PFD report

Harry George Mellor · Prevention of Future Deaths report

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Issued 22 Oct 2015•Nottinghamshire

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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: 4
Recipients: 5
Responses found: 8
Stated actions: 7

Recipients and published responses

Department of Health and Social CareNo response found General Medical CouncilResponse found NHS Nottingham and Nottinghamshire Integrated Care Board

Response foundNottinghamshire Safeguarding Children Partnership

No response foundPublic Health EnglandResponse found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 17 November 2014 I commenced an investigation into the death of Harry George Mellor a child aged 8 years. The investigation concluded at the end of the inquest on 5th October 2015. The conclusion of the inquest was that Harry had died from pyelonephritis. I recorded a short form conclusion of natural causes.

Circumstances of the death

1. At the age of 13 months Harry’s parents expressed concern about Harry’s lack of developmental progress and infrequent bowel movements. Despite extensive medical investigations between 2007 and 2010, it was not possible to identify the cause of Harry’s hypotonia and hypermobility, and consequently the long term paediatric plan for Harry was to provide support via occupational therapy, physiotherapy, and on-going paediatric review and assessment. Harry made remarkable progress with his mobility but continued to experience problems with toileting and was prone to constipation. He was never continent of urine and faeces and wore nappies throughout life.

2. Although Harry had chronic health needs and remained open to the paediatric team, Harry was not subject to any further paediatric review after 10 March 2011. This was due to a combination of unfortunate circumstances. A partial booking system for paediatric appointments, which was in place in late 2011, required Harry’s mother to contact the hospital to arrange an appointment date. The request was sent to the wrong address and Harry’s mother was not aware of the need to arrange a further appointment. This failure went un-noticed until Harry’s death in October 2014.

3. In December 2012, Harry’s GP de-registered Harry, because his family had moved to a new house outside the practice area. Despite further house moves Harry’s mother did not register Harry with a new GP after his de-registration in December 2012. This failure also went un-noticed until Harry’s death in October 2014.

4. In the autumn of 2014 Harry began to complain of stomach pains. The mother believed that these symptoms were a recurrence of Harry’s usual and long-standing problems with constipation and administered laxative medication.

5. On 28 October 2014 Harry collapsed unexpectedly at his child minder’s home. Despite prompt emergency treatment it was not possible to revive Harry and he was pronounced dead shortly after his arrival at the emergency department.

Concerns and recipient responses

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

Concerns raised4

Lack of a reliable system to identify children de-registered from a General Practice
Lack of a legal requirement to register or re-register children with a General Practitioner
Failure to ensure a new General Practitioner is identified and notified before a child is de-registered

Responses linked to these concerns

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

Actions described in response 3

Action
Publish professional guidance requiring doctors to support vulnerable children, share information, act on safeguarding concerns, and contribute to safe care handovers.
Stated by General Medical CouncilStated completed
Action
Commission an independent review of GP involvement and the circumstances of GP deregistration in the case.
Stated by NHS England (North Midlands and NHS Nottingham and Nottinghamshire Integrated Care Board and Newark & Sherwood CCG and Nottingham City CCG and Nottingham North & East CCGStated planned
Action
Request that GP registration and deregistration issues are included in the serious case review terms of reference.
Stated by NHS England (North Midlands and NHS Nottingham and Nottinghamshire Integrated Care Board and Newark & Sherwood CCG and Nottingham City CCG and Nottingham North & East CCGStated planned

Respondent positions 9

Position
Determining the process for registering patients in general practice falls outside the respondent’s direct role.
Stated by Public Health EnglandOutside remit

Position
NHS England is responsible for commenting on GP registration and addressing concerns about loss of continuity of care.
Stated by Public Health EnglandRedirects responsibility
Position
NHS England is responsible for national clinical-monitoring systems, administrative removals and records transfers; NHS systems changes should be pursued with relevant organisations.
Stated by General Medical CouncilRedirects responsibility
Position
Designing and operating healthcare services and clinical-care management systems are outside the respondent’s direct role.
Stated by General Medical CouncilOutside remit
Position
The respondent lacks power to require parents or guardians to register children with GPs or notify GPs when leaving practice areas.
Stated by General Medical CouncilUnable to act
Position
No compulsory GP registration will be introduced because registration is not legally required and there are no plans to make it compulsory.
Stated by Rt Hon Alistair Burt MPNo action considered necessary
Position
GP deregistration was considered reasonable after the family moved outside the practice area, with no prevention of registering with another GP.
Stated by Rt Hon Alistair Burt MPDisputes the concern
Position
The legislative framework governing child GP registration is outside the CCG’s remit.
Stated by NHS England (North Midlands and NHS Nottingham and Nottinghamshire Integrated Care Board and Newark & Sherwood CCG and Nottingham City CCG and Nottingham North & East CCGOutside remit
Position
Existing attendance checks and revised paediatric pathways locally mitigate the risk of children lacking appropriate primary care.
Stated by NHS England (North Midlands and NHS Nottingham and Nottinghamshire Integrated Care Board and Newark & Sherwood CCG and Nottingham City CCG and Nottingham North & East CCGExisting arrangements considered sufficient

Other statements in published responses

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

Recipient-stated actions 4

1
Alert the relevant NHS England team and Nottinghamshire public health director about the GP registration concern.
Stated by Public Health EnglandStated completed
2
Ask the Department of Health and NHS England to review NHS processes to reduce or eliminate recurrence of similar failures.
Stated by Rt Hon Alistair Burt MPStated planned
3
Share the CCG GP independent medical review and subsequent action plan by 31 March 2016.
Stated by NHS England (North Midlands and NHS Nottingham and Nottinghamshire Integrated Care Board and Newark & Sherwood CCG and Nottingham City CCG and Nottingham North & East CCGStated planned
4
Request assurance from specialist paediatric services that DNA procedures are being effectively implemented.
Stated by NHS England (North Midlands and NHS Nottingham and Nottinghamshire Integrated Care Board and Newark & Sherwood CCG and Nottingham City CCG and Nottingham North & East CCGStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised4

Lack of a reliable system to identify children de-registered from a General Practice

Lack of a legal requirement to register or re-register children with a General Practitioner

Failure to ensure a new General Practitioner is identified and notified before a child is de-registered

Failure to directly inform paediatric and physiotherapy services of a child's de-registration

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.3

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.9

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.4

Actions described in response 3

Respondent positions 9

Recipient-stated actions 4