Recurance · prevention of future deaths reports
Pre-inquest brief
Out-of-hours clinicians cannot access regular GP records
The earlier warning
David Buttriss · 12 Jan 2018 · Emma Carlyon, Cornwall and the Isles of Scilly
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
judiciary.uk/prevention-of-future-death-reports/david-buttriss
What was promised
Stated action 1 · response to David Buttriss (12 Jan 2018) · stated timescale: none stated
“Devon Integrated Urgent Care Service, in conjunction with Devon Partnership Trust, have community mental health practitioners (CMHP) working within our Clinical Assessment Providing out-of-hours medical care for the NHS across the county Devon Doctors Ltd - Company No.”
Stated action 2 · response to David Buttriss (12 Jan 2018) · stated timescale: none stated
“NHS England proposes to disseminate a reminder to GPs to safety net urgent mental health referrals, reflecting in particular the inherent vulnerabilities associated with patients with mental health problems who may find it more difficult to engage with specialist mental health services when they are acutely unwell, and furthermore consider giving a patient written guidance on what to expect and when following a referral, given the impact mental health problems have on concentration and hence memory”
Stated action 3 · response to Amy Hogan (31 Jul 2020) · stated timescale: March 2022
“We are working with GP system suppliers and NHS England and NHS Improvement continue to make progress.”
What recurred
- 31 Jul 2020 · Amy Hogan · Christopher Morris · Identical hazard · confidence 0.90 (high)
- 18 Apr 2023 · Patrick Soames · Edmund Gritt · Closely related · confidence 0.86 (high)
- 19 May 2025 · John Spencer · Edward Steele · Closely related · confidence 0.80 (moderate)
The clearest link, quoted from both reports:
Earlier · David Buttriss · 12 Jan 2018
“The Out of Hours GP, EE cid not have access to either the mental health or GP records”
Later · Amy Hogan · 31 Jul 2020
“the out of hours GP reviewing Miss [name redacted] had no electronic access to her regular GP records”
What happened next
No web check of the stated actions has been published for this chain.