GP Continuity of Care Breakdown
Failures in delivering continuity of care within GP practices, often due to contract limitations, leading to delayed diagnoses.
491 items
8 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
90match
#27 - Personal lists are essential for improving continuity of care in NHS general practice.
Personal lists are the best way to deliver continuity of care and are therefore an essential component of improving the levels of continuity provided in NHS general practice. We recognise the pressures in general practice but we believe that delivering high levels of continuity will reduce pressure on GPs rather than increase it by enabling them to be...
Matched on
terms: care, continuity
Committee recommendation
83match
#2 - Lack of continuity of care fragments support for people with severe mental illness
Continuity of care is a necessity for people with severe mental illness. It is essential to the delivery of high-quality care. When it is present, it prevents crisis, builds trust, and supports recovery. When it is absent, it fragments support, burdens families, and puts lives at risk. This continuity must be built into the design of mental health...
Matched on
terms: care, continuity
Committee recommendation
82match
#26 - Additional funding required for continuity leads and administrative staff in Primary Care Networks.
NHS England should provide Primary Care Networks with additional funding to appoint a ‘continuity lead’ for at least one session per week, and additional admin staff funding to support the lead in the role. The role of the continuity lead GP would be to support practices within their network to increase the proportion of patients consulting with their...
Matched on
terms: care, continuity
Committee recommendation
82match
#25 - National continuity of care measure required for all GP practices by 2024.
NHS England should introduce a national measure of continuity of care to be reported by all GP practices by 2024. The new measure should be based on existing models such as the Usual Provider Continuity Index and the St Leonard’s Index of Continuity of Care and in the short term should be based on measuring either continuity delivered...
Matched on
terms: care, continuity
Committee recommendation
82match
#24 - Routine measurement of continuity of care is essential for improvement efforts and targeted support.
Unless continuity of care is routinely measured GP practices and Primary Care Networks will be unable to identify where to focus improvement efforts. NHS England will also be unable to effectively target support without establishing a baseline for the provision of continuity of care. Measuring the proportion of appointments delivered by a named GP is simple and easily...
Matched on
terms: care, continuity
Committee recommendation
82match
#21 - Continuity of care is a vital, evidence-backed goal benefiting NHS general practice patients and GPs.
We believe that continuity of care is one of the most important goals for NHS general practice. There is a wealth of evidence that higher levels of continuity of care in general practice are better for both patients and GPs themselves. Continuity of care is more efficient for GPs, improves their shared decision making with patients, and provides...
Matched on
terms: care, continuity
Committee recommendation
82match
#20 - Declining continuity of care in general practice is concerning and inadequately prioritised nationally.
We are extremely concerned about declining provision of continuity of care in general practice. We recognise the enormous pressure that GP services are under but it is unacceptable that one of the defining standards of general practice has been allowed to erode in this way. While we recognise the importance of continuity of information and accountability, and the...
Matched on
terms: care, continuity
Committee recommendation
78match
#23 - Government and NHS England must acknowledge declining continuity of care and prioritise its reversal.
The Government and NHS England must acknowledge the decline in continuity of care in recent years and make it an explicit national priority to reverse this decline.
Matched on
terms: care, continuity
Committee recommendation
78match
#22 - All patients benefit from continuity of care, even without expressed preference for it.
We recognise that continuity of care is valued differently by different patients. However, just because a patient does not necessarily express a preference for continuity of care, it does not mean that they will not benefit from receiving it. It is clearly the case that even a patient who is young and generally healthy would be better served,...
Matched on
terms: care, continuity
PFD report
73match
Ryan Singh Bhogal
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.
Matched on
terms: care, continuity
PFD report
69match
Terence O’Connell
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.
Matched on
terms: breakdown, care
PFD report
69match
Dorothy Townley
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.
Matched on
terms: breakdown, care
PFD report
69match
Richard Parkes
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.
Matched on
terms: care, continuity
PFD report
69match
Christopher Fairhurst
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.
Matched on
terms: care, continuity
PFD report
69match
Jacqueline Elliott
Inadequate medication review processes, poor documentation, high-volume painkiller prescribing despite overdose history, and lack of continuity of care led to reliance on painkillers.
Matched on
terms: care, continuity
PFD report
69match
Brian Wareham
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.
Matched on
terms: breakdown, care
LGO / SPSO decision
65match
PSOW-202501595 - A GP Practice in the area of Betsi Cadwaladr University Health Board
We investigated a complaint brought by M’s mother, Mrs P, which focused on whether M’s consultations with clinicians at a GP practice (“the GP Practice”) in relation to abdominal symptoms between 11 March 2024 and 8 June 2024 were appropriately managed and whether there were any missed opportunities to diagnose appendicitis. The investigation found that there were omissions...
Matched on
terms: care
Committee recommendation
64match
#28 - NHS England's crucial role championing personal list model and setting 2027 ambition.
As part of wider efforts to improve continuity of care NHS England should champion the personal list model rather than dismissing it as unachievable. NHS England should set a stretching ambition that by 2027 80% of practices have returned to personal list continuity and provide support for practices to do so.
Matched on
terms: care, continuity
PFD report
61match
Teresa Lonergan
The patient accumulated a dangerous hoard of prescribed controlled drugs due to a lack of monitoring by healthcare professionals, enabling a fatal overdose.
Matched on
terms: care
PFD report
61match
Andrey Wakefield
Poor communication of patient discharge information to GPs, especially for practices distant from the hospital, poses a significant risk to ongoing patient care.
Matched on
terms: care
PFD report
61match
Audrey Garland
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.
Matched on
terms: care
PFD report
61match
Joan Richardson
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.
Matched on
terms: care
PFD report
57match
Julia Dell
The medical service received from primary care was exemplary during the period examined, with no concerns identified in the provided text.
Matched on
terms: care
PFD report
57match
Darren Arnoup
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.
Matched on
terms: care
PFD report
57match
Courtney Mills
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.
Matched on
terms: breakdown
PFD report
57match
Daniel McCallum Keane
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.
Matched on
terms: care
PFD report
57match
Ernest Higgs
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.
Matched on
terms: care
PFD report
57match
Patrick McGagh
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.
Matched on
terms: care
PFD report
57match
Ruth Milne
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.
Matched on
terms: continuity
PFD report
57match
Sarah Kiff
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.
Matched on
terms: care
PFD report
57match
Sophie Holman
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.
Matched on
terms: care
PFD report
57match
Peter Garvin
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.
Matched on
terms: care
Committee recommendation
56match
#30 - Necessity for re-implementing personal lists in the NHS GP contract from 2030.
NHS England should re-implement personal lists in the GP contract from 2030 onwards. (Paragraph 103) General practice and new NHS organisations
Matched on
terms: care
Committee recommendation
56match
#29 - Examine limiting patient list sizes to 2500, reducing to 1850 over five years.
The Government should examine the possibility of limiting the list size of patients to, for example, 2500 on a list, which would slowly reduce to a figure of around 1850 over five years as more GPs are recruited as planned. These numbers should reflect varying levels of need in local populations. This would draw us closer in line...
Matched on
terms: care, continuity
PFD report
53match
Elsie Raper
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.
Matched on
classifier match
PFD report
53match
Timothy Jones
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.
Matched on
classifier match
Committee recommendation
53match
#25 - NHS England is optimistic about future diagnostics, but GP engagement on prescribing is needed.
NHS England told us that it is more optimistic about the future use of diagnostics. It told us that there would be “an explosion” of point of care diagnostic tests as well as a very bright future for their use once the evidence base is ready. It agreed that it needs to engage more with GPs about prescribing...
Matched on
terms: care
PPO recommendation
53match
The healthcare provider
The healthcare provider should ensure there is a GP onsite in line with the primary care service specification for prisons in England.
Matched on
terms: care
PHSO casework decision
52match
P-003330 - A practice in the Dorset area
Mrs T complains the Practice denied her husband’s request for a home visit on19 July 2023, instead arranging a telephone consultation for 8 August with an unacceptable wait of 20 days for GP care. Mrs T complains the Practice then failed to arrange a home visit, despite agreement from the GP on 8 August that Mr T should...
Matched on
terms: care
LGO / SPSO decision
51match
PSOW-202003164 - Cwm Taf Morgannwg University Health Board
Mr B complained about the care and treatment provided to his late brother, Mr F, by a GP Practice (“the Practice”) in the area of Cwm Taf Morgannwg University Health Board. Mr B complained that between 6 February 2017 and 2 January 2020, the Practice failed to carry out appropriate and timely investigations that might have enabled an...
Matched on
terms: care
LGO / SPSO decision
51match
PSOW-202200229 - A GP Practice in the area of Swansea Bay University Health Board
Mrs A complained about care and treatment provided to her late husband in December 2020 and January 2021. She was unhappy that he was examined in the car park, was not prescribed further medication or offered oxygen and was not referred to hospital. Mrs A did not accept the explanations provided by the Practice. The Ombudsman found that...
Matched on
terms: care
LGO / SPSO decision
51match
PSOW-202207050 - Aneurin Bevan University Health Board
Mr R complained about care and treatment provided to his late wife, Mrs R, by Aneurin Bevan University Health Board (“the Health Board”), a GP Practice (“the Practice”) in the area of the Health Board, and Gloucestershire Hospitals NHS Foundation Trust (“the First Trust”). The Public Services Ombudsman for Wales (“the PSOW”) and the Parliamentary and Health Service...
Matched on
terms: care
LGO / SPSO decision
51match
PSOW-202307376 - A GP Practice in the area of Betsi Cadwaladr University Health Board
Ms Y complained about the care a GP Practice in the area of Betsi Cadwaladr University Health Board, had provided to her. She specifically complained about comments made to her when she contacted the practice about her symptoms and said that the Practice did not provide appropriate support when she contacted it about pain management due to her...
Matched on
terms: care
Committee recommendation
51match
#2 - Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
In response to this Report the Government and NHS England should be clear in acknowledging that there is a crisis in general practice and set out in more detail the steps they are taking in response to this crisis in the short term, to protect patient safety, strengthen continuity, improve access and reduce GP workloads.
Matched on
terms: care, continuity
PFD report
49match
Pauline Meredith
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.
Matched on
classifier match
PFD report
49match
Leslie Harding
There was a failure to take prompt action and ensure robust treatment for a patient with a suspected life-threatening pulmonary embolus over a critical period.
Matched on
classifier match
PFD report
49match
Margaret Pegnall
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.
Matched on
classifier match
PFD report
49match
Lindsey Hassall
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.
Matched on
classifier match
PFD report
49match
Maureen Campbell-Scott
A referral was sent to the wrong team and then lost, causing a four-month delay in assessment. There were also delays in delivering clinic letters to the GP, and prescribing did not always follow the psychiatric team's directions.
Matched on
classifier match
PFD report
49match
George Thompson
Insufficient doctor staffing meant no home visits could be undertaken even if clinically indicated, due to one doctor covering all duties and emergencies.
Matched on
classifier match