Concerns raised 2 Insufficient coordination and communication between primary and secondary care providers View source Failure of primary and secondary care providers to access each other’s electronic medical records View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.
View source
Action
Raise staff awareness within the Practice of the agreed communication measures.
View source
Action
Continue timely verbal communication with GPiMHS staff about at-risk patients and confirm those communications by email.
View source
Action
Work with the ICB to find a solution to the Practice’s clinical estate constraints affecting interaction with GPiMHS staff.
View source
Action
Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.
View source See 2 more actions
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AI-generated summary
Tammy Denise Milward · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Tammy Denise Milward, who had severe obsessive compulsive disorder and dependence on prescribed medication, was found unresponsive at home on 1 January 2024 after concerns were raised about her wellbeing. The medical cause of death was mixed drug toxicity, with toxicology showing prescribed medication in excess of prescribed levels and cocaine use shortly before her death. The principal concern was limited coordination and communication between primary and secondary care providers, including poor connectivity between their electronic record systems.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Esher Green Surgery; that does not assign responsibility.
PFD Monitor interpretation Insufficient coordination and communication between primary and secondary care providers
Wider context from the report “The Inquest heard evidence that Ms Milward’s case presented treatment challenges which several agencies sought to address but there was limited coordination, in particular that:
a. The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS. As a result, neither the GP practice, nor GPimhs was aware that the other had received messages from or about Ms Milward on 28 December 2023. The coroner heard from SABP that there is ongoing work ongoing to create greater connectivity between the various electronic record systems, but this work is not yet complete.
b. The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs . The coroner was told that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support) but that levels of interaction varied and was sometimes also undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices.
The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Esher Green Surgery; that does not assign responsibility.
PFD Monitor interpretation Failure of primary and secondary care providers to access each other’s electronic medical records
Wider context from the report “The Inquest heard evidence that Ms Milward’s case presented treatment challenges which several agencies sought to address but there was limited coordination, in particular that:
a. The Coroner heard that the GP could not see GPimhs medical records (or any SABP notes) which are recorded on SystmOne and that GPimhs could not easily access the GP medical records held on EMIS . As a result, neither the GP practice, nor GPimhs was aware that the other had received messages from or about Ms Milward on 28 December 2023. The coroner heard from SABP that there is ongoing work ongoing to create greater connectivity between the various electronic record systems, but this work is not yet complete .
b. The evidence heard suggests that there was little personal or practical interaction between the GP practice and GPimhs. The coroner was told that GPimhs had been recently introduced by SABP to work alongside GPs (addressing a need in primary care to provide mental health support) but that levels of interaction varied and was sometimes also undermined by a lack of suitable estate for co-location of GPimhs staff in GP practices.
The coroner is concerned that the lack of coordination and communication between primary and secondary care providers may place patients at risk of early death.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.
Verbatim wording from the response “As such in respect of this Concern a., we consider we cannot proactively do anything save bring this to the attention of the ICB as it is a commissioning issue, which we have done, and later react to requests from SABP, subject to approval from the ICB, to facilitate integration of the clinical IT systems which, of course we will do and would expect the other 100 plus practices to do likewise.” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Raise staff awareness within the Practice of the agreed communication measures.
Verbatim wording from the response “These measures have already been discussed as a practice with staff amongst whom we have raised awareness, but this advice might benefit from being disseminated by SABP Surrey-wide.” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue timely verbal communication with GPiMHS staff about at-risk patients and confirm those communications by email.
Verbatim wording from the response “(iii) We will continue to have timely verbal communication with GPiMHS staff when concerns arise about a patient at risk and follow the same up by email.” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Work with the ICB to find a solution to the Practice’s clinical estate constraints affecting interaction with GPiMHS staff.
Verbatim wording from the response “Clinical space in GP practices is usually fully utilised by the practices themselves and this is the case at our Practice. We are currently working with the ICB on finding a solution to our own estate’s challenges but are aware that there is pressure on GP space Surrey wide. As such, we consider that in-person interactions are unlikely to be effected Surrey-wide so email and telephone interactions should be prioritised in our view. This concern b. is not specific to the Practice but is Surrey-wide for all practices and any action taken by the Practice alone will not address the wider community unless SABP seek a uniform approach.” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.
Verbatim wording from the response “(ii) Pending IT integration, which needs to be effected as soon as possible, we will implement any temporary measures recommended by the ICB, alongside the other 100 plus practices. We believe it is important that any changes are effected Surrey-wide and not on an ad hoc basis for an individual practice; and” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Fully utilised clinical space and Surrey-wide space pressures make regular in-person GPiMHS interaction unlikely, so email and telephone should be prioritised.
Verbatim wording from the response “The majority of GPiMHS consultations for our Practice patients take place away from our surgery building, either at other NHS estates or via remote consultations. We have consequently not had regular in-person interactions with SABP staff, as they are not frequently on-site with our clinicians. Communication is therefore usually via email and/or by telephone.” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The practice cannot independently improve communication across Surrey; practice-level action will not address the wider issue without a uniform SABP approach.
Verbatim wording from the response “Clinical space in GP practices is usually fully utilised by the practices themselves and this is the case at our Practice. We are currently working with the ICB on finding a solution to our own estate’s challenges but are aware that there is pressure on GP space Surrey wide. As such, we consider that in-person interactions are unlikely to be effected Surrey-wide so email and telephone interactions should be prioritised in our view. This concern b. is not specific to the Practice but is Surrey-wide for all practices and any action taken by the Practice alone will not address the wider community unless SABP seek a uniform approach.” Source location Response from Esher Green Surgery
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Electronic record connectivity is a commissioning responsibility for the Surrey-wide ICB, not an individual GP practice.
Verbatim wording from the response “General Practice Integrated Mental Health Service (“GPiMHS”) is a Surrey wide system run by Surrey and Borders Partnership NHS Foundation Trust (“SABP”) and commissioned by Surrey Heartlands Integrated Care Board (“ICB”).” Source location Response from Esher Green Surgery
Open published response
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Request correction
Addressed to Esher Green Surgery (previous provider), now represented here by Esher Green Surgery.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations