Alex Ganski

Mr Joseph Turner  
HM Area Coroner  
West Sussex, Brighton and Hove  
The Coroner’s Office 
Woodvale  
Lewes Road  
Brighton  
BN2 3QB 

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

3 August 2026 

Dear Mr Turner, 

Re: Regulation 28 Report to Prevent Future Deaths – Alex Ganski who died on 
20 July 2024.  

Thank  you  for  your  Report  to  Prevent  Future  Deaths  (hereafter  “Report”)  dated  15 
June  2026  concerning  the  death  of  Alex  Ganski  on  20  July  2024.  In  advance  of 
responding to the specific concerns raised in your Report, I would like to express my 
deep condolences to Alex’s family and loved ones. NHS England is keen to assure 
the family and yourself that the concerns raised about Alex’s care have been listened 
to and reflected upon.   

Your Report raised the following concerns:   

1.  There is a lack of national policy, guidance or structure to enable there to be a 
designated lead or ‘single point of contact’ with full oversight of, and authority 
over a patient’s care in the community and who could alert all agencies involved 
in providing care of any changes with the patient.   

2.  A  lack  of  national  protocols  means  the  sharing  and  updating  of  information 
relating to physical and mental health changes and addiction was fragmented.  

3.  There is no national initiative to share records and information across agencies 

and currently depends on voluntary local arrangements.  

4.  There is an absence of guidance or advice to frontline emergency crews who 
are  called  to  patients  with  complex  and  overlapping  clinical,  behaviour  and 
addiction  issues,  when  such  crews may  be unaware  of  the extent  of  partner 
agency  involvement.  This  creates  a  missed  opportunity  to  update  and  refer 
them to partner agencies. 

                                                                                                                       
 
 
 
 
 
 
 
 
  
 
 
 
 
 
 
 
 
 
 
 1.  National policy to enable a designated lead for care 

As  part  of  a  national  pilot  to  transform  mental  health  care,  six  new  neighbourhood 
mental health hubs are being developed across England. 

These hubs are designed to bring services closer to home, offering round-the-clock 
support in local settings. They provide walk-in access, co-located support teams, and 
in  some  cases,  short-stay  beds  —  all  helping  to  reduce  hospital  admissions  and 
provide earlier, more joined-up care. 

The  24/7  Neighbourhood  Mental  Health  Centre  (NMHC)  model  represents  a 
fundamental shift in how mental health care is organised, addressing long-standing 
issues of fragmented provision and poor continuity of care. Traditional systems often 
require people to navigate multiple services, repeat their story, and experience unclear 
thresholds and disjointed support. NMHCs respond directly to this by offering an open-
access,  neighbourhood-based  model  that  simplifies  pathways  and  centres  care 
around the person. 

A key strength of the model is its focus on continuity of care. Rather than being passed 
between different teams such as community, crisis, and inpatient services, individuals 
are  supported  by  one  consistent  team  across  their  whole  journey.  This  reduces 
duplication, avoids repeated assessments, and enables staff to build strong, trusting 
relationships. These relationships are critical in mental health care, supporting better 
engagement, earlier identification of deterioration, and more personalised care. 

This  integrated  approach  improves  oversight  of  care.  With  shared  information 
systems, joint working, and a clear sense of responsibility for a defined neighbourhood 
population,  teams  are  better  able  to  understand  an  individual’s  needs  and  respond 
proactively.  The  model  supports  improved  information  sharing  and  real-time 
coordination, meaning risks can be identified earlier and care can be adjusted quickly. 
As a result, people are less likely to fall through gaps or experience crisis escalation 
due to disconnected services. 

NHS England has piloted the approach over the past two years, with an independent 
evaluation. Further roll-out is currently underway. 

2.  National  protocols  for  sharing  information  about  changes  to  a  person’s 

health  

NHS  England  is  committed  to  supporting  the  sharing  of  critical  clinical  information 
across NHS organisations. This is discussed in more detail at point 3below.  

The Connecting  Care  Records  (ConCR)  programme facilitated  the  extensive  and 
collaborative  sharing  of  patient  data  and  information  across  care  settings  and 
geographic boundaries to enable the delivery of more patient-centred care, in line with 
the NHS 10 Year Health Plan and Long Term Plan. 

The  NMHC  model detailed  above,  supports improved  information sharing  and  real-
time  coordination,  meaning  risks  can  be  identified  earlier and  care  can be  adjusted 

 
 
 quickly.  As  a  result,  people  are  less  likely  to  fall  through  gaps  or  experience  crisis 
escalation due to disconnected services. 

3.  Lack of a national initiative to share records and information 

The National Care Records Service (NCRS) provides a quick, secure way to access 
national  patient  information  to  improve  clinical  decision  making  and  healthcare 
outcomes, and it is free to use. NCRS is internet based, accessible via a web browser. 
NHS  England’s national digital team  have  advised  that  they  would  expect  the  local 
Mental Health Trust, and the local Drug and Alcohol treatment service to have access 
to patient’s summary care records via NCRS however utilisation of this resource will 
vary according to the local business processes. Further information on NCRS can be 
available here: National Care Records Service - NHS England Digital.  

The NCRS provides access to a patient’s Summary Care Records (SCR). The SCR is 
a national database that holds electronic records of important information such as a 
current medication, allergies and details of any previous bad reactions to medicines. 
It is created from GP medical records – whenever a GP record is updated, the changes 
are synchronized to SCR. It can be seen and used by authorised staff in other areas 
of the health and care system who are involved in the patient’s direct care but do not 
need  access  to  the patient’s  full  record.  As  such, the  SCR  is intended  to provide a 
summary to patient’s during an unscheduled care encounter.  

As a minimum, the SCR contains important information about: 

•  Current medication 
•  Allergies and details of any previous reactions to medicines  
•  The name, address, date of birth and NHS number of the patient 

In  addition,  details  of  long-term  conditions,  significant  medical  history,  or  specific 
communications needs, are now included by default with an SCR, unless the client 
has  previously  told  the  NHS  that  they  did  not  want  this  information  to  be  shared. 
Further  information,  and  to  illustrate  the  type  of  content  included  in  an  SCR,  an 
example of SCR is available here: Additional Information in SCR - NHS England Digital 

Additional information in  the  SCR  includes  the  active problems  and  significant past 
problems (from Optum/TPP/Medicus provider systems) for a patient as recorded by 
their registered GP practice.  

The  SCR  can  also  include  more  information  in  addition  to  the  patient’s  current 
medication,  allergies  and  adverse  reactions  to  medicines  which  is  referred  to  as 
‘Additional Information’. This ‘Additional Information’ may include significant medical 
history, anticipatory care information (such as information about the management of 
long-term  conditions), immunisations  or  specific  communication  needs.  This  is  now 
included by default for patients with an SCR, unless they have previously told the NHS 
that they did not want this information to be shared. This can include, for example, any 
history of deliberate self harm, suicide attempts or suicidal ideation. The SCR is not 
intended to include the full detail of a patient’s care plan and the design/format of the 
SCR does not support this. However, the SCR can include a signpost to the existence 
of a care plan, either by a relevant code such as:  

 
 
 
 
 
 
 •  Emergency health care plan 
•  Emergency medicine care plan 
•  Liaison psychiatry care plan 
•  Mental health crisis plan 
•  Crisis plan 
•  Treatment escalation plan 
•  Vulnerable adult care plan 
•  Community mental health care plan 
•  Or via a text free entry 

Regarding SCR, as of 29 June 2026, 88% of the population of England (approx. 60 
million  patients)  have  an  SCR  with  Additional  Information,  7.3%  have  a  Core  Only 
SCR (Allergies and Medications only) and 1.5% have Opted Out of SCR. Furthermore, 
where possible, patient’s need to provide their Permission to View before their SCR 
can be accessed. However, an Emergency Access option is available for scenarios 
where  a  patient  is  not  able  to  provide  their  Permission  to  View  e.g.  the  patient  is 
unconscious.   

NHS  England’s National Record Locator (NRL) service  allows health  or social  care 
workers to find and access patient information shared by other health and social care 
organisations across England, to support the direct care of a patient. It does this by 
recording the location of digital (and paper) records within the NHS and provides an 
index  of  pointers/bookmarks  that  contain  the  information  required  to  retrieve  key 
patient  information  from  the  source.  The  vision  is  to  improve  cross-border 
interoperability  and  help  make  data  sharing  possible  by  allowing  healthcare 
professionals, such as Care Coordinators within a Mental Health Trust to securely and 
remotely retrieve information from source at the point of need so that they can get a 
longitudinal view of a patient’s records and an indication of their treatment history. The 
National Record Locator (NRL) removes the need for organisations to create duplicate 
copies of information across systems and organisations, by facilitating access to up- 
to-date information directly from the source. It will also provide users with an indication 
of the organisations with which a patient currently has a care relationship to enable a 
user to contact the service responsible for a plan to support the individual in the event 
of a crisis. 

Mental Health Crisis plans are one of the pointer types supported by the NRL Service. 
NRL does not store any of the Mental Health data but points users to where they can 
find  it.  NRL  Information  can  be  consumed  from  source  through  the  National  Care 
Records  Service  (NCRS).  In  instances  where  multiple  pointers  are  returned,  users 
have the ability to sort results by creation date. 

With regards to the sharing of care plans, the NHS tends to share those Care Plans 
that need to be viewed by multiple different healthcare professionals and organisations 
with those organisations that are involved with creating, managing and updating these 
care plans (as well as the patient). However, those care plans which are more service 
specific  that  detail  how  a  patient  should  be  cared  for  by  a  specific  service  are  less 

 
 
 
 likely to be shared with multiple other healthcare providers that may be involved in the 
patient’s care.  

Connecting Care Records 

The NCRS complements Connecting Care Records (ConCR), also known as Shared 
Care Records. Every Integrated Care Board (ICB) has a shared care record (ShCR) 
in place, which provides, through different suppliers, a mechanism to access shared 
information  between  NHS  Trusts  and  general  practice.  Shared  Care  Records  will 
include  prescribed  medications  and  will  typically  hold  more  information  about  an 
individual than a Summary Care Record.   

A  number  of primary  care  networks,  local  authorities  and  other  community 
organisations are also accessing information from the ShCR and providing information 
into their local ShCR.   

Responsibility for delivering shared care records sits with local Integrated Care Boards 
(ICBs). Each ICB’s shared care records are developed in response to the health and 
care needs of the local area, existing systems, and future planning. This means some 
of their shared care records are available to neighbouring ICBs, while others are only 
supported within their own ICB. Future plans include making shared care records link 
together regardless of where you live or receive care in England.  

The  interoperability programme  of  work  supports  the  provision  of  interoperable 
records across England, sharing patient data across health and social care providers 
through ShCRs. National interoperability is needed as circa 20% of patients have care 
provided outside  of  their home  ICB boundary.  This  work  is  evolving  into  the  Single 
Patient  Record,  which  will  bring  together  a  patient’s  health  information  so  that  it  is 
joined up across all health and care settings.    

We note that ‘Plexus’ provides the shared care record for Sussex, and they are already 
connected to the National Record Locator (NRL).  They are sharing patient pointers to 
Mental Health Crisis Plans from Sussex Partnership NHS FT, and they went live on 3 
November  2025.   However,  the  PDF  documents  they  are  sharing  do  not  currently 
contain any clinical information specific to the patient  – it’s a generic document that 
contains the SPFT team contact information. 

Further information should be sought with regards to the actual content of the SCR 
and information held on ConCR in addition to accessed clinical information  which may 
help assist with the identification of the ‘Care Gaps’ to which the Coroner refers.  

Your Report indicates that Alex had formally been diagnosed with suicidal thoughts, 
anxiety  and  depression  and  drug  misuse  so  it  would  be  reasonable  to  expect  that 
these diagnoses and medications prescribed for anxiety and depression (including the 
‘Last Issued’ dates) would be visible in Alex’s SCR provided the patient had not ‘opted 
out’. Brief further clinical details, for example, regarding the history of suicidal thoughts, 
previous  overdoses  or  acts  of  deliberate  self-harm,  and  the  use  of  illicit  drugs 
(cannabis,  ketamine  and  diazepam)  may  also  have  been  included  in  Alex’s  SCR 

 where this information had been coded into Alex’s GP record. The SCR would have 
been available to paramedics / front line emergency staff.  

Furthermore,  SCR  can  include  signposting  (and  possibly  contact  details)  for  other 
healthcare  services  and  professionals  that  are  involved  in  the  patient’s  care  for 
example,  the  local  Trust  Mental  Health  assessment  and  treatment  service,  the 
patient’s  registered  Mental  Health  Nurse,  the  local  Drug  and  Alcohol  Wellbeing 
network key worker, the emergency contact details of a specialist support team, where 
this information had been recorded and coded into the patient’s GP record. However 
the SCR does not contain correspondence, so would not include information regarding 
the  correspondence  between  the  local Mental Health  Trust  and  patient’s  registered 
GP or other services involved.  

The local drug and alcohol service are currently commissioned by the Local Authority 
and  not  the  NHS  and  as  such  they  run  on  different  systems.  However,  the  NHS 
England South East Region advises us that the two services work together where they 
can. 

As noted above, NHS England and DHSC have published Fit for the Future: 10 Year 
Health  Plan  for  England,  which  sets  out  the  government’s  plan  for  healthcare  in 
England over the next decade. The Plan includes a commitment to give patients ‘a 
single,  secure  and  authoritative  account  of  their  data  –  a  single  patient  record’  to 
support more coordinated, personalised and predictive care. 

4.  Absence of guidance or advice to frontline emergency crews 

Ambulance  clinicians  are  primarily  responsible  for  assessing  and  managing  the 
patient's  immediate  clinical  needs  and  determining  the  most  appropriate  course  of 
action based on the information available at the time. 

Ambulance  clinicians  may  have  access  to  additional  patient  information  through 
systems such as the Summary Care Record and other locally available shared care 
records, where these are available and appropriate to access. Access to information-
sharing systems and the extent of information available varies between local areas. 
National  policy  and  professional  guidance  are  clear  that  appropriate  information 
sharing is a fundamental part of delivering safe and effective care across the NHS. 
Clinicians are also able to share relevant information for the purposes of direct care in 
accordance with established information governance principles.  

Where a patient consents, or where information sharing is otherwise justified for direct 
care,  ambulance  clinicians  may  contact  other  healthcare  professionals  or  specialist 
services  involved  in  a  patient's  care.  However,  the  availability  of  referral  routes, 
specialist services and information-sharing arrangements is determined locally and is 
not subject to a single nationally mandated model.  

National  policy  and  professional  guidance  are  clear  that  appropriate  information 
sharing is a fundamental part of delivering safe and effective care across the NHS.  

 
 
 
 
 
 NHS  England  continues  to  support  improvements  in  interoperability  and  the 
development of shared care records to enable safer, more joined up care. This under 
pins  the  approach  of  moving  from  analogue  to  digital,  hospital  to  community  and 
treatment to prevention as outlined in the 10 Year Health Plan.  These developments 
aim  to  improve  information flow while  ensuring  that data  is shared  with  appropriate 
clinical context and in line with professional standards, so that information generated 
in one care setting is not misinterpreted or used inappropriately in another. 

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 Alex, 
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