Incomplete GP Patient Data Transfer
Incomplete transfer of patient data between GP practices, creating significant risks for continuity of care.
262 items
11 sources
2 inquiries
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
77match
Robert Davidson
Care home staff lacked basic emergency training, including 999 procedures and CPR. Health Care Assistants had insufficient experience, and vital patient information like PICA behaviour was not transferred between facilities.
Matched on
terms: patient, transfer
PFD report
73match
Hope Evans
Critical patient history, including IVF treatment abroad and ESBL E. coli infection, was not effectively transferred between hospitals. This led to inappropriate treatment and a lack of necessary barrier nursing, highlighting failures in inter-hospital documentation.
Matched on
terms: patient, transfer
PFD report
69match
Alfie Rose
Poor inter-hospital communication and ineffective information sharing systems led to missed opportunities for patient transfer and treatment. Clinicians require better education on neurological referral protocols.
Matched on
terms: patient, transfer
PFD report
65match
John Lloyd
Frequent failures in the hospital's electronic system to notify GPs of patient admissions jeopardised continuity of care and could lead to inappropriate treatment courses and poorer outcomes.
Matched on
terms: patient
PFD report
65match
Suzanne Greenwood
Lack of systems and protocols for contacting patients who miss appointments, informing GPs of non-attendance or discharge, and ensuring continuity of care when patients are lost to follow-up.
Matched on
terms: patient
PFD report
65match
Constance Connolly
The report describes failures in the handover of patients needing urgent follow-up, including a doctor not following up on a scan they ordered, and a breakdown in communication between different care teams resulting in a cancelled appointment and no further action.
Matched on
terms: patient
PFD report
65match
Stephen Leven
The lack of access for secondary care to crucial GP patient information, specifically a haemophilia diagnosis, poses a significant risk of future preventable deaths.
Matched on
terms: patient
Inquiry recommendation
65match
IHRD-11 - Patient Transfer Protocol
There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Matched on
terms: patient, transfer
PFD report
61match
Ricky Anderson
Mental health services failed to inform the GP of hospital admissions, relied excessively on family for post-discharge monitoring, and discharged a patient early without a care plan.
Matched on
terms: patient
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: patient
PFD report
61match
Philip Dean
Mental health services were underfunded and under-resourced, leading to fragmented care, inadequate recording of critical information, and delayed professional assessments for severely unwell patients.
Matched on
terms: patient
PFD report
61match
Stephen Morris
Inadequate information exchange between mental health services when a patient moved areas led to a lack of detailed, up-to-date patient history, compromising risk assessment and response.
Matched on
terms: patient
PFD report
61match
James Stewart
There was no system for new GP practices to verify medication with previous providers for nursing home patients, leading to prescribing errors and reliance on unqualified staff for medication initiation.
Matched on
terms: patient
PFD report
61match
Hilda Harris
The community INR testing booking system is unreliable due to failures in appointment transfer and an unreliable notification system for omissions by family or carers.
Matched on
terms: transfer
PFD report
61match
Alec Mathias
Critical drug sensitivity information was not included in discharge letters sent to the patient's GP, nor was it highlighted in hospital records, posing a significant risk.
Matched on
terms: patient
PFD report
61match
Olive Daynes
A GP was unaware of hospital advice regarding a patient's medication change and increased INR levels, due to a delay in the hospital letter arriving at the surgery, and the patient's INR subsequently increased significantly before her death.
Matched on
terms: patient
PFD report
61match
Beryl Foster
The practice of posting endoscopy discharge summaries, instead of emailing them, critically delayed GP awareness of medication changes, risking patient safety.
Matched on
terms: patient
Inquiry recommendation
61match
IBI-8b - New Patient Registration Screening
As a matter of routine, new patients registering at a practice should be asked if they have had such a transfusion.
Matched on
terms: patient
PFD report
57match
Mone White
There is no system to ensure specialist hospital advice for patients with complex clinical requirements is consistently communicated to all treating clinicians.
Matched on
terms: patient
PFD report
57match
George Leonard Parkes
Failure to follow up on a patient with an abdominal aortic aneurysm led to its rupture and death. A specialist nurse clinic and dedicated patient register could prevent future 'lost to follow-up' situations.
Matched on
terms: patient
PFD report
57match
Graham Darby
A crucial communication breakdown occurred as a patient's explicit suicide threat regarding eviction was not adequately flagged to the housing provider by mental health services. This prevented the housing provider from taking appropriate preventative actions.
Matched on
terms: patient
PFD report
57match
Yaser Saleh
The GP's computer system only prompts reviews for patients on regular prescriptions, failing to identify those with chronic diseases like asthma who are not currently prescribed medication but still require monitoring, posing a risk of preventable deaths.
Matched on
terms: patient
PFD report
57match
Rita Paton
There's no reliable system to ensure blood tests are completed and reported to GPs, or for managing appointments for patients lacking capacity when family are excluded. Attending medical crews also lack access to vital past medical and medication history.
Matched on
terms: patient
PFD report
57match
Colin Moulton
Critical patient information was lost during verbal paramedic-to-triage nurse handovers. Additionally, the ambulance service failed to notify the hospital of their presence when responding to a patient already on hospital grounds, missing a crucial connection.
Matched on
terms: patient
PFD report
57match
Dorothy Cooper
Inadequate information transfer during inter-hospital referrals and the receiving team's failure to proactively address missing clinical data risked incorrect diagnoses and treatment plans.
Matched on
terms: transfer
PFD report
57match
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
classifier match
PFD report
57match
Richard Grant
Critical delays occurred in referring a patient who attempted suicide to the correct mental health team, and the GP was not promptly informed of assessment outcomes. This risked the patient not receiving timely mental health support.
Matched on
terms: patient
PFD report
57match
Gordon Arthur
The absence of clear policies for requesting and communicating results of investigative tests to consultants led to critical delays in diagnosing and treating a patient's infection, risking future harm.
Matched on
terms: patient
PFD report
57match
Doreen Stapleton
An obsolete email address caused a critical district nursing referral to fail upon discharge, compounded by inadequate, explicit communication to a vulnerable patient and family about the fatal risks of missed medication and follow-up contact.
Matched on
terms: patient
PFD report
57match
Marian Dale
The District Nursing Team lacked a central, contemporaneous record-keeping system, storing all notes at the patient's home, and had no protocol for their retrieval after death.
Matched on
terms: patient
PFD report
57match
Sarah Poole
There were failures to record the reviewing doctor for an ECG and to account for previous abnormal ECG results during patient handover from paramedics.
Matched on
terms: patient
PFD report
57match
Frances Greenhalgh
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.
Matched on
terms: patient
PFD report
57match
Ernest Smith
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.
Matched on
terms: patient
PPO recommendation
56match
The Head of Healthcare at HMP Lowdham Grange
The Head of Healthcare at HMP Lowdham Grange should ensure that prisoners with significant health needs are transferred in line with national instructions, including that: • significant health information is shared with the receiving prison, including about significant diagnoses, recent emergency hospital admission and hospital follow up appointments; and • all critical prescribed medications are transferred with prisoners...
Matched on
terms: transfer
PFD report
53match
Simon McAndrew
Poor communication between different NHS Trusts, particularly regarding mental health and drug misuse information, resulted in important details being missed, inappropriate referrals, and a lack of effective care coordination.
Matched on
classifier match
PFD report
53match
Thomas Farrell
The care home failed to obtain a full prescription history from the GP, resulting in critical medications not being administered and creating a clear risk of harm to residents.
Matched on
classifier match
PFD report
53match
David Baddeley
Incompatible electronic records, poor communication between practices, and delayed record reviews led to critical mental health diagnoses and medication needs being repeatedly missed.
Matched on
classifier match
PFD report
53match
Harry Mellor
There is no reliable system to track child GP de-registration, creating significant safeguarding risks, especially for children with chronic health needs, as specialist teams are not informed.
Matched on
classifier match
PFD report
53match
Alan Ludlow
Critical information about residents' past incidents and risks is not adequately exchanged between care providers during placement. This leads to new homes being unaware of vital safety history for vulnerable individuals.
Matched on
classifier match
PFD report
53match
Harold Goulding
Communication breakdown between the care home, GP, and anti-coagulation clinic led to medication mismanagement. The care home lacked systems to inform agencies of new GPs and ensure GPs review medication records.
Matched on
classifier match
PFD report
53match
Rohid Shergill
Lack of clear protocols for NGT feeding parental competence, poor information sharing between trusts, and inadequate training for staff on pH testing and syringe hygiene compromised care for a child in the community.
Matched on
classifier match
PFD report
53match
Mohammad Ashraf
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.
Matched on
classifier match
Committee recommendation
52match
#13 - Ensure consistent identifiers alert schools and GPs when children move into temporary accommodation.
Currently, schools are not always notified when a pupil becomes homeless or changes school due to a move into temporary accommodation. This prevents schools from offering additional support which those children may require. Similarly, GPs are often unaware that families are experiencing homelessness, leaving an incomplete picture of the health impacts of homelessness on children. (Conclusion, Paragraph 64)...
Matched on
terms: incomplete
Committee recommendation
51match
#9 - Slow progress on data sharing delays essential substance misuse support for prison leavers.
In 2017 this Committee recommended that HMPPS and NHS England (NHSE) improve information-sharing arrangements between health, prison and probation staff following concerns that healthcare records do not follow patients as they enter or leave prisons.18 The NAO found that HMPPS and NHSE have been slow to improve the collection and sharing of prison leavers’ data, limiting their ability...
Matched on
terms: patient
IMB annual report
51match
Stocken (2022)
HMP Stocken generally provides a safe and humane environment, with strong efforts in safer custody and no deaths in custody this year. However, the Board highlights significant challenges including chronic understaffing across various departments, persistent delays in staff vetting, and a critical shortage of secure mental health provision, leading to unsuitable placements within the prison. Issues with prisoner...
Matched on
terms: incomplete, transfer
PFD report
49match
Derek Thomas
Prison reception procedures failed under extreme pressure, leading to suicide risk information being overlooked due to staffing issues. Additionally, there was poor communication and conflicting understanding between prison and escort staff regarding critical safety form procedures.
Matched on
classifier match
PFD report
49match
Irene Pearson
Matrifen patch warnings about hot baths are obscure and vague, and dangerous advice was given to use baths for patch removal. Poor liaison on opiate prescribing and unclear, scanty GP electronic notes contributed to unsafe care.
Matched on
classifier match
PFD report
49match
Raymond Edwards
A critical lack of a reliable system for disseminating histology results to named consultants meant crucial diagnostic information was not promptly reviewed, posing a significant risk of delayed diagnosis and treatment in future cases.
Matched on
classifier match
PFD report
49match
Richard Walsh
There were failures in communication between custodial and health professionals regarding the deceased's risks and needs, with crucial information being lost as he moved through different services; there was a lack of a national process for sharing mental health assessment information.
Matched on
classifier match
PFD report
49match
Johan Pambou
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.
Matched on
classifier match