Tammy Denise Milward · Prevention of Future Deaths report

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Issued 15 Jan 2025•Surrey

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
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
7

Described in 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.

Report evidence summary

Concerns raised2

  1. Insufficient coordination and communication between primary and secondary care providers
    Part of recurring concern: Unreliable coordination and information sharing between primary and secondary care
  2. Failure of primary and secondary care providers to access each other’s electronic medical records
    Part of recurring concern: Unreliable access to relevant clinical records for safe carePart of recurring concern: Unreliable coordination and information sharing between primary and secondary carePart of recurring concern: Unreliable inter-agency information sharing for coordinated care

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.7

  1. Esher Green Surgery

    Notify the ICB about the need for improved connectivity and clinical information sharing between electronic record systems.

  2. Esher Green Surgery

    Raise staff awareness within the Practice of the agreed communication measures.

  3. Esher Green Surgery

    Continue timely verbal communication with GPiMHS staff about at-risk patients and confirm those communications by email.

  4. Esher Green Surgery

    Work with the ICB to find a solution to the Practice’s clinical estate constraints affecting interaction with GPiMHS staff.

  5. Esher Green Surgery

    Implement temporary or other changes recommended by the ICB or SABP to support clinical information sharing and communication pending IT integration.

  6. Surrey Heartlands ICB

    Provide live GP medication and correspondence feeds with embedded single-sign-on access through the Surrey Care Record.

  7. Surrey Heartlands ICB

    Implement a live Surrey Care Record feed displaying complete GP consultation free text, including historic consultations.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Esher Green Surgery

    Fully utilised clinical space and Surrey-wide space pressures make regular in-person GPiMHS interaction unlikely, so email and telephone should be prioritised.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. Esher Green Surgery

    The practice cannot independently improve communication across Surrey; practice-level action will not address the wider issue without a uniform SABP approach.

    Unable to actThe respondent said that a constraint prevented them from taking the relevant action.
  3. Esher Green Surgery

    Electronic record connectivity is a commissioning responsibility for the Surrey-wide ICB, not an individual GP practice.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
  4. Surrey Heartlands ICB

    Surrey Care Record access is considered sufficient to resolve the risk of GPimhs staff lacking necessary GP record information.

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

    Existing practice email arrangements are considered sufficient to mitigate urgent and non-urgent communication risks between GPimhs staff and practices.

    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

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. ”

Is this part of a recurring concern?

Yes — Unreliable coordination and information sharing between primary and secondary care.

Open source report

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 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. ”

Is this part of a recurring concern?

Yes — Unreliable access to relevant clinical records for safe care; Unreliable coordination and information sharing between primary and secondary care; Unreliable inter-agency information sharing for coordinated care.

Open source report

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
Page 2 · response
Published 16 January 2025

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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
Page 3 · response
Published 16 January 2025

Open published response

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
Page 3 · response
Published 16 January 2025

Open published response

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
Page 2 · response
Published 16 January 2025

Open published response

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
Page 3 · response
Published 16 January 2025

Open published response

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

Provide live GP medication and correspondence feeds with embedded single-sign-on access through the Surrey Care Record.

Verbatim wording from the response

“Currently the Surrey Care Record does share a live feed of the GP medication, all GP held letters and also any letters sent from an acute trust to the GP (live feed again). By mid-April we will have been able to implement a live feed from the GP system which will show the entire consultation free text, including historic consultations. This will effectively give the meat (all clinically relevant) GP record to the health professional treating that patient. Patient/pharmacy messages are stored within the GP record as an administration consultation and as such any messages from the pharmacist to the GP will be fully visible to the GPimhs team. Of note, there is embedded link (single sign on) from within the SABP system so that it requires only one button push from the SABP System One record, in order to automatically open up the Surrey Care Record for that patient.”

Source location

Response from Surrey Heartlands ICB
Page 1 · response
Published 16 January 2025

Open published response

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 a live Surrey Care Record feed displaying complete GP consultation free text, including historic consultations.

Verbatim wording from the response

“Currently the Surrey Care Record does share a live feed of the GP medication, all GP held letters and also any letters sent from an acute trust to the GP (live feed again). By mid-April we will have been able to implement a live feed from the GP system which will show the entire consultation free text, including historic consultations. This will effectively give the meat (all clinically relevant) GP record to the health professional treating that patient. Patient/pharmacy messages are stored within the GP record as an administration consultation and as such any messages from the pharmacist to the GP will be fully visible to the GPimhs team. Of note, there is embedded link (single sign on) from within the SABP system so that it requires only one button push from the SABP System One record, in order to automatically open up the Surrey Care Record for that patient.”

Source location

Response from Surrey Heartlands ICB
Page 1 · response
Published 16 January 2025

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

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
Page 2 · response
Published 16 January 2025

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

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
Page 2 · response
Published 16 January 2025

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

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
Page 1 · response
Published 16 January 2025

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

Surrey Care Record access is considered sufficient to resolve the risk of GPimhs staff lacking necessary GP record information.

Verbatim wording from the response

“Any data is only two mouse clicks away. This should fully resolve the issue of the GPimhs staff not being able to see the GP record to the degree that is required to mitigate this risk.”

Source location

Response from Surrey Heartlands ICB
Page 1 · response
Published 16 January 2025

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

Existing practice email arrangements are considered sufficient to mitigate urgent and non-urgent communication risks between GPimhs staff and practices.

Verbatim wording from the response

“In order for GPimhs staff to communicate with the practice, each practice has a specific email for their reception. This email address can be provided to SABP by each practice. It is monitored by the practice during opening hours and any urgent emails would be forwarded on to the duty doctor within the practice. This would allow urgent (but not emergency) communication between the GPimhs team and the practice. The GPs can reply to this using the AccuRx email solution which writes any sent emails back into the clinical system, so that they are again visible to the system (SECAMB,111,OOH, and acute trust A&E).”

Source location

Response from Surrey Heartlands ICB
Page 1 · response
Published 16 January 2025

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

Official responses located
2/2

Data last updated 7 September 2026