GP oversight of specialist care
GPs lacking internal systems and a clear monitoring role to assess the quality and outcomes of specialist services.
200 items
7 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
69match
Aimee Varney
NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Matched on
terms: care, specialist
PFD report
69match
Keith Harwood
Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.
Matched on
terms: care, specialist
Inquiry recommendation
67match
IBI-6a(i) - Hepatologist Oversight and Fibroscan Access
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical review, either nurse-led, consultant-led or, where appropriate, by a GP with a specialist interest in hepatitis
Matched on
terms: care, oversight, specialist
Inquiry recommendation
66match
F123 - Responsibility for monitoring delivery of standards and quality
GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so...
Matched on
terms: specialist
PFD report
65match
Violet Nelson
Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.
Matched on
terms: oversight
PFD report
65match
Patricia McAdam
The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.
Matched on
terms: care
Committee recommendation
62match
#17 - Forty-Fourth Report - NHS backlogs and waiting times in England
We asked about how patients other than the longest waiters and those with the highest clinical priority would be supported while they waited. NHSE&I stated that GPs had a role in managing these patients and that it was also asking secondary care clinicians to ensure patients were clearly informed about their position on waiting lists. NHSE&I explained that...
Matched on
terms: care
PFD report
61match
Michael Uriely
Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.
Matched on
terms: care
PFD report
61match
Miriam Tighe
Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.
Matched on
terms: care
PFD report
61match
Graham Earl
GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Matched on
terms: specialist
PFD report
61match
Sharon Reeve
A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed diagnoses, and wasted time for complex cases.
Matched on
terms: specialist
PFD report
61match
Darren King
There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
Matched on
terms: care
PFD report
61match
Sam Pringle
Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.
Matched on
terms: care
PPO recommendation
61match
The Head of Healthcare
The Head of Healthcare should ensure that GPs conduct a full, documented clinical assessment, in line with relevant guidance, to inform medication reviews and changes.
Matched on
terms: care
PFD report
57match
Jacqueline Allwood
The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.
Matched on
terms: care
PFD report
57match
Stuart Campbell
Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.
Matched on
terms: care
PFD report
57match
Rita Taylor
Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient care plan.
Matched on
terms: care
PFD report
57match
Stuart Clarke
The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.
Matched on
terms: care
PFD report
57match
Brenda Drew
The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.
Matched on
terms: oversight
PFD report
57match
Jake Perry
Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require a named local consultant and consultation with the overseeing hospital's specialist department upon admission.
Matched on
terms: specialist
Committee recommendation
56match
#15 - GP advice and guidance scheme demonstrates significant growth in specialist input
NHSE said that it had made progress in some areas, partly where necessity during the Covid 19 pandemic had driven the adoption of technology. NHSE highlighted the advice and guidance scheme, which allows GPs to request specialist input without going through a full referral. This scheme had seen continued growth with 1.1 million requests expected to go through...
Matched on
terms: specialist
PFD report
53match
Amna Umer Ahmed
Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.
Matched on
classifier match
PFD report
53match
Jonathan Thorpe
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.
Matched on
classifier match
PFD report
53match
Jorge Castro
A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to highlight uncollected prescriptions, especially for dependent patients.
Matched on
classifier match
PFD report
53match
Ursula Keogh
Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health and education professionals.
Matched on
classifier match
PFD report
53match
Nathan Cooke
There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Matched on
classifier match
PFD report
53match
Katie Corrigan
There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.
Matched on
classifier match
PFD report
53match
Rory Attwood
The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Matched on
classifier match
PPO recommendation
53match
The Head of Healthcare and the Lead GP (HMP Oakwood)
The Head of Healthcare and the Lead GP should review the terms of reference of the multi-professional complex case clinic/conference (MPCCC) process to ensure that: • crucial information is appropriately reviewed and shared at meetings, and • patients receive continuity of care.
Matched on
terms: care
PHSO casework decision
53match
P-001511 - A healthcare provider in the Nottingham area
Mr D complains that the healthcare provider did not promptly arrange an urgent dermatology appointment for him and prescribed him medication without physically examining him first in December 2018.
Matched on
terms: care
PHSO casework decision
52match
P-003648 - Royal Devon University Healthcare NHS Foundation Trust
Mr A has suffered symptoms of his hypothyroidism and believes he has not had support for the level of monitoring and the medication needed to alleviate those symptoms.
Matched on
terms: care
Inquiry recommendation
51match
IBI-6a(ii) - Specialist Hepatology Centre Access
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Matched on
terms: care, specialist
LGO / SPSO decision
50match
PSOW-202401069 - Cardiff and Vale University Health Board
Miss C complained about the care and treatment she received from the Health Board, specifically; • Whether the Commissioning Team appropriately considered requests received on her behalf between 2022 and 2023 • Whether it was clinically appropriate that she was repatriated to the Spinal Team in June 2022 and whether this decision was communicated to her appropriately and...
Matched on
terms: care, specialist
PFD report
49match
Lucy Goulding
There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.
Matched on
classifier match
PFD report
49match
Yuki Ivy Norman-Knight
Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.
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classifier match
PFD report
49match
Michael Tarratt
There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
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classifier match
PFD report
49match
Lisa Webb
Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.
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classifier match
PFD report
49match
Sadik Miah
Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.
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classifier match
PFD report
49match
Brian Francis
A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.
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classifier match
PFD report
49match
Mary Marshall
A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.
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classifier match
PFD report
49match
Grant Richards
The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.
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classifier match
PFD report
49match
Jamie Elliott
Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.
Matched on
classifier match
PFD report
49match
Michael Halfpenny
A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.
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classifier match
PFD report
49match
Dean Rowland
Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
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classifier match
PFD report
49match
Daniel Young
GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.
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classifier match
PFD report
49match
Michelle Roach
GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.
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classifier match
PFD report
49match
Robin McEwan
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.
Matched on
classifier match
PFD report
49match
Brenda McWilliams
Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.
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classifier match
PFD report
49match
Anita Loi
Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.
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classifier match
PFD report
49match
Natasha Abrahart
NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.
Matched on
classifier match