GP Continuity of Care Breakdown
70 items
2 sources
Failures in delivering continuity of care within GP practices, often due to contract limitations, leading to delayed diagnoses.
Cross-Source Insight
GP Continuity of Care Breakdown has been flagged across 2 independent accountability sources:
2 inquiry recs
68 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (2)
2 — Patient-focused correspondence
Recommendation: We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than …
Gov response: Accepted. The Academy of Medical Royal Colleges updated their 2018 guidance 'Please write to me' in light of this recommendation. Guidance emphasises writing directly to patients, copying in GPs, using clear language. NHS England is …
Accepted
No update 2+ yrs
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
PFD Reports (68)
Mark Simpson
Concerns: NHS 111 reports to GP practices are not always reviewed by medically qualified staff, and critical information is often not added to patients' medical records, risking inappropriate clinical decisions.
Pending
Joan Talbot
Concerns: Due to a lack of continuity across different admitting teams, the significance of a patient's repeated symptoms was not fully appreciated, delaying necessary investigation.
Response: Kings College Hospital NHS Trust has established a cross-Trust 'Documentation Quality Improvement Working Group' to improve the use of their EPIC record system. This group will define metrics, identify barriers …
Responded
Mark Foster
Concerns: The practice suffers from a lack of unified leadership, poor governance, and an inadequate system for investigating incidents.
Response: The surgery has appointed a new practice manager and GP partner for governance, implemented a new governance structure, and revised its Significant Event Policy. All staff are now instructed to …
Responded
Mark Smith
Concerns: The GP practice lacked a system or policy to ensure appropriate medication reviews for vulnerable patients with addiction or self-harm history, risking stockpiling and misuse of prescribed drugs.
Responded
Daniel Hatchett
Concerns: GP appointments and chronic disease review templates are inadequate for holistically assessing mental health decline in patients with chronic conditions, especially for middle-aged men.
Responded
Thomas Mallinson
Concerns: An overcomplex system led to neglect, with no single body taking responsibility for the patient's urgent care. Failures included inappropriate advice, insufficient staff, and critical communication gaps between emergency services.
Responded
Jyoti Rao
Concerns: The 'Consultant of the Week' model prevented complex transplant patients from having a named consultant, risking discontinuity of care and a comprehensive long-term view of their post-operative recovery.
Responded
George Coulthard
Concerns: Significant hospital discharge delays due to care home shortages, coupled with poor communication between hospital and community teams, led to confused care plans. Limited community wound care access further exacerbated health risks.
Responded
David Power
Concerns: A patient was denied crucial talking therapies due to conflicting "stability" criteria between mental health services, a policy unknown to the referring team. This systemic lack of shared understanding creates a risk of future deaths.
Responded
David Riley
Concerns: Inconsistent application of guidance for pausing DOACs and poor communication regarding time-critical medication instructions increased the risk of harm for patients with atrial fibrillation.
Responded
Mohamed Ellaboudy
Concerns: Mental health care coordination post-discharge was inadequate, characterized by reliance on telephone appointments, unclear MDT thresholds, and a lack of clear family reporting routes, risking patient safety.
Responded
Alexander Reid
Concerns: An incorrect BMI entry in GP records led to the deceased being wrongly identified as vulnerable for early COVID-19 vaccination. The system lacked validation rules to challenge such data errors, contributing to his death.
Responded
Tom Sweeting
Concerns: Poor communication between the hospital and General Practice led to a critical delay in prescribing antidepressant medication for a patient reporting suicidal thoughts.
Responded
Joy Ebanks
Concerns: Prolonged prescribing of dependency-forming drugs (Oxycodone, Pregabalin) without reduction plans, despite internal guidance on the hazards of long-term use, contributed to toxicity.
Responded
Olivia Russell
Concerns: GPs may not routinely discuss medication risks, such as relapse or initial worsening symptoms, contradicting NICE guidance, due to varied approaches and time limitations. A significant event meeting regarding the death was also delayed for over two years.
Overdue
Edward Rhodes
Concerns: There was a breakdown in communication between GP and an addict regarding mental health referral steps, relying solely on verbal discussions without an automatic referral system or written confirmation, leading to unmet care.
Responded
Christine Cumbers
Concerns: The GP practice failed to implement identified learnings from its Significant Event Analysis report, and lacked plans or timescales for addressing recognised shortcomings, risking future reoccurrences.
Responded
Aoife McAdam
Concerns: A patient prescribed a cardiotoxic medication for anxiety was not advised to safely dispose of it after switching, leaving her with a significant, unneeded quantity that led to an overdose.
Responded
Nicola Norman
Concerns: The Single Point of Access (SPA) system failed by using non-clinical staff who did not adequately assess suicidality, follow up on distressed callers, or routinely escalate critical concerns to clinicians or the GP.
Overdue
Carol Cole
Concerns: A flawed process for sharing Public Protection Notices (PPNs) with GPs in the Dorset Council area meant crucial mental health concerns were not received, leading to missed patient assessments.
Responded
Brian Wareham
Concerns: A significant breakdown in communication and trust between primary and secondary care led to vulnerable patients being discharged without adequate information or support regarding complex medical conditions.
Responded
Sameena Javed
Concerns: The GP practice lacked written procedures for administrative staff to escalate critical incoming correspondence to medical staff, risking important actions being overlooked.
Overdue
Maria McGauran
Concerns: The surgery failed to conduct a medication review or consider alternative pain management, despite long-standing family concerns about the patient's excessive use and hoarding of codeine.
Responded
Nichola Lomax
Concerns: Doctors lacked training on eating disorder guidance (MARSIPAN) and pathways to specialist advice. Restrictive referral criteria for community services led to inadequate monitoring by non-specialist GPs.
Overdue
Siwan Smith
Concerns: Medical centre reception staff failed to adequately assess a distressed patient's urgent mental health needs, not providing an emergency appointment or clinical callback, raising concerns about future risk to patients.
Responded
Anita Mandalia
Concerns: The provided text is incomplete and does not contain specific concerns for summarization.
Overdue
Margaret Sales
Concerns: Incomplete patient records, difficulty contacting on-call medical staff, and a critical failure to refer the patient for post-discharge monitoring created significant care gaps.
Responded
Roger Wood
Concerns: A critical AAA scan result was not acted upon by the GP, and the updated referral policy still relies on GP action rather than direct automatic referral, risking similar failures.
Overdue
Andrew McCall
Concerns: A critical lack of verification for patients' methadone prescriptions by GPs, who rely on self-declaration, led to potentially harmful prescribing of other medications for drug-seeking behavior.
Responded
Peter Garvin
Concerns: Poor communication between the CMHT and GP, a lack of local mental health beds, and a policy to discharge NHS patients seeking private care negatively impacted patient care. A carer's assessment was also not offered.
Overdue
Sophie Holman
Concerns: Fragmented asthma care lacked coordinated records, long-term management plans, and guideline adherence, resulting in missed risk factors, excessive medication, and no clear clinical responsibility.
Overdue
George Thompson
Concerns: Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.
Responded
Jacqueline Elliott
Concerns: Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Responded
Ruth Edwards
Concerns: Patient discharge after an overdose failed to include psychiatric liaison assessment, passing critical responsibility to the family. Inadequate history-taking led to underestimated risk, and insufficient GP medication reviews created an overdose risk.
Responded
Robin McEwan
Concerns: Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Responded
Nigel Handscomb
Concerns: Incomplete and inaccurate GP consultation notes, made several hours after the fact, failed to record critical patient information, including examination findings and medication adherence, alongside unrecorded verbal instructions.
Overdue
Graeme Mathieson
Concerns: GPs face unmanageable time constraints without proper triage, and professionals are confused about mental health patient pathways, especially after incorrect discharge from services.
Overdue
Maureen Campbell-Scott
Concerns: Systemic failures in mental health referral and communication between GP and mental health trust led to significant delays in patient assessment and medication management.
Responded
Ernest Smith
Concerns: The system for managing GP correspondence and medication review requests remains flawed. There is also no clear system to update GPs when patients are not under the medical team, risking unrecognised disengagement.
Responded
Penelope Benton
Concerns: The General Practitioner was not informed of a previous tramadol overdose in the hospital discharge letter, preventing complete medical history.
Responded
Lindsey Hassall
Concerns: There was no record of police information to mental health practitioners, delayed and destroyed patient notes, inaccessible documentation, and a GP's incorrect assumption about referrals.
Overdue
Sarah Kiff
Concerns: GPs failed to follow cancer referral guidance, exhibited poor communication and record-keeping, and provided perfunctory care. Additionally, processes for reviewing test results were inadequate.
Responded
Christopher Fairhurst
Concerns: Systemic GP shortages, reliance on locums, and insufficient training are causing reduced patient access, poor continuity of care, and insufficient consultation times. Struggling specialist mental health services are also unsafely raising referral thresholds.
Overdue
Dean Rowland
Concerns: Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Responded
Ruth Milne
Concerns: Concerns about the lack of continuity and appropriateness of GP medical staff, and whether vital recommendations from a 2015 safeguarding report have been fully implemented.
Responded
Timothy Jones
Concerns: GP practice had poor record-keeping, unclear home visit request procedures, misclassified clinical tasks as 'admin', and a policy discouraging home visits for complex patients, leading to inadequate assessment.
Overdue
Miles Abel
Responded
Patrick McGagh
Concerns: A patient was discharged without a discharge letter or prescribed antibiotics being provided to his GP or care staff, leaving them unaware of his medication needs.
Responded
Ernest Higgs
Concerns: Confusion arose from unrecorded GP advice in multi-disciplinary notes and unconfirmed telephone advice. Conflicting information between care providers also caused significant delays in diagnostic testing.
Overdue
Elsie Raper
Concerns: A patient's severe tibia and fibula fractures remained undiagnosed for four days despite regular medical visits, leading to extreme pain and contributing to her death.
Overdue
Christopher Stubbs
Concerns: The abrupt cessation of critical medication upon hospital discharge, with a follow-up GP review failing to occur, highlighted a need to improve systems for acting on discharge summaries regarding patient medication.
Overdue
Richard Parkes
Concerns: Poor GP record-keeping and a rigid policy of refusing to see late patients, even those with known complex medical histories, posed inherent risks to patient care continuity.
Overdue
Ryan Singh Bhogal
Concerns: GP practice lacked continuity of care and 'Red Flag' identification for a child with prolonged illness, while the hospital failed to adequately review GP medical records during admission.
Overdue
Margaret Pegnall
Concerns: A GP practice had a vague domestic abuse flowchart focused on depression, lacked a specific domestic abuse questionnaire, and had no system for escalating urgent patient calls.
Pending
Joan Richardson
Concerns: The GP practice failed to provide emergency care during training closure, delaying assessment of an obviously unwell patient by 24 hours, which contributed to her death.
Overdue
Audrey Garland
Concerns: Failures by GP and District Nursing services to recognize and appropriately treat severe ulcers, combined with a lack of arranged hospital transport, resulted in inadequate care and examination.
Overdue
Daniel McCallum Keane
Concerns: The GP's inadequate record-keeping and inaction, despite being alerted to an "extremely worrying" and high-risk situation for a diabetic patient, critically failed to ensure appropriate care and follow-up.
Responded
Courtney Mills
Concerns: Repeated prescription errors and severe communication breakdowns between the GP surgery and hospital led to dangerous delays in obtaining critical medication, putting the patient at risk of withdrawal.
Responded
Darren Arnoup
Concerns: Concerns exist regarding the coordination and handover of care for a patient with known mental health issues and suicidal ideation following discharge and communication to the GP.
Overdue
Andrey Wakefield
Concerns: Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Responded
David Chatburn
Concerns: The GP failed to refer the patient to psychiatric services, inappropriately managed medication, and had poor record-keeping. Systemic issues included bureaucratic barriers to mental health referrals and non-medical triage.
Overdue
Teresa Lonergan
Concerns: The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Overdue
Pauline Meredith
Concerns: Concerns include prolonged prescribing of excessive medication without review, adding morphine to a high-dose regimen for an alcohol-dependent patient, and a GP's perceived reluctance to address family concerns. Delayed involvement of mental health services was also noted.
Response: The surgery is undertaking an audit of all patients on opioid medication, developing a new protocol for prescribing opioids for chronic pain, and will train staff on this protocol. They …
Overdue
Jonathan Thorpe
Concerns: A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Overdue
Terence O’Connell
Concerns: A severe communication breakdown between the care home, district nurses, and out-of-hours GP led to the patient not being seen, alongside a lack of vital clinical monitoring for two days.
Response: The care home, through Gabbandco, disputes the coroner's finding of a communication breakdown involving them. They assert that any breakdown occurred between the district nurses and the out-of-hours GP service, …
Response: The Health Board accepts the inquest findings and has implemented clear SBAR (Situation, Background, Assessment, Recommendation) message sheets for switchboard staff. This ensures more detailed recording of out-of-hours requests for …
Overdue
Dorothy Townley
Concerns: Significant communication breakdowns between District Nurses and the GP, inadequate burns treatment knowledge and training, and unclear procedures for urgent blood tests compromised patient care.
Response: The Royal College of General Practitioners clarifies its role in providing training and professional development to GPs, outlining existing curriculum sections relevant to inter-professional communication and patient safety. They note …
Responded
Jill Sinson
Concerns: The GP failed to adequately monitor the deceased, prescribed large quantities of unsupervised medication despite a self-harm history, and staff neglected to review critical records or consultant advice.
Overdue
Joshua Burgess
Concerns: Communication failures between the hospital neurology department and GP surgery meant critical medication dosage changes were not formally instructed or acted upon by clinical staff.
Responded