Ronald Richard TILLEY · Prevention of Future Deaths report

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Issued 4 Dec 2020•North East Kent

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Failure to notify the existing GP when the Personal Demographics service is updated or amended

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. NHS England

    Rationalise and streamline systems and data flows for managing primary care registration.

  2. NHS England

    Bring the case circumstances to the registration programme for consideration through consultation with system users and stakeholders.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. NHS England

    GMS registration changes notify the old GP practice, while ‘Other’ services registrations do not update PDS or require such notification.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. NHS England

    Established registration processes and data-quality controls are considered effective for identifying and correcting the small proportion of GP practice-code mismatches.

    Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to notify the existing GP when the Personal Demographics service is updated or amended

Wider context from the report

“(1) When the Personal Demographics service is updated or amended there is no notification sent to the existing GP noted on the system ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Rationalise and streamline systems and data flows for managing primary care registration.

Verbatim wording from the response

“Whilst statistics may reflect positively on the system as a whole, I recognise that the key element of a quality service is the experience of individual patients and NHS Digital will take steps within its power to further reduce the risk of such untoward events. A programme of work is running which is in the process of rationalising and streamlining the systems and data flows in the management of primary care registration. The circumstances surrounding Mr Tilley's death will be brought to the attention of this programme so that improvements may be considered through appropriate consultation with system users and stakeholders.”

Source location

2020-0278-Response-from-NHS-Digital-Redacted
Page 5 · response
Published 6 January 2021

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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

Bring the case circumstances to the registration programme for consideration through consultation with system users and stakeholders.

Verbatim wording from the response

“Whilst statistics may reflect positively on the system as a whole, I recognise that the key element of a quality service is the experience of individual patients and NHS Digital will take steps within its power to further reduce the risk of such untoward events. A programme of work is running which is in the process of rationalising and streamlining the systems and data flows in the management of primary care registration. The circumstances surrounding Mr Tilley's death will be brought to the attention of this programme so that improvements may be considered through appropriate consultation with system users and stakeholders.”

Source location

2020-0278-Response-from-NHS-Digital-Redacted
Page 5 · response
Published 6 January 2021

Open published response

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

GMS registration changes notify the old GP practice, while ‘Other’ services registrations do not update PDS or require such notification.

Verbatim wording from the response

“In either case, Primary Care Support England (‘PCSE’), who have responsibility for managing primary care registration on behalf of NHS England, will validate and complete the registration by updating PDS with the GP practice code, depending on the chosen pathway, and apply a geographic administrative indicator known as an NHAIS cipher. In completing this action, a series of notifications is triggered from PDS to inform the old GP practice of the transfer and deduct the patient from the practice’s patient list and, separately, to initiate the transfer of the patient’s paper medical record envelope, which is often referred to as “the Lloyd George”.”

Source location

2020-0278-Response-from-NHS-Digital-Redacted
Page 3 · response
Published 6 January 2021

Open published response

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

Established registration processes and data-quality controls are considered effective for identifying and correcting the small proportion of GP practice-code mismatches.

Verbatim wording from the response

“There are around 60 million patients registered for primary care in England. Between April 2018 and December 2020 there were almost 16 million patient registration transfers between GPs. Allowing for business-as-usual differences where a new registration has been recorded but not yet validated in line with processes already described, it is unusual for there to be a mismatch between the GP practice code held on PDS and that recorded on the GP clinical systems across England. Recent analysis undertaken on this metric has shown the level of mismatch to be less than 1% of the total registered population, which is illustrative of the strength of the data quality across the system. This also demonstrates that the business processes and systems in place”

Source location

2020-0278-Response-from-NHS-Digital-Redacted
Page 4 · response
Published 6 January 2021

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026