  being  used  for  an  established,  licensed  indication/dose. 
Alternatively,  it  is  being  used  for  an  off-label  indication  that  is  considered  to  be 
standard therapy (i.e. supported by a consensus of recommended opinion or evidence 
base  BNF / BNFc,  reputable  clinical  guideline  etc) and/or agreed by  NENC  Clinical 
Effectiveness and Governance (CEG) Subcommittee.  

2. The medicine can be prescribed on FP10 and there are no issues around primary 
care procurement, or commissioning.  

3. Primary care able to take full responsibility for prescribing after initiation or (after 
recommendation by a specialist and on-going prescribing. ICB prescribing guidelines 
or NICE guidance may apply.  

4. Is considered safe, and can be safely maintained and monitored in primary care.  

5.  Dose  adjustments  can  be  undertaken  with  relative  ease  and  are  supported  by 
readily available guidance (e.g. the product license / BNF).  

6. The indication is non-specialist and is amenable to management in primary care.  

7.  There  are  no  service,  commissioning  or  restrictions  on  community  pharmacy 
procurement (i.e. BNF states for hospital use only or wholesaler/manufacturer restricts 
supply to secondary care) associated with primary care prescribing or dispensing of 
the medicine.  

8. Require no routine monitoring from the specialist but there is a route available to 
seek advice from specialist if needed.  

 9. The specialist will counsel the patient on the medication and its use.” 

This formulary shows that it is permissible for a secondary care specialist to prescribe 
a  drug  like  balsalazide,  before  a  GP  is  asked  to  take  responsibility  for  ongoing 
prescribing.  It  also  makes  it  clear  that  if  the  medication  is  required  urgently,  the 
secondary  care  clinician  should  issue  the  first  prescription  and  then  ask  the  GP  to 
continue it, although if it is not urgent, then it is also possible for the secondary care 
specialist to recommend that the GP prescribed the medicine, provided that they have 
counselled the patient on the medicine and its use (point 9 in the list above). In light of 
this, we consider there may have been some misunderstanding about the suggestion 
that  ‘current  practice  does  not  allow  for  a  specialist  to  issue  a  prescription  for  the 
required drugs at the point of diagnosis.’ 

While it is the case that if the GP had issued a prescription that Mrs Lydon would have 
ensured she received the clinically indicated drugs’ promptly, it is also the case that if 
the  specialist  had  issued  the  prescription  Mrs  Lydon  would  have  received  the 
medication even more quickly and would have avoided the risk of the prescription not 
being actioned by the GP. 

Accessing medical records from other trusts 

The  Frontline  Digitisation  (FD)  Programme,  has  reviewed  the  position  at  South 
Tyneside  and  Sunderland  NHS  Foundation  Trust  and  Gateshead  Health  NHS 
Foundation Trust.  

The  South  Tyneside  and  Sunderland  NHS  Foundation  Trust  uses  the  Meditech 
Electronic Patient Record (EPR) system and was the first hospital in the country to 
achieve Global Digital Exemplar (GDE) status, having been accredited at Level 7 by 
Healthcare Information and Management Systems Society (HIMSS). As part of the FD 
Programme,  the  Trust  was  assessed  as  already  having  an  EPR  that  met  the 
Programme’s  core  standards  against  the  Digital  Capability  Framework  (DCF).  The 
Trust  has  also  secured  limited  FD  Programme  funding  for  hardware  investment  to 
support the extension and enhancement of future clinical ways of working. 

Gateshead Health NHS Foundation Trust has the System C Electronic Patient Record 
(EPR)  system  in  place.  It  was  similarly  assessed  through  the  FD  Programme  as 
already having an EPR that met the Programme’s core standards against the DCF. 
The  Trust  has  secured  limited  FD  Programme  funding  to  invest  in  additional 
functionality to support its EPR. 

The FD Programme has advised that both Trusts securely share electronic information 
with health and care partners through the Great North Care Record (GNCR). However, 
EPR  systems  are  configured  and  managed  locally,  in  line  with  contractual 
arrangements between individual Trusts and their technology suppliers. Accordingly, 
levels of interoperability may vary depending on local infrastructure and information 
governance arrangements. 

 
 
 Local  EPR  implementations  should  operate  under  the  oversight  of  a  Trust  Clinical 
Safety Officer (CSO). The CSO is a registered healthcare professional responsible for 
overseeing the clinical safety and risk management of health IT systems and ensuring 
that  such  systems  are  safe  for  patient  use.  Digital  safety  is  a  critical  component  of 
patient safety. 

Suppliers and Trusts are jointly accountable for compliance with the two mandatory 
Clinical  Risk  Management  Standards  defined  under  Section  250  of  the  Health  and 
Social Care Act 2012: 

•  DCB0129:  Clinical  Risk  Management:  its  Application  in  the  Manufacture  of 

Health IT Systems 

•  DCB0160:  Clinical  Risk  Management:  its  Application  in  the  Deployment  and 

Use of Health IT Systems 

DCB0160 is an ongoing and iterative process rather than a one-time assessment. All 
modifications to the EPR, including system upgrades, configuration changes such as 
to  change  clinic  letter  templates,  and  incident  management,  must  be  proactively 
assessed  for  their  potential  impact  on  patient  safety  throughout  the  lifecycle  of  the 
system.  Any  identified  hazards  or  foreseeable  scenarios  of  patient  harm,  whether 
arising from system functionality, configuration or user interaction, must be recorded 
in  a  Hazard  Log,  which  should  be  actively  maintained  and  updated,  together  with 
associated controls or mitigations. 

Trusts are also required to operate formal incident management systems to support 
the  monitoring,  reporting  and  investigation  of  clinical  incidents  or  near  misses 
associated  with  EPR  systems.  These  arrangements  should  support  organisational 
learning,  continuous  improvement  and  appropriate  system  changes  in  response  to 
identified risks. 

The  FD  Programme  supports  provider  organisations  to  procure  EPR  systems  and 
provides  guidance  on  implementation  to  enhance  local  digital  capability  and 
interoperability,  including  improving  the  ability  of  different  digital  systems  to 
communicate effectively. 

Further investment in digital transformation has been confirmed through the Frontline 
Productivity  (FP)  Programme,  a  four-year  initiative  commencing  in  April  2026.  This 
programme is intended to enable NHS organisations to realise the benefits of digitising 
patient data through further optimisation of EPR capability. Building on the experience 
and  lessons  from  preceding  programmes  such  as  Frontline  Digitisation,  the  FP 
Programme will also support analysis of digital health events to identify root causes 
and  inform  refinement  of  processes  and  systems  to  support  future  resilience  and 
effectiveness. 

The  newly  published  Fit  for  the  Future:  10  Year  Plan  for  England  sets  out  the 
government’s  plan  for  healthcare  in  England  over  the  next  10  years,  including  a 
commitment  to  give  patients  ‘a  single  patient  record  (SPR)  –  to  enable  more 
coordinated, personalised and predictive care.’ However, rather than building an SPR 
from scratch, a likely solution may include improved interoperability between the many 
systems currently in operation, recognising the challenge of sharing medical records 

 and results within and between organisations, including social care and commissioned 
organisations, that use different technologies. 

The interface between Primary and Secondary Care 

An initiative called the ‘Red Tape Challenge’ was developed to improve the interface 
between primary and secondary care, such as how referrals are made and managed, 
patient discharge and how different parts of the health service communicate with each 
other.  The  Red  Tape Challenge  led  to 10  recommendations,  which  were  cascaded 
through  Regional  Medical  Directors.  The  focus  of  the  Red  Tape  Challenge  is 
on reducing unnecessary bureaucracy, improving communication and understanding, 
strengthening  culture  and  interface  working  between  primary  and  secondary  care, 
improving  digital  and  estates 
infrastructure,  streamlining  healthcare  delivery, 
enhancing patient experience, and freeing up clinical time. Those especially relating 
to this case include: 

•  Recommendation  3:  Adoption  of  electronic  prescribing  (EPS)  in  secondary 
care,  greater  access  to  shared  care  records  and  greater  interoperability  of 
Electronic  Patient  Records  (EPRs),  starting  with  the  sharing  of  structured 
medication information 

•  Recommendation 5: Greater standardisation of forms and process 
•  Recommendation 6: Prescriptions should be issued in outpatients for 28-days, 
unless clinically inappropriate – local guidance would also define expectations 
regarding supply of medicines during admissions and at discharge 

Implementation of the Red Tape Challenge is being driven by ICBs and supported by 
national  oversight from  leads  across  primary  and  secondary  care,  pharmacy, 
medicines, estates, and transformation directorates. 

The  GIRFT Bridging  the  Gap guidance  is  now  embedded  in  the  regular  national 
self-assessment tool to help providers identify barriers and enablers to better interface 
working.  Analysis of the  latest  trust  self-assessments  shows  encouraging  progress, 
with many organisations having established local interface groups and interface liaison 
officers. 

The  Academy  of  Medical  Royal  Colleges has  also  published  an  ‘Escape  the  Tape’ 
document  setting  out  practical  quick  wins  to  improve  the  primary-secondary  care 
interface and raising the visibility of the Red Tape Challenge.  

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 Mrs 
Lydon, 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