Coroner’s safety report sent to Secretary of State and Royal College after content of 111 call not recorded in GP notes

On 2 and 3 March 2026, HM Senior Coroner for Blackpool and Fylde, Alan Wilson, heard the inquest into the death of Mark Simpson. He identified ongoing systemic risks that resulted in him issuing a report to prevent future deaths to the Royal College of General Practitioners and the Secretary of State for Health and Social Care.

Mr Simpson had consulted his general practitioner about chest pain in May 2025 and, as a result, he was referred for an urgent appointment at Blackpool Victoria Hospital. The referral was received but, during the triage process, it was downgraded to a routine appointment so that, rather than being seen in a matter of weeks, Mr Simpson received a letter informing him that he would be seen around April 2026.

Some months later, Mr Simpson called 111 to report a seven-hour period of chest pain. He was not referred to a clinician and was advised to seek medical help if the pain returned. The next month, he attended an appointment with a nurse practitioner at his GP’s surgery and reported chest pain. The nurse consulted the duty GP but no immediate action was recommended. Two days later, on 22 October 2025, Mr Simpson died at home from acute heart failure at the age of 59.

At the inquest, the Senior Coroner received evidence from Mr Simpson’s GPs and hospital staff. It transpired that the urgent referral had been downgraded because the cardiology consultant who reviewed the GP’s referral had not realised he was required to mark the case as urgent, assuming that original urgency would be carried through to the next stage of the process. In fact, the administrative clerk who made the booking saw only the consultant’s notes and not the GP’s original form. The consultant told the Senior Coroner that he had never received training on the triage process. Mr Simpson was not seen at hospital before his death.

The GP who was consulted by the nurse two days before Mr Simpson died told the Senior Coroner that he had been aware of the urgent referral made in May 2025 but did not know about the seven-hour episode of chest pain the previous month. He said that such information would have changed his advice. Inspection of Mr Simpson’s GP records showed that the existence of the 111 call had been noted in a line entry, but none of the information he gave, including the fact of the pain or its duration, had been entered. Therefore, without a proactive search of the documents on his file, it was not easily available to the GP. A routine review of the GP records would have shown the episode some months earlier in May, but not the much longer episode the previous month. The GP told the Senior Coroner that when the information sent from the 111 service was received by the GP surgery, it had been reviewed by a member of staff who was not medically qualified.

After hearing from Mr Simpson’s family at the inquest, the Senior Coroner considered that the failure to record important information provided during a 111 call on a patient’s GP records (which might be relevant to future diagnoses and urgency of treatment) gave rise to a risk that future deaths could occur unless action is taken. He issued a report to prevent future deaths (under paragraph 7 of Schedule 5 to the Coroners and Justice Act 2009) to the Royal College of General Practitioners and the Secretary of State for Health and Social Care. The recipients must respond to the Senior Coroner by 11 May 2026. A copy of each response will also be sent to the Chief Coroner for England and Wales.

Mr Simpson’s family were represented at the inquest by William Dean, instructed by Susan Liver, a partner at Birchall Blackburn Law.