GP Continuity of Care Breakdown
Failures in delivering continuity of care within GP practices, often due to contract limitations, leading to delayed diagnoses.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
HSSIB recommendation
95match
Continuity of care: delayed diagnosis in GP practices
HSSIB recommends that the Department of Health and Social Care ensures that the GP contract explicitly includes and supports the need for GP practices to deliver continuity of care. This is to improve patient safety by building clinician–patient relationships as well as providing continuity of information.
Matched on
terms: care, continuity
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
The coroner identified a lack of continuity of care at the GP practice and suggested a review of "Red Flag" identification for children. Concerns were also raised regarding the hospital's policy for reviewing GP medical records during young children's admissions.
Matched on
terms: care, continuity
PFD report
73match
Christopher Fairhurst
The report highlights significant GP shortages, leading to unmanageable workloads, reduced patient access to timely appointments, and a lack of continuity of care. Concerns were also noted regarding the adequacy of GP training and increased thresholds for specialist neurodevelopmental services.
Matched on
terms: care, continuity
PFD report
73match
Jacqueline Elliott
The GP practice's computer system incorrectly classified repeat prescriptions, hindering medication reviews, and clinical notes lacked sufficient detail. A lack of continuity of care led to repeated painkiller prescriptions without exploring alternative treatments, and a large tramadol prescription was issued without clear rationale.
Matched on
terms: care, continuity
PFD report
69match
Terrance O’Connell
A communication breakdown between the care home, district nurses, and out-of-hours GP meant Mr O'Connell was not seen by clinical staff. There was no direct monitoring of his oral input and urinary output, and no clinical assessment for two days.
Matched on
terms: breakdown, care
PFD report
69match
Sarah Kiff
The coroner identified that GPs did not follow cancer referral guidance, and noted poor medical record keeping, communication, and inadequate processes for reviewing test results. Concerns also included a lack of continuity of care and reluctance among some doctors to perform internal examinations.
Matched on
terms: care, continuity
PFD report
69match
Brian Wareham
The coroner identified a significant breakdown in communication, trust, and respect between primary and secondary care. This left vulnerable patients without appropriate information and support, exemplified by a GP not directly addressing discharge concerns with hospital staff.
Matched on
terms: breakdown, care
PFD report
65match
Teresa Lonergan
The general practice did not monitor the patient's consumption of controlled drug prescriptions, leading to a significant accumulation of medication. This situation was exacerbated as the care worker administering the drugs did not report medical instructions.
Matched on
terms: care
CQC action
65match
Westmorland General Hospital
The service should continue to act to ensure women received continuity of care in line with national recommendations and targets.
Matched on
terms: care, continuity
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
#4 - 79th Report - Supporting people with frailty outside hospitals
NHS England has overloaded GPs, who have limited capacity, with new and expanding priorities. NHSE has prioritised improving patients’ access and digital access to general practice. It recognises that pushing to improve one aspect of care inevitably causes consequences to appear elsewhere, in this case, support for people with frailty.NHSE is looking at interventions that could be done...
Matched on
terms: care, continuity
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
NCEPOD recommendation
62match
Transition From Child Into Adult Healthcare
Matched on
terms: care
PFD report
61match
Ruth Milne
The coroner identified concerns regarding the continuity and appropriateness of medical staff dispatched by Hawthorn Medical Practice GPs, and questioned the implementation status of recommendations from a November 2015 safeguarding report.
Matched on
terms: continuity
PFD report
61match
Lindsey Hassall
The coroner noted a lack of recording for verbal information shared with RAID practitioners and that Lifeline/CGL notes were not promptly entered, with some contemporaneous notes later destroyed. Concerns also included Pennine Care documentation accessibility and a GP practice's assumption that a referral had already been made.
Matched on
terms: care
PFD report
61match
Peter Garvin
The coroner identified a lack of direct doctor-to-doctor communication for prescribing and insufficient local mental health beds. Concerns also covered absent NHS/private psychiatric care collaboration and delayed carer's assessments.
Matched on
terms: care
PFD report
57match
Dorothy Townley
Insufficient direct communication between District Nurses and the GP, especially regarding patient condition, wound care, and urgent blood tests. The District Nursing Team also lacked knowledge and training in burns treatment, and their wound assessment chart was inadequate.
Matched on
terms: care
PFD report
57match
Julia Dell
The coroner noted a lack of formal handover between GPs when the patient changed doctors, and that a care plan from the Community Mental Health Team was not actioned upon receipt. This resulted in primary care being unaware of the patient's fluctuating mood.
Matched on
terms: care
PFD report
57match
Joan Richardson
The coroner noted concerns regarding GP practices closing for staff training without a doctor available for emergencies during normal hours, and the impact of a significant delay in assessing an obviously unwell patient leading to delayed hospital referral.
Matched on
classifier match
PFD report
57match
Ernest Smith
Concerns persist regarding the system for considering GP correspondence, including medication review requests, which remains unchanged. Additionally, there is no clear system for updating GPs on patient progress or disengagement when care is led by non-medical multidisciplinary teams.
Matched on
terms: care
PFD report
57match
Graeme Mathieson
The coroner identified issues with insufficient time for GP psychiatric assessments and a lack of clarity among professionals regarding mental health patient pathways. Concerns were also raised about the extent to which care coordinators can exercise clinical judgment.
Matched on
terms: care
PFD report
57match
Sophie Holman
The coroner identified a lack of coordinated, long-term management for the child's chronic asthma, with care focused on isolated acute events rather than the underlying condition. This included no single professional taking overall responsibility, insufficient adherence to national guidelines, and inadequate record-keeping regarding risk factors and medication.
Matched on
terms: care
PFD report
57match
Nichola Lomax
Inadequate training of doctors on eating disorders and MARSIPAN guidance, a lack of clear pathways for accessing specialist advice, and referral criteria for eating disorder services that exclude patients with very low BMIs, meaning non-specialists coordinate their care.
Matched on
terms: care
Committee recommendation
57match
#15 - 79th Report - Supporting people with frailty outside hospitals
We were concerned that GPs might not be prioritising care for those with or at risk of frailty. NHSE acknowledged that GPs were not formally assessing enough of their patients for frailty.32 NHSE recognised that it had pushed GP practices very hard over the past couple of years to improve access. However, it agreed that since capacity is...
Matched on
terms: care
HSSIB recommendation
57match
Digital tools for online consultation in general practice
National healthcare organisations can improve patient safety by considering how long-term condition management and proactive health promotion can be accomplished alongside the online consultation model of general practice, which may limit opportunities to provide holistic care to patients.
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
Audrey Garland
Concerns included the GP practice's failure to recognise the severity of ulceration and the District Nursing service's inadequate treatment of necrotic ulcers. A lack of organised transport also prevented the patient from attending necessary hospital appointments.
Matched on
classifier match
PFD report
53match
Elsie Raper
The coroner identified a delay in diagnosing a patient's tibia and fibula fractures, which remained undiagnosed for several days despite regular GP and nurse visits, leading to extreme pain for the patient.
Matched on
classifier match
PFD report
53match
Maureen Campbell-Scott
The coroner identified significant delays in mental health referrals due to misdirection and loss, and frequent delays in delivering clinic letters from the mental health trust to the GP. This caused challenges for GPs in rapidly and accurately implementing specialist-directed medication changes, indicating a need for improved inter-agency communication and protocols.
Matched on
classifier match
PFD report
53match
Sameena Javed
The coroner noted the GP practice lacks a written procedure or guidance for administrative staff on triaging incoming correspondence, potentially leading to medical staff not seeing communications requiring action.
Matched on
classifier match
Committee recommendation
53match
#2 - 79th Report - Supporting people with frailty outside hospitals
NHS England is not reducing the unacceptable variation in support for people with frailty across and within Integrated Care Boards (ICBs). There is significant and unexplained regional variation between areas – 32 out of 106 local NHS areas assessed less than 10% of patients aged 65 and over. The NICE’s guidelines specify that any patient living with frailty...
Matched on
terms: care
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
HSSIB recommendation
53match
Workforce and patient safety: primary and community care co-ordination for people with long-term conditions
HSSIB recommends that NHS England/Department of Health and Social Care, working with other relevant organisations, reviews and evaluates the implementation of the care co-ordinator role. This is to ensure that all patients with long-term conditions have their care co-ordinated and that they have a single point of contact 24 hours a day, 7 days a week, to help...
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
HSSIB recommendation
52match
Workforce and patient safety
HSSIB recommends that NHS England undertakes an evaluation of the risks to patient safety of online consultation tools in general practice, taking into account the findings of this investigation, recent research, and the experiences of general practices. This is to identify and implement actions to support the safe delivery of care using online consultation tools in line with...
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