“are: The Inquest heard evidence that Ms Milward’s case presented treatment challenges…”
Dated 15 Jan 2025, from the coroner for Surrey. Sent to 2 organisations or people.
A coroner wrote this report after an inquest, to warn the organisations below about a risk of further deaths.
The 56-day response deadline
Deadline passedReplies were due by 12 Mar 2025. A reply may have been sent and not yet published.
Organisations that receive a report must reply to the coroner within 56 days, saying what they will do or why they will do nothing. We show whether a response is published on judiciary.uk.
- Report dated15 Jan 2025
- Deadline12 Mar 2025
- Published on judiciary.uk16 Jan 2025
- Today23 Oct 2026
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Responses from each recipient
| Sent to | Response |
|---|---|
| Surrey and Borders Partnership NHS Foundation Trust | Response published, not yet matchedA response is published with this report. We haven’t yet matched it to the organisation it’s from, so it may be this one’s. |
| Esher Green Surgery | Response publishedPublished on judiciary.uk in January 2025. |
Some responses were published as scans, so their text was read automatically. Check the wording against the original before you quote it.
The coroner’s concerns
are: 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.
An extract. Read the full report, including the circumstances of the death, on the Courts and Tribunals Judiciary website.
- Source
- judiciary.uk, Prevention of Future Deaths reports, 2025-0027
- Added to Minute Book
- 8 Oct 2026
- Reuse
- We show short extracts and link to the original. We don’t host the full report.
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Contains public sector information licensed under the Open Government Licence v3.0. Source: Courts and Tribunals Judiciary, judiciary.uk. Open Government Licence v3.0
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