Incomplete GP Patient Data Transfer
145 items
2 sources
Incomplete transfer of patient data between GP practices, creating significant risks for continuity of care.
Cross-Source Insight
Incomplete GP Patient Data Transfer has been flagged across 2 independent accountability sources:
3 inquiry recs
142 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (3)
IBI-8a — Pre-1996 Transfusion Testing
Recommendation: When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.
Gov response: UK Government NHS England is committed to identifying all those infected with a bloodborne disease, however it is transmitted. We would like to reassure the public that evidence shows the likelihood of contracting Hepatitis C …
Accepted
Delivered
IBI-8b — New Patient Registration Screening
Recommendation: As a matter of routine, new patients registering at a practice should be asked if they have had such a transfusion.
Gov response: UK Government NHS England is committed to identifying all those infected with a bloodborne disease, however it is transmitted. We would like to reassure the public that evidence shows the likelihood of contracting Hepatitis C …
Accepted
Delivered
IHRD-11 — Patient Transfer Protocol
Recommendation: There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Gov response: Transfer protocols developed and implemented across HSC Trusts.
Accepted
Delivered
PFD Reports (142) — showing 100 most recent
James Fitzpatrick
Concerns: A lack of national and local written guidance for patient handovers between staff and wards leads to incorrect or incomplete information being transferred, risking patient care.
Pending
Winifred Wardle
Concerns: The hospital lacks a clear multi-disciplinary protocol for CT scan requests, with unclear escalation lines when requests are rejected and inadequate record-keeping of decision-making processes.
Overdue
Urielle Kuyenga
Concerns: A critical communication breakdown between hospital and GP regarding medication monitoring, combined with repeated failures by GPs to check clinical records, left a child unprotected from fatal infection.
Response: The Trust has appointed an HCC governance lead, updated the standard operating procedure for transfers of care following an audit, and incorporated patient representatives into service meetings. They are also …
Response: The practice has audited Sickle Cell Disease patients, proactively contacts them for annual medication reviews, and clarified prescribing responsibilities with specialists. They have implemented electronic repeat dispensing for these patients, …
Response: The Department has introduced an incentive in the 2025/26 GP contract for identifying patients needing care continuity and implemented "Jess's Rule" (Three Strikes and Rethink) in September 2025 to encourage …
Response: PELC has expanded its policy to require clinicians to review individual records when seeing patients and has shared this learning with staff, including the requirement in staff contracts. They are …
Responded
Alan Mitchell
Concerns: A patient's lifelong repeat prescription was removed by software without GP notification or patient choice, creating a risk that essential medication may not be provided, especially for vulnerable patients.
Response: Optum disputes the factual accuracy of the concern, clarifying that their EMIS Web system does not automatically remove repeat prescriptions after 12 months without GP notification. They explain the system …
Responded
Gloria Simon (1)
Concerns: A GP's misreading of oxygen saturation levels and incorrect assumption about the care facility's status led to inadequate assessment. The GP also failed to review patient history or ensure timely observations.
Response: Marine Lake Medical Practice acknowledges the care provided was below expected standards and plans a formal Significant Event Analysis to review the case. They will also review and take action …
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
Sarah Healey
Concerns: Inadequate information sharing and a lack of a joined-up approach across health services for mental health patients with physical issues led to fragmented care. Over-reliance on remote appointments may fail vulnerable individuals.
Response: The Department of Health and Social Care notes there are no plans to develop a national policy on mandatory face-to-face appointments. They are working with NHS England on new Personalised …
Responded
Steven Turzynski
Concerns: Inadequate communication between dietetic teams and insufficient monitoring of telephone-based nutritional assessments for cancer patients led to poor nutritional status and potentially earlier death.
Response: Velindre University NHS Trust has undertaken a comprehensive review, implementing improvements to nutritional assessment, strengthening communication, and introducing guidelines for dietetic assessments and face-to-face consultations. A draft Standard Operating Procedure …
Response: Aneurin Bevan University Health Board has implemented a strengthened governance framework for nutrition and hydration, including a Strategic Nutrition and Hydration Group. They are also developing a joint Standard Operating …
Responded
Jake Girton
Concerns: Police failed to inform the hospital of a patient's release from custody, hindering mental health support efforts. The Metropolitan Police Service also showed no evidence of identifying shortcomings or implementing remediation.
Overdue
Honoria Culshaw (1)
Concerns: Critical information regarding the need for pacemaker extraction was not adequately communicated between specialist and local hospitals, nor to the patient's GP, delaying essential treatment for infection.
Responded
Christopher Bird
Concerns: Concerns were raised about the reliability of the nhs.net email system for transmitting critical mental health information to GPs, leading to systemic communication breakdowns between secondary and primary care.
Overdue
Christian Marsh Prevention of future deaths report
Concerns: There is no formal system for communication, information sharing, and handover of patient data between a respite facility and the Intensive Support Service, creating significant risk.
Responded
Alfie Lydon
Concerns: Hospital trusts generally lack processes to document external calls from midwives, leading to poor continuity and escalation of care, especially regarding parental concerns, and increasing risk of future deaths.
Responded
REDACTED
Concerns: Inadequate face-to-face weight monitoring, confusion over consultant-to-consultant referrals, and discharge from CAMHS without direct patient contact or engagement exploration were significant concerns. Dietetic assessments were also limited to telephone.
Responded
Chloe Ellis
Concerns: Lack of commissioning means NHS 111 online assessment outcomes are not accessible to Emergency Department clinicians, hindering comprehensive history taking and failing to act as a crucial information failsafe.
Responded
Lila Marsland
Concerns: The Child Sepsis Screening Tool is not fully embedded, meningitis guidelines are not completely implemented, and fragmented record-keeping across systems risks vital clinical information being lost.
Responded
Margaret Reeves
Concerns: Inadequate information sharing with GPs risks patients receiving either no medication or excessive, duplicative prescriptions, posing a significant safety concern.
Responded
Abdulrahman Alajmi
Concerns: UK hospitals lack a set procedure for accepting international patients, often receiving individuals sicker than anticipated due to inaccurate information and insufficient systems for safe transfer and treatment.
Overdue
Patricia Catterall
Concerns: The nursing home's pre-transfer assessment process was inadequate, relying on incomplete documentation and lacking face-to-face evaluations, resulting in missed critical patient information.
Responded
June Thompson
Concerns: Major operations proceeded without surgical teams having full knowledge of disease progression, resulting from unreported errors and a lack of policy for processing medical reports from other hospitals.
Responded
Winnie Harrop
Concerns: Inadequate guidance exists for discharging overly sedated patients with new oxygen needs from hospital to a non-nursing care home, compounded by missing critical information in discharge letters.
Responded
Leanne Carroll
Concerns: The Perinatal Mental Health Service suffers from insufficient awareness among health professionals, inadequate staffing levels, and a lack of documented decisions and discussions in patient records at the Single Point of Access.
Responded
Mark Fernandez
Concerns: Inadequate information was provided in a specialist referral, the hospital passport was unused, and a best interest decision failed to incorporate crucial input from long-term carers and social services.
Responded
Alexander Channing
Concerns: Systemic failures in mental health care transfer protocols, university staff training, hospital discharge planning, and patient information sharing policies created significant risks for a vulnerable student.
Responded
Andrew Heys
Concerns: Out-of-hours GPs lack training on internal protocols and accessing patient records, compounded by fragmented NHS IT systems that prevent health professionals from accessing crucial patient data.
Responded
Tammy Milward
Concerns: Incompatible electronic record systems and poor co-location hinder coordination and communication between GP practices and mental health services, placing patients at risk of early death.
Responded
Aarav Chopra
Concerns: Lack of guidance for immunocompromised patient antibiotics, unclear trainee competence, and poor consent processes were evident. Inadequate learning from deaths and fragmented electronic records also led to missed patient risk factors.
Responded
Maria Simpson
Concerns: GPs lack a uniform national electronic patient record system, causing delays in record transfer and fragmented storage of historic documents, making quick access to all patient information difficult.
Responded
Neil Yates
Concerns: There are concerning delays in transmitting information about prescribed medication from voluntary and NHS organizations to GP surgeries.
Responded
Henry Grierson
Concerns: The college safeguarding team lacked awareness of a student discontinuing external mental health support, indicating a critical communication breakdown between the college and mental health organizations.
Responded
Lee Armstrong
Concerns: Emergency call systems fail to solicit or share existing medical conditions with ambulance call handlers, who also lack access to patient records, risking inadequate responses for patients, particularly those with conditions causing confusion.
Responded
Wendy Afford
Concerns: Multiple failures in care home practice include inadequate risk assessments, incomplete records for repositioning and body mapping, lack of management oversight, and insufficient staff training on skin integrity.
Overdue
Allan Hamilton
Concerns: A GP practice's electronic contact system lacked robust processes for tracking, triaging, and auditing email queries, leading to missed patient contacts and delayed medical advice.
Responded
Lee Purkis
Concerns: A critical Mental Health Treatment Requirement was not transferred or communicated between Trusts, highlighting a systemic failure in MHTR administration and probation oversight.
Responded
David Almond
Concerns: Hospital doctors lacked access to crucial GP records for out-of-area patients due to IT system differences, and a practitioner failed to arrange appropriate follow-up despite the patient's history.
Responded
Thomas Geraghty
Concerns: A patient was deregistered from their GP surgery without notification, discontinuing vital antipsychotic medication. There is no process to ensure continuity of essential prescriptions when patients are removed, risking their health.
Responded
Sabina Wood
Concerns: The practice of preparing speculative discharge summaries before patient readiness, coupled with IT system flaws and a lack of clear policy, risks inaccurate medical information being disseminated to GPs.
Responded
Alan Smith
Concerns: GPs lacked understanding of timely referrals for vascular and district nursing services, compounded by poor communication and fragmented care across multiple trusts with incompatible IT systems.
Responded
Isaac Onyeka
Concerns: Gaps in public and practitioner knowledge about Down Syndrome immune deficiency, lack of GP record access for NHS111, and absence of sepsis recognition guides for darker skin tones pose risks.
Responded
Samuel Jordan
Concerns: Prison healthcare's inability to access temporary GP mental health records via the NHS spine meant critical information regarding a prisoner's anxiety and medication was missing, contributing to their death.
Responded
Andrew Guillaume
Concerns: Communication breakdowns from inaccessible switchboards and unknown emergency numbers, combined with an incomplete referral, caused significant delays in patient discussion and transfer.
Responded
Katharine Fox
Concerns: A critical disconnection between hospital and community psychology services, compounded by a lack of handover and incompatible computer systems, resulted in substantial wait times and impaired continuity of care.
Responded
Jennifer Whinney
Concerns: Critical patient notes were not sent to an external appointment due to non-electronic records and a lack of clear responsibility for ensuring their transfer, risking incomplete medical history.
Responded
Mohammed Akram
Concerns: A lack of routine cross-referencing between prescribed and collected medication, and the failure to notify GPs when patients don't collect essential prescriptions, poses a significant risk.
Responded
Leya Adris
Concerns: A patient with escalating mental health concerns, including suicidal ideation, did not receive critical psychiatrist input because the GP's urgent referral was incorrectly diverted by the single point of access system.
Responded
Carol Leeming
Concerns: A lack of mandatory induction training and online facilities for out-of-hours GPs, coupled with staff confusion over call centre systems and high GP turnover, compromises service quality.
Responded
Sebastian Daniels
Concerns: Critical blood test results were not escalated, discharge summaries to GPs were unclear, and clozapine patients missed vital annual blood tests due to inconvenient separate phlebotomy appointments.
Responded
James Philliskirk
Concerns: Junior staff failed to escalate concerns, exacerbated by unclear guidance on chickenpox reinfection, confirmation bias, and inadequate assessment of skin lesions. GP referrals were also not given sufficient weight, delaying crucial treatment.
Responded
Caroline Forte
Concerns: There is no clear pathway for sharing private psychiatrist consultation details and medication information with NHS Trusts, leading to a loss of critical patient history in acute and mental health settings.
Responded
Anthony Ingram
Concerns: Crucial information about a suicidal missing person, including means of suicide and transport, was not shared between police forces due to a lack of standardized cross-border protocols.
Responded
Rachelle Ross
Concerns: GP IT systems lack automatic flags for patients who miss national smear test invitations, leading to inconsistent follow-up and reduced patient safety.
Responded
Ania Sohail
Concerns: Online prescribing lacks integrated systems to prevent over-prescription or inform GPs of dispensed medication, posing risks. Additionally, mental health care plans contained inaccuracies and staff lacked mandatory refresher training.
Responded
Hugo Carlos
Concerns: The GP clinical system lacks a scheduled task feature for future alerts, burdening patients with follow-up responsibility and risking missed essential investigations.
Overdue
Derek Larkin
Concerns: Inability of Dorset Council's Adult Social Care system (Mosaic) to communicate with NHS SytemOne prevents social care teams from accessing vital patient medication and review information, hindering comprehensive care.
Responded
Richard Shannon
Concerns: Critical communication breakdowns during hospital discharge led to a failure in securing a pressure-relieving bed and a lack of clear instructions for daily skin integrity checks by district nurses and carers, exacerbated by social services missing key risk information.
Responded
Sally-Ann Few
Concerns: Critical medication information was lost between GP and hospital systems, leading to incorrect prescribing and potential pain control issues. Additionally, medical record-keeping was poor, failing to document clinical decisions and discussions.
Responded
Stephen Wells
Concerns: Significant communication failures between trusts, an outdated service agreement, and reliance on informal referral "workarounds" led to a cancer patient missing crucial chemotherapy, with GPs lacking clear guidance on escalating concerns.
Responded
Lewis Powter
Concerns: There is no clear policy for multi-agency information sharing meetings for complex IPP offenders, particularly when agencies lack access to shared record systems.
Overdue
Fadzai Chitakunye
Concerns: Significant delays in transferring patient notes between GPs risk important medical history being missed, especially for patients unable to effectively communicate their past health information.
Responded
Robert Wright
Concerns: Internal hospital referrals were paper-based and not promptly integrated into patient notes, leaving busy clinicians without immediate access to complete patient referral information.
Responded
David Walker
Concerns: Frequent changes in care coordinators and the failure to obtain critical collateral information from other healthcare trusts on admission resulted in a fragmented understanding of the patient's risks.
Responded
Brooke Martin
Concerns: Incompatible electronic patient record systems across the NHS lead to significant difficulties in healthcare providers accessing full patient histories. This lack of information sharing compromises risk assessments and specialist care.
Responded
Helen McLean
Concerns: The hospital failed to accurately send patient discharge summaries, including medication details, to the correct GP practice, causing critical information to be lost.
Responded
Cecilia Edwards
Concerns: A pressure ulcer was not promptly referred to a tissue viability nurse, district nursing relied heavily on agency staff without clear protocols, and nurse-carer visit coordination was inadequate.
Responded
Monica McCormick
Concerns: A critical pathology report indicating malignancy was not followed up due to a missed form and multiple communication failures, delaying essential chemotherapy that could have prolonged life.
Responded
Norma Bradbury
Concerns: A significant delay in the hospital discharge letter reaching the GP led to a missed timely review of medication and blood pressure, causing a gap in essential post-discharge care.
Overdue
Ronald Tilley
Concerns: Lack of notification to existing GPs when patient demographic information is updated risks critical communication breakdowns and outdated patient records.
Responded
Christine Forbes
Concerns: Patients registering at new GP surgeries lack their complete medical history, leading to doctors treating and prescribing medication without full and necessary information.
Overdue
Amy Hogan
Concerns: Incomplete transfer of GP records and a lack of electronic access for out-of-hours services meant critical patient medical history was unavailable. This created significant risks for vulnerable patients, hindering comprehensive assessment.
Overdue
Omarian Brooks
Concerns: The GP was not informed of the patient's critical deterioration in time, likely preventing a hospital admission that could have saved their life.
Overdue
Maureen Brown
Concerns: The electronic patient transfer system provides insufficient information for effective handovers between wards, as national policy limits the data shared, risking missed critical details.
Overdue
Thomas Wedrychowski
Concerns: Annual monitoring for diabetes in patients on antipsychotics may be insufficient for high-risk individuals, and there is a critical lack of physical healthcare information sharing between primary and secondary care providers.
Overdue
Alex Grady
Concerns: A GP-led alcohol detoxification lacked specialized support, follow-up appointments were insufficient, and a computer system glitch prevented GPs from accessing a complete list of previous prescriptions.
Overdue
Dorothy Macey
Concerns: Failures in district nurse care included not photographing wounds, poor information sharing with GPs about treatment delays, incomplete electronic records, missed sepsis checks, and inadequate care plan updates.
Overdue
Sandra Scott
Concerns: A GP system flaw prevented a patient from receiving prescribed medication, and hospital staff failed to act on critical test results for a discharged patient, both contributing to preventable death.
Overdue
Christopher Byron
Concerns: Lack of documented referral policies between nursing teams and staff shortages hindered continuity of care. Hospital guidelines for anaemia management and iron infusion observation were not followed, compounded by unrecorded pharmacist-clinician discussions.
Overdue
Sharon Reeve
Concerns: 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.
Overdue
Feni Lee
Concerns: An inadequate medication review failed to address unlicensed drug use and a vulnerable patient's needs, compounded by severe delays in internal post redirection between GP practices for critical hospital correspondence.
Responded
Beverley Shaw
Concerns: Critical communication failures between Turning Point and the GP regarding butane gas misuse and medication reviews occurred. Incomplete medical record transfers between substance misuse services also posed risks.
Responded
Christopher Seal
Concerns: Multiple failures in information sharing, record keeping (RIO system), and lack of "no response" or "welfare check" policies in primary care, exacerbated by staff training issues and limited communication options.
Responded
Natalie Hunter
Concerns: The Isle of Wight NHS Trust frequently fails to provide timely discharge summaries to GPs, hindering continuous patient care, especially for mental health needs. Additionally, underfunding has led to inadequate out-of-hours mental health staffing.
Overdue
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
Michelle Roach
Concerns: 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.
Overdue
Allan Shepard
Concerns: Response times for falls were missed due to inadequate staffing with one-person responder units, and crucial updated patient information was not passed to the third-party call centre.
Overdue
Grahame Searby
Concerns: The mental health team's lack of access to GP databases (EMIS) hinders comprehensive information gathering, necessitating a review of operational systems to improve data access.
Overdue
Ross Reeves
Concerns: The patient's transfer to his new GP was identified as likely unsafe.
Overdue
Kenneth Longley
Concerns: A nearly three-month delay in sending crucial medical information to the patient's GP after an echocardiogram created a risk of future deaths due to delayed diagnosis and treatment.
Overdue
Peter Stojilkovic
Concerns: Poor communication post-discharge about melatonin prescribing and a complex, inconsistent system of national and local drug blacklists forced patients to seek medication from unlicensed online sources.
Responded
Joan Betteridge
Concerns: Inadequate systems for requesting and tracking X-rays in GP surgeries and hospital ED led to significant delays in repeat X-rays and radiology reviews, stemming from unprogressed requests and incorrect referral classifications.
Responded
Pauline Pryor
Concerns: Critical communication failures between the nursing home and GP, an inadequate system for monitoring lithium toxicity, and an unread consultant email led to missed essential blood tests and unmanaged medication changes.
Responded
David Buttriss
Concerns: Critical communication breakdowns between GP and mental health services, fragmented healthcare records, and a lack of clarity in mental health crisis pathways across multiple agencies hindered effective care.
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
Frances Greenhalgh
Concerns: A GP surgery failed to properly record and integrate a crucial treatment plan notification from the RAID Team into the patient's medical records and computer system, leading to a lack of awareness and follow-up.
Overdue
Mohammad Ashraf
Concerns: Inaccurate and delayed care plans, poor communication between the school and catering service, and a failure to disseminate critical safety recommendations by the local authority resulted in inadequate allergy management for pupils.
Responded
Constance Connolly
Concerns: Systemic failures in patient handover, including lack of follow-up on urgent scans, poor communication with GPs, and incorrect cancellation of outpatient appointments, severely delayed critical diagnostic investigations.
Responded
Sarah Poole
Concerns: There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.
Responded
Stephen Leven
Concerns: The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.
Responded
Johan Pambou
Concerns: The GP practice lacked an adequate system to action hospital letters, leading to missed vaccinations. Concerns were also raised about the availability of essential vaccines and GPs' knowledge of how to access them.
Responded
Beryl Foster
Concerns: The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.
Overdue
Olive Daynes
Concerns: Delayed postal communication from the hospital meant the GP was unaware of critical medication changes and advice, leading to a patient's INR increasing dangerously without intervention.
Responded