PFD report

Samuel Thomas Jordan · Prevention of Future Deaths report

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Issued 2 Feb 2024•Exeter and Greater Devon

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear 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
5

Described in responses

Recipients and published responses

Source document

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. Lack of access to temporary GP practice records through the NHS Spine
    Part of recurring concern: Electronic patient records failing to make relevant clinical information available and actionablePart of recurring concern: Failure to provide clinicians with complete prisoner information for safe assessmentPart of recurring concern: Unreliable consolidation and access to patients’ cross-service clinical risk information
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

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

  1. Action

    Improve information sharing between the detained estate and wider NHS by enabling access to Spine-connected services, including PDS, eRS and GP2GP Transfer.

    Stated by NHS EnglandStated in progressThe respondent said that this action was in progress when they made their response on 12 February 2024.
  2. Action

    Provide GP2GP electronic transfer of community GP records into and out of healthcare systems across the adult male and children’s secure estate.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing temporary-registration and detained-estate information-sharing processes are considered sufficient, subject to consent and direct contact where necessary.

    Stated by NHS EnglandExisting 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

Lack of access to temporary GP practice records through the NHS Spine

Wider context from the report

“During the four months before his imprisonment, Samuel Jordan had been receiving treatment for severe anxiety while registered as a temporary patient with a medical practice in Launceston, Cornwall. Samuel had come to Cornwall from his home in Whitchurch, Hampshire where he was registered with another GP practice. On entering HMP Exeter, the prison Healthcare obtained a summary of Samuel’s GP records from Hampshire via the NHS spine. The records from the Launceston practice were not sent to the prison since the NHS spine only operates to transmit records from the permanent GP practice and not a practice consulted on a temporary basis. As a result, Exeter Prison Healthcare was unaware of Samuel’s mental health issues immediately before coming to Prison and was unaware of a current medication prescription lack of which the jury found contributed to Samuel’s death. The inquest heard that prisoners coming to prison frequently were nomadic and frequently had registered with GP practices on a temporary basis and records from such practices not coming to the notice of prison healthcare as such records are not accessible through the NHS spine. Lack of access through the NHS Spine to the records of the practice where Samuel was registered as a temporary patient was, the jury found, a contributory factor in Samuel’s death. ”

Is this part of a recurring concern?

Yes — Electronic patient records failing to make relevant clinical information available and actionable; Failure to provide clinicians with complete prisoner information for safe assessment; Unreliable consolidation and access to patients’ cross-service clinical risk information.

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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

Improve information sharing between the detained estate and wider NHS by enabling access to Spine-connected services, including PDS, eRS and GP2GP Transfer.

Verbatim wording from the response

“NHS England has been working to improve the processes around information sharing between the detained estate and the wider NHS. This includes enabling access to a range of Spine connected services including Personal Demographics Service (PDS), Electronic Referral Service (eRS) and GP2GP Transfer. As a result of these changes, some patients transferring into the detained estate will have a GP2GP transfer whereby the patient’s electronic GP record is sent from their previously registered GP Practice to the new GP Practice that they register with within the detained estate. Further details are available via the links below:”

Source location

Response from NHS England
Page 1 · response
Published 12 February 2024

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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

Provide GP2GP electronic transfer of community GP records into and out of healthcare systems across the adult male and children’s secure estate.

Verbatim wording from the response

“Patients within the adult male and children and young people’s secure estate (adult male prisons, young offender institutions and secure training centres) have the opportunity to register with healthcare at their place of detention. This means a GP2GP transfer can now take place, electronically transferring the patient’s community GP record into the clinical system in place across the secure estate, and then back out to the community when the patient registers with a GP on release. The ability for a GP2GP transfer of a community GP record into the prison healthcare system was rolled out to the male prison estate between February and July 2022, so this option was not available at the time of Samuel’s death, but I hope provides assurance around current practice.”

Source location

Response from NHS England
Page 2 · response
Published 12 February 2024

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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

Existing temporary-registration and detained-estate information-sharing processes are considered sufficient, subject to consent and direct contact where necessary.

Verbatim wording from the response

“In summary, there are existing processes around the management of temporary resident patients. These support GP Practices to take over the management of patients by registering them permanently at the new practice where this is appropriate. Where care continues to be provided on a temporary basis, there are existing information flows to send information about the care episode back to the patients’ registered GP Practice via the GMS3 form, where the patient has consented, and for this information to then be integrated into the patients’ registered GP record so that”

Source location

Response from NHS England
Page 2 · response
Published 12 February 2024

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Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.3

  1. 1

    Discuss Reports to Prevent Future Deaths through the Regulation 28 Working Group and share resulting learning and insights across national and regional NHS services.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
  2. 2

    Include long-term conditions, significant medical history and specific communication needs by default in patients’ Summary Care Records unless patients opt out.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.
  3. 3

    Migrate detained-estate clinical users from the Summary Care Record application to the National Care Records Service.

    Stated by NHS EnglandStated completedThe respondent said that this action was complete when they made their response on 12 February 2024.

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

Discuss Reports to Prevent Future Deaths through the Regulation 28 Working Group and share resulting learning and insights across national and regional NHS services.

Verbatim wording from the response

“I would also like to provide further assurances on 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 preventable deaths are shared across the NHS at both a national and regional level and helps us pay close attention to any emerging trends that may require further review and action.”

Source location

Response from NHS England
Page 3 · response
Published 12 February 2024

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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

Include long-term conditions, significant medical history and specific communication needs by default in patients’ Summary Care Records unless patients opt out.

Verbatim wording from the response

“In addition, details of long-term conditions, significant medical history, or specific communications needs, is now included by default for patients with an SCR, unless they have previously told the NHS that they do not want this information to be shared. For more information, and to illustrate the type of content included in an SCR, an example SCR is available here: Additional Information in the SCR”

Source location

Response from NHS England
Page 3 · response
Published 12 February 2024

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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

Migrate detained-estate clinical users from the Summary Care Record application to the National Care Records Service.

Verbatim wording from the response

“The Summary Care Record has been enabled for viewing in the detained estate for a number of years. In 2020, when Samuel died, SCRs were accessed using the Summary Care Record application. However, currently users across the detained estate will access the SCR via the National Care Records Service NCRS (see further information below).”

Source location

Response from NHS England
Page 2 · response
Published 12 February 2024

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