GP Continuity of Care Breakdown
Failures in delivering continuity of care within GP practices, often due to contract limitations, leading to delayed diagnoses.
Source spread
Where this theme appears
This theme appears across 16 independent accountability sources, so the source mix matters as much as the headline total.
5 inquiry recs
75 PFD reports
37 committee recs
9 HSSIB recs
2 CQC actions
2 PPO recs
4 IMB recs
1 Scottish FAI
148 DHR recs
62 PHSO decisions
317 LGO/SPSO decisions
Browse by source
Source-grouped records are useful for tracing where a concern came from. Large sections show the 50 strongest matches for that source; counts still show the full theme total.
Inquiry recommendations(5)
18 — Role of general practitioners
Recommendation: The employment of general practitioners should be rationalised to cover the day-to-day needs of long-stay patients: but their valuable contribution should not be regarded as a substitute for specialist services.
Unknown
79 — Allocate a social worker of home authority
Recommendation: Where a child is placed outside the area of its own home authority a social worker preferably of the home authority should be identified and allocated to that child (17.9).
Unknown
66 — Assigning personal officers to prisoners
Recommendation: Personal officers should be assigned to individual prisoners, not to a group of cells. They should be members of a small team, so that when a prisoner’s personal officer is not on duty, the prisoner can approach another member of …
Unknown
LAMI-72 — Ensure identified GP for children with deliberate harm concerns discharged from hospital.
Recommendation: No child about whom there are concerns about deliberate harm should be discharged from hospital back into the community without an identified GP. Responsibility for ensuring this happens rests with the hospital consultant under whose care the child has been …
Unknown
2 — Patient-focused correspondence
Recommendation: We recommend that it should be standard practice that consultants in both the NHS and the independent sector should write to patients, outlining their condition and treatment, in simple language, and copy this letter to the patient's GP, rather than …
Gov response: Accept Guidance across the healthcare system now states that consultants should write directly to patients and in a way they understand. Key stakeholders have committed to writing to their members to encourage uptake. Over the …
Accepted
Prevention of Future Deaths reports(75)— showing 50 strongest matches
Jill Sinson
Concerns: The coroner noted insufficient regular monitoring by the GP and a Staff Nurse's assessment that lacked appropriate referral and review of medical records. Unsupervised monthly prescriptions of significant medication were also issued without due consideration of the deceased's self-harm history.
Overdue
Terrance O’Connell
Concerns: 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.
Response (Gabbandco): • Monkstone House implemented a policy to send patients to A&E if a health professional does not attend within one hour of being called. • The catheter care policy was … (AI summary)
Response: • The Health Board implemented SBAR (Situation, Background, Assessment, Recommendation) message sheets for switchboard staff to record out-of-hours requests for District Nurses in greater detail. • The Clinical Manager for … (AI summary)
Overdue
Dorothy Townley
Concerns: 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.
Response (Royal College of General Practitioners): • The Royal College of General Practitioners stated it influences general practitioner training through its established GP Curriculum, which includes guidelines for best practice. • The College noted that its … (AI summary)
Responded
Jonathan Thorpe
Concerns: During GP consultations for a patient with depression and a history of self-harm, the coroner noted no reference to Mental Health Services, nor was advice sought regarding previous involvement or need for further input.
Overdue
Pauline Meredith
Concerns: The coroner identified concerns regarding the lack of a formal medication review process for a patient on long-term, high-dose medication, especially the addition of morphine with alcohol dependence. The report also noted a perceived reluctance by the GP to address family concerns and insufficient engagement with community mental health services.
Response (Browning Street Surgery): • The practice has formally instigated a programme of regular meetings to review all deaths in patients under 50 and will develop criteria to identify complex patients for discussion at … (AI summary)
Overdue
Julia Dell
Concerns: 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.
Overdue
Teresa Lonergan
Concerns: 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.
Overdue
David Chatburn
Concerns: The coroner identified issues with the GP's clinical management of the patient's mental health, including the absence of specialist referral and lack of recognised assessment tools. Concerns were also raised about bureaucratic barriers preventing GPs from easily accessing mental health services.
Response (Department of Health): • Department of Health officials consulted NHS England regarding the coroner's report. • The Department of Health noted that from April 2014, patients with mental health conditions gained the legal … (AI summary)
Overdue
Leslie Harding
Concerns: The coroner noted a lack of prompt action in treating a suspected life-threatening condition and insufficient effort to address the reasons behind a patient's apparent non-compliance with vital anti-coagulation medication.
Response (Oakside Surgery): • An individual staff member adopted a system for writing notes using a computer appointment system and a ring-bound notebook. • The practice reviewed advice for patients beginning anti-coagulation and … (AI summary)
Responded
Andrey Wakefield
Concerns: The coroner noted deficiencies in the communication of patient discharge information from the hospital to GPs, particularly for practices outside the immediate area. This issue was highlighted as potentially worsening with the integration of Stafford Hospital into the Trust.
Response (University Hospital of North Staffordshire): • The Trust had implemented an electronic clinical correspondence solution for GP practices in Stoke on Trent and North Staffordshire. • A solution was developed and funded to extend electronic … (AI summary)
Responded
Darren Arnoup
Concerns: The coroner raised concerns regarding the process for managing an individual's mental health risks, including suicidal ideation, after specific details had been communicated to their GP practice.
Response: • The medical centre conducted a detailed review of events and commissioned an external medical records review, committing to implement its recommendations. • The medical centre amended its procedures to … (AI summary)
Overdue
Courtney Mills
Concerns: The coroner noted repeated difficulties in obtaining a specific medication (Clonidine) for a patient, caused by prescription errors and a lack of communication between the GP surgery and the hospital. These issues led to delays that put the patient at risk of withdrawal symptoms.
Response (Portsmouth Hospitals NHS Trust): • The Trust stated that its Children's Assessment Unit (CAU) has an established process for prescribing and dispensing non-routine medicines when community pharmacists encounter difficulties. • The Trust confirmed it … (AI summary)
Response (Waterside Medical Centre): • The GP contacted the pharmacist and the on-call paediatrician to address the immediate issue of obtaining Clonidine medication. • The GP supplied a handwritten prescription for a thirty-day supply … (AI summary)
Responded
Daniel McCallum Keane
Concerns: The coroner noted inadequate record-keeping and unclear processes for prescribing medication within the GP practice. Concerns were also raised about the GP's lack of action after being alerted to a patient's extreme risk and difficulty managing their diabetes.
Response (Department of Health): • The patient safety expert group (primary care) at NHS England is undertaking work on safer discharge from hospital. • NHS England is currently considering the long-term implications of developing … (AI summary)
Responded
Audrey Garland
Concerns: 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.
Response: • The District Nursing service strengthened clinical supervision, including daily joint visits with senior nurses and focused support for individual nurses on wound care. • The service implemented quarterly record-keeping … (AI summary)
Overdue
Joan Richardson
Concerns: 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.
Response (Leeds West Clinical Commissioning Group): • A joint letter will be sent to all practice managers and senior partners in Leeds, reminding them of their obligations and recommending improvements to patient communication regarding urgent care … (AI summary)
Overdue
Margaret Pegnall
Concerns: The coroner noted the GP's domestic violence flowchart was vague and focused on depression rather than abuse risk, lacking a specific questionnaire for domestic abuse. There was also no method for staff to escalate urgent patient calls.
Response (Margaret Pegnall): • The practice incorporated a DASH-based questionnaire and assessment for domestic abuse into its protocol. • DASH questionnaire responses are now scanned to patient records to document domestic abuse and … (AI summary)
Responded
Ryan Singh Bhogal
Concerns: 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.
Response (The Royal Wolverhampton NHS Trust): • The Trust will introduce a Standard Operating Procedure (SOP) by 30th June 2016 to guide clinicians on reviewing relevant patient information, including GP medical records, during assessment and admission. … (AI summary)
Overdue
Richard Parkes
Concerns: The coroner noted poor record keeping, including missing appointment records, and concerns about a policy of not seeing patients who are more than ten minutes late, even with known medical history.
Overdue
Christopher Stubbs
Concerns: The coroner identified concerns with the effectiveness of office systems for receiving hospital discharge summaries advising medication review, specifically that a GP review of Christopher's medication did not take place.
Overdue
Elsie Raper
Concerns: 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.
Response (elsie Raper): • The organisation stated that falls in elderly, frail individuals should prompt investigations and prompt referral for assessment, including x-rays, without delay. • The organisation indicated that care plans should … (AI summary)
Response (Four Seasons Health Care): • Implemented 24-hour falls observation charts to monitor residents more closely after a fall. • Compiled a list of residents with osteoporosis and updated their care plans to incorporate details … (AI summary)
Responded
Ernest Higgs
Concerns: The coroner identified gaps in record-keeping for GP advice in multi-disciplinary notes and a lack of a safe system for documenting and confirming telephone advice. Conflicting information between providers also delayed out-of-hours pathology testing for community patients.
Response (Epsom and St Helier University Hospital NHS Trust): • The Trust will include a statement in its GP newsletter to remind general practitioners of 24-hour access to the pathology department. • The Trust will send a letter to … (AI summary)
Response (Surrey Downs Clinical Commissioning Group): • The Quality Committee undertook an in-depth analysis of nursing and residential care home quality. • The CCG is developing a nursing home Primary Care Standard that will include requirements … (AI summary)
Response (The Ashlea Medical Practice): • The practice discussed the issue of multi-disciplinary notes with the nursing home and agreed that nursing home staff will be responsible for writing contemporaneous notes during GP attendance. • … (AI summary)
Responded
Patrick McGagh
Concerns: The coroner noted that the GP did not receive a discharge letter from Wythenshawe Hospital, and the patient was not provided with prescribed antibiotics upon discharge.
Response (Manchester University NHS Foundation Trust): • The Trust undertook a retrospective audit in the Emergency Department regarding discharge prescriptions and the documentation of medication communication and dispensing. • Staff in the Emergency Department and Clinical … (AI summary)
Responded
Miles Abel
Concerns: Concerns were raised regarding the GP referral procedure to the Community Mental Health Team, specifically the lack of an audit trail for faxed requests and inconsistent follow-up calls to confirm receipt. This meant the CMHT might be unaware of patient referrals.
Response (The Endless Street Doctors Surgery): • The surgery has instituted a new Standard Operating Procedure for urgent fax referrals. • A fax log documentation system has been implemented to record who sent faxes, and the … (AI summary)
Response (Department of Health): • The Department of Health noted that Endless Street Surgery had implemented a strengthened system for referring patients to the Community Mental Health Team. (AI summary)
Responded
Timothy Jones
Concerns: The coroner identified gaps in record-keeping and communication processes regarding home visit requests between the GP and residential home, including clinical assessments being misclassified as "admin tasks." Concerns were also raised about the lack of GP clinical assessment for a deteriorating patient, the suitability of the home visit policy for complex conditions, and the choice of antibiotics.
Response (Solihull Clinical Commissioning Group): • The CCG stated it would send a communication and issue a learning alert to all member practices regarding the issues raised, including home visit requests, policies, and task classification. … (AI summary)
Overdue
Ruth Milne
Concerns: 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.
Response (Ruth Milne): • The organisation has established additional leg ulcer clinics and implemented a caseload review tool across Lincolnshire Community Health Services (LCHS), with case managers allocated to GP practices. • A … (AI summary)
Overdue
Dean Rowland
Concerns: The coroner noted delays in the deceased's ability to discuss antidepressant medication with a GP and concerns about his discharge from the community mental health team after a single consultation without a follow-up plan, despite prior suicide attempts.
Response (South Staffordshire and Shropshire Healthcare): • The Community Mental Health Team (CMHT) conducted an assessment of Mr. Rowland's needs within expected referral timeframes. • The CMHT determined Mr. Rowland was at low risk for self-harm … (AI summary)
Response (Peel Medical Practice): • The practice has instituted a duty doctor and telephone triage system. • Patients requiring an appointment sooner than a routine slot are offered a callback from the duty team. … (AI summary)
Responded
Christopher Fairhurst
Concerns: 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.
Overdue
Ernest Smith
Concerns: 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.
Response (Surrey NHS Trust): • The Trust's Adult Mental Health Division created an action plan to address the concerns. • The action plan will be monitored at monthly Adult Mental Health Directorate Quality Assurance … (AI summary)
Responded
Penelope Benton
Concerns: The General Practitioner was not made aware of a previous tramadol overdose as this information was omitted from the hospital discharge letter.
Response (Dudley and Walsall NHS Trust): • The Trust will conduct a review of its standards around discharge communications. • The Trust will reiterate to medical staff the importance of including incidents and risk factors in … (AI summary)
Responded
Sarah Kiff
Concerns: 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.
Response (Stonefield Street Surgery): • The practice implemented new protocols for high vaginal swabs (HVS) and internal referrals, including a mechanism for patients to be referred to a preferred clinician for intimate examinations. • … (AI summary)
Responded
Lindsey Hassall
Concerns: 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.
Response: • Pennine Care prepared a plan to ensure staff record verbal police handovers, improve documentation accessibility, and clarify referral processes through updated procedures, staff briefings, and induction. • Dr Marshall … (AI summary)
Overdue
Maureen Campbell-Scott
Concerns: 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.
Response (NELFT): • NELFT held two meetings with the practice and will reconvene another to discuss and agree a way forward on prescribing responsibilities. • NELFT provided personal contact details of consultants … (AI summary)
Overdue
Graeme Mathieson
Concerns: 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.
Overdue
Nigel Handscomb
Concerns: The coroner identified incomplete and inaccurate GP consultation notes, specifically noting missing records of a chest examination, the patient's lithium medication adherence, and a swallow test. There was also a discrepancy between recorded and verbal medication instructions.
Overdue
Robin McEwan
Concerns: The coroner identified a lack of direct communication between private therapy and the GP regarding the patient's welfare, and insufficient exploration of potential family support when professional help was not immediately available.
Response (Harrogate CCG): • The CCG will review the referral process for private counselling services to ensure GPs are informed of patient progress. • The CCG will review and further develop its website … (AI summary)
Responded
Ruth Edwards
Concerns: The coroner noted a surprising discharge from hospital after an overdose without a psychiatric liaison assessment, poor history-taking at UHW, and insufficient GP medication reviews contributing to an overdose risk.
Response (West Quay Centre): • The practice appointed a full-time Clinical Pharmacist within the last 12 months to oversee and improve governance regarding repeat and acute prescribing and patient monitoring. • The practice achieved … (AI summary)
Response: • The Health Board stated that all staff will be reminded of the importance of full and diligent information taking. • The issue of frequent medication reviews will be raised … (AI summary)
Responded
Jacqueline Elliott
Concerns: 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.
Response (Trafford CCG and Department of Health and Social Care): • The CCG stated it would raise awareness among GPs and pharmacists regarding the review of acute and repeat medications, with related safeguarding training having commenced in March 2019. • … (AI summary)
Responded
George Thompson
Concerns: The coroner noted concerns regarding insufficient doctor staffing, as only one doctor was on duty for multiple responsibilities, and the practice lacked resources to undertake a home visit even if indicated.
Response (H.T Practice): • The practice reviewed its home visit protocols and stated they are robust for the current team. • The practice committed to arranging telephone and systems training for the doctor … (AI summary)
Responded
Sophie Holman
Concerns: 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.
Response (NHS England): • NHS England stated it would launch a Children and Young People's Transformation Board from April 2019 and roll out Children and Young People's clinical networks in Autumn 2019 to … (AI summary)
Overdue
Peter Garvin
Concerns: 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.
Response (CNWL NHS Trust): • The Trust has developed a protocol for staff on how to work with colleagues in private sector organisations. • The protocol also outlines how staff should explain processes to … (AI summary)
Overdue
Andrew McCall
Concerns: The coroner noted that a system dependent on patient self-declaration meant GPs were often unaware their patients were on opiate replacement therapy, risking the prescription of unsuitable medications.
Response (NHS England): • NHS England will ask Addiction Dependency Solutions to review and verify processes for collecting and sharing GP data. • NHS England will share this communication with the Local Authority … (AI summary)
Responded
Roger Wood
Concerns: The coroner raised concerns that the referral pathway for abdominal aortic aneurysms (AAAs) measuring 5.5cm or greater includes the GP's role as a potentially redundant link, which could lead to vital diagnostic information not being acted upon.
Overdue
Margaret Sales
Concerns: The coroner noted incomplete patient records, difficulty contacting on-call medical staff, and a lack of communication with the GP regarding required post-discharge nutrition monitoring, leading to a gap in follow-up.
Response (Queen Elizabeth Hospital Kings Lynn): • The Trust has notified clinical teams regarding record completion, is auditing records, and has initiated quality improvement projects, including a planned transfer to Electronic Patient Records. • The clinical … (AI summary)
Responded
Anita Mandalia
Concerns: The GP surgery continued a medication prescription beyond recommended guidelines without review. Concerns also included the lack of re-referral to mental health services despite instructions, and access to excess medication contrary to overdose mitigation measures.
Overdue
Siwan Smith
Concerns: The coroner noted that reception staff did not adequately assess a distressed patient's need for an urgent mental health appointment, raising concerns about a lack of awareness regarding when a patient requires a clinical assessment for mental health concerns.
Response (Taffs Well Medical Centre): • The medical centre implemented a system to display a "High risk mental health" pop-up message on patient records for individuals with relevant medical history or medication. • The medical … (AI summary)
Responded
Sameena Javed
Concerns: 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.
Overdue
Nichola Lomax
Concerns: 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.
Response (Response regarding Nichola Lomax): • The Royal College of Psychiatrists published a Position Statement outlining a blueprint for training at all levels in eating disorders and developed online training materials for medical students and … (AI summary)
Overdue
Brian Wareham
Concerns: 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.
Response (The Richmond Clinic): • The practice investigated the matter internally. • It explored current communication options between primary and secondary care and ensured clinical staff were aware of them. • It addressed specific … (AI summary)
Response (Aneurin Bevan University Health Board): • A single point of access Flow Centre for urgent referrals has been established, offering an option to speak to a Medical Consultant for clinical advice. • Direct access telephone … (AI summary)
Responded
Carol Cole
Concerns: The coroner raises concerns that the indirect process for sharing Public Protection Notices (PPNs) with General Practitioners for residents in the Dorset Council area may prevent GPs from receiving critical information. This can lead to missed opportunities for patient assessment and support.
Response (Dorset Police): • Dorset Police conducted a review with Adult Social Care partners between 16 February and 16 March 2022, which identified differing PPN sharing processes. • The Dorset Adult Access Team … (AI summary)
Response (Dorset Council): • Dorset Council reviewed the Public Protection Notice (PPN) sharing process with Dorset Police and Bournemouth, Christchurch and Poole Council. • Dorset Council amended its internal process on 25 February … (AI summary)
Responded
Maria McGauran
Concerns: A requested review of the patient's multiple medications was not undertaken, and the Surgery could have considered alternative pain management earlier to prevent overdose risks.
Response (Alvaston Medical Centre): • Alvaston Medical Centre recruited two clinical pharmacists to conduct structured patient medication reviews. • The centre implemented a practice to ensure high-risk scheduled drugs do not form part of … (AI summary)
Responded
Select committee recommendations(37)
#15 —
Recommendation: 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 …
Response attribution not verified
#2 —
Recommendation: 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 …
Response attribution not verified
#19 —
Recommendation: We are concerned about reports of older prisoners being released without prescription medication or without being registered with a GP. We recommend all older prisoners are supported to register with a GP prior to release; where a prisoner is unable …
Response attribution not verified
#25 — NHS England is optimistic about future diagnostics, but GP engagement on prescribing is needed.
Recommendation: 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 …
Response attribution not verified
#2 — Lack of continuity of care fragments support for people with severe mental illness
Recommendation: 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, …
Response attribution not verified
#4 —
Recommendation: 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 …
Response attribution not verified
#30 — Necessity for re-implementing personal lists in the NHS GP contract from 2030.
Recommendation: NHS England should re-implement personal lists in the GP contract from 2030 onwards. (Paragraph 103) General practice and new NHS organisations
Response attribution not verified
#28 — NHS England's crucial role championing personal list model and setting 2027 ambition.
Recommendation: 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 …
Gov response: Do not accept. The Department does not accept this recommendation. We agree that continuity of care is important within general practice but do not agree that requiring a return to the personal list model is …
Rejected
#27 — Personal lists are essential for improving continuity of care in NHS general practice.
Recommendation: 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 …
Response attribution not verified
#26 — Additional funding required for continuity leads and administrative staff in Primary Care Networks.
Recommendation: 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 …
Gov response: Do not accept. The Department does not accept this recommendation. Whilst we believe continuity is an important element of care, we believe that it should be considered alongside other expectations of Primary Care Networks (PCNs) …
Rejected
#25 — National continuity of care measure required for all GP practices by 2024.
Recommendation: 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 …
Gov response: Partially accept. The Department partially accepts this recommendation. We agree that continuity of care is important in general practice, and we are introducing methods to further promote continuity of care in general practice to help …
Rejected
#24 — Routine measurement of continuity of care is essential for improvement efforts and targeted support.
Recommendation: 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 …
Response attribution not verified
#23 — Government and NHS England must acknowledge declining continuity of care and prioritise its reversal.
Recommendation: 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.
Gov response: Partially accept. The Department partially accepts this recommendation. As mandated in the GP contract, all patients must be assigned a named GP, who must lead in overseeing the care provided to a patient. Practices must …
Accepted in Part
#22 — All patients benefit from continuity of care, even without expressed preference for it.
Recommendation: 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 …
Response attribution not verified
#21 — Continuity of care is a vital, evidence-backed goal benefiting NHS general practice patients and GPs.
Recommendation: 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 …
Response attribution not verified
#20 — Declining continuity of care in general practice is concerning and inadequately prioritised nationally.
Recommendation: 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 …
Response attribution not verified
#15 —
Recommendation: The number of missing referrals and the size of the waiting list make for a daunting situation when it comes to the needs of patients. Thinking about the recent changes to GPs’ workload to allow them to focus on booster …
Response attribution not verified
#20 —
Recommendation: The renewal of the Women’s Health Strategy must include an objective accompanied by clear actions to improve the level of awareness among all primary care practitioners of menstrual health conditions, including that symptoms can begin at puberty. This will require …
Response attribution not verified
#29 — Examine limiting patient list sizes to 2500, reducing to 1850 over five years.
Recommendation: 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. …
Gov response: Do not accept. We recognise that GP to patient ratios and the size of patient lists can vary across England. However, as independent contractors, it is for each general practice to determine the size and …
Position Not Stated
#16 — Medicine shortages reinforce public concerns about GP referrals from community pharmacies.
Recommendation: Public concerns about being referred back to the GP if they use community pharmacy to access healthcare should ring alarm bells for the Government. It is encouraging that this does not seem to be the experience within Pharmacy First, but …
Response attribution not verified
#11 —
Recommendation: The very large numbers of people who have not presented for healthcare, or were not able to obtain it, during the pandemic, as well as those who have already been on waiting lists for long periods of time present a …
Response attribution not verified
#15 —
Recommendation: NHSE’s elective recovery programme includes plans for: • GPs to handle many elective cases previously dealt with by hospital doctors. Instead of referring some patients for elective care, GPs manage them within the 24 C&AG’s Report, paras 7, 1.15; Autumn …
Response attribution not verified
#19 —
Recommendation: Dismissal of women’s period problems and the normalisation of period-related pain in primary care is now recognised as a concern by the healthcare sector. However, there is little evidence of systemic improvement. Young women and girls are still reporting their …
Response attribution not verified
#14 —
Recommendation: The Department and NHSE&I are now managing a large, growing and diverse set of challenges to elective and cancer care on top of the ongoing pandemic. We asked how the Department and NHSE&I expected the accelerated and expanded vaccine booster …
Response attribution not verified
#2 —
Recommendation: GPs will be the first port of call for many women who are experiencing perimenopause or menopause. It is vital that women can trust their GPs and that GPs feel confident and well-equipped in diagnosing a condition that affects half …
Response attribution not verified
#2 — Acknowledge general practice crisis and detail short-term steps to improve patient safety and access.
Recommendation: 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 …
Gov response: Partially accept. The Department partially accepts this recommendation. We recognise that some people are facing challenges trying to access general practice services in a timely way, and general practice teams have been working immensely hard …
Accepted in Part
#1 — General practice in crisis due to poor patient access and safety risks, unacknowledged by government.
Recommendation: The first step to solving a problem is to acknowledge it and we believe that general practice is in crisis. It is clear from the latest GP Patient survey results that despite the best efforts of GPs, the elastic has …
Response attribution not verified
#28 —
Recommendation: The Government Equalities Office and Department for Health and Social Care should develop a healthcare strategy for transgender and non-binary people within the next year. The strategy should include: • improved and mandatory training for GPs around treating trans and …
Response attribution not verified
#45 — Accelerate plans for GP partners to operate as LLPs to limit financial risk exposure.
Recommendation: The Government should accelerate plans to allow GP partners to operate as Limited Liability Partnerships or other similar models which limit the amount of risk to which GP partners are exposed. (Paragraph 144) 46 The future of general practice
Response attribution not verified
#44 — Consider adopting Scottish GP premises model and increase investment in general practice estate.
Recommendation: The Government should consider adopting the approach to GP premises taken in Scotland and conduct its own analysis of whether this would be viable for general practice in England. More widely the Government must make additional investment available for the …
Gov response: Partially accept. The Department partially accepts this recommendation. In 2019, the General Practice Premises Policy Review2 highlighted the challenges faced by GPs and the wider NHS in terms of property ownership and liabilities. Stakeholders including …
Accepted in Part
#43 — GP premises remain a significant burden, hindering retention and undermining patient care.
Recommendation: Despite the risk associated with GP premises continuing to be a significant burden on existing GP partners and a barrier to entry for potential new partners, little progress appears to have been made on this issue. Until the Government grips …
Response attribution not verified
#42 — Reaffirm Government commitment to GP partnership model and detail support for its future.
Recommendation: In response to this Report the Government should reaffirm its commitment to maintaining the GP partnership model and explain how it will take forward our recommendations to better support the partnership model, alongside ongoing work to enable other models of …
Response attribution not verified
#41 — GP partners faced regrettable uncertainty, now reassured Government will maintain partnership model.
Recommendation: It is regrettable that during a time of intense pressure for GPs, following a massive effort by GPs to lead the vital covid-19 vaccination programme, that GP partners were subjected to such open speculation and uncertainty about their futures. It …
Response attribution not verified
#12 — Further steps needed to address general practice administrative workload.
Recommendation: NHS England should take further steps to address the administrative workload in general practice, including by introducing e-prescribing in hospitals and focusing on the primary-secondary care interface by encouraging ICSs to provide a reporting tool for GPs to report inappropriate …
Gov response: Partially accept. The Department partially accepts this recommendation. We agree that e-prescribing should be introduced in hospitals. Work is already underway, with NHS England working on a 3-year programme for hospitals. The Academy of Medical …
Rejected
#11 — General practice administrative workload remains unsustainable despite initial reduction efforts.
Recommendation: The Government and NHS England have made a start on reducing the administrative workload in general practice, and it is also encouraging to see some Integrated Care Systems agreeing to try to reduce the amount of work that is inappropriately …
Response attribution not verified
#3 — Commission a review into short-term problems constraining primary care, including IT and administrative tasks.
Recommendation: The Government should commission a review into short-term problems that constrain primary care including, but not limited to: the interface between primary and secondary care, prescribing from signing to dispensing, administrative tasks e.g. reports and sick notes, day-to-day usability of …
Gov response: Partially accept. The Department partially accepts this recommendation. We agree with the need to explore solutions to problems which constrain primary care, particularly given the high levels of demand and workforce pressures. However, we do …
Accepted in Part
#4 — Medicine shortages risk negating general practice capacity gains from Pharmacy First.
Recommendation: It is also especially worrying that shortages are resulting in patients being directed back into general practice. There is a serious risk that any capacity that general practice gains, through services like Pharmacy First, will be negated by the time …
Response attribution not verified
HSSIB safety recommendations(9)
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.
Safety Observation
Continuity of care: delayed diagnosis in GP practices
GP practices can improve patient safety by aligning their staff wellbeing and patient safety policies to those of NHS England’s proposed patient safety strategy.
Safety Observation
Continuity of care: delayed diagnosis in GP practices
HSSIB recommends that NHS England updates the GP IT standards to ensure that patient continuity of care is maintained, including the identification and prioritisation (technically known as ‘clear surfacing’) of information to health and care professionals, when patients visit GP …
Safety Recommendation
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 …
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
The Practice now schedules patient reviews at 12-month intervals in advance for patients with mental health needs.
Safety Action
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 …
Safety Recommendation
Potential under-recognised risk of harm from the use of propranolol
The Practice developed new guidance for patients new to antidepressants. This prompts its GPs to arrange patient reviews at: two weeks, more frequently over the first three months, a three-month follow-up, and then a further follow-up in six to 12 …
Safety Action
Management of chronic asthma in children aged 16 years and under
It may be beneficial if every child with asthma (confirmed or suspected) has access to a healthcare professional who has been trained in accordance with a nationally recognised training programme and undertakes regular reviews and continuing educational support. HSIB notes …
Safety Observation
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 …
Safety Recommendation
NCEPOD recommendations(3)
Transition From Child Into Adult Healthcare
Wording not shown. See the report on NCEPOD's website.
Transition From Child Into Adult Healthcare
Epilepsy
Wording not shown. See the report on NCEPOD's website.
Epilepsy
Crohn’s Disease
Wording not shown. See the report on NCEPOD's website.
Crohn’s Disease
CQC inspection actions(2)
Westmorland General Hospital
The service should continue to act to ensure women received continuity of care in line with national recommendations and targets.
Should Do
Family Nurse Partnership & Health Visiting
The service should implement new tools and processes to enable effective reallocation of caseloads when staff members go on long-term leave or move job roles.
Should Do
PPO death in custody recommendations(2)
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.
The GP provider
The GP provider should review the prison GP wait times to ensure all is being done to bring it in line with community access to GPs.
IMB individual recommendations(4)
Erlestoke (2020)
To the Governor, and Avon and Wiltshire Mental Health Partnership Trust: What is intended to be done to improve the waiting time for routine GP appointments? (see paragraph 8.6)
Other
Bronzefield (2023)
How does NHS England plan to address the Board’s concern regarding the lack of a GP physically present at the prison during the weekends, and the fact that there is only a substance misuse GP at the prison on Mondays?
NHS / Healthcare Provider
Bronzefield (2025)
How does NHS England propose to remedy the deficiency in GP cover in reception (6.1)?
NHS / Healthcare Provider
Implemented
Gatwick IRC/RSTHF (2022)
Strengthen the encouragement given to arriving men to take up a Rule 34 appointment with the centre GP. Ensure that healthcare staff involved in initial assessments fully describe the purpose of the Rule 34 appointment (section 4.4.2).
NHS / Healthcare Provider
Health investigations(159)
Independent investigation: Henrietta Leane, Cricklewood (1997) — Rec (xii)
The Trust should impress upon patients and their General Practitioners the importance of adhering to the regime of medication recommended in the Out-patient Clinic.
london
Independent investigation: Sarah Jane Coghlan, Middlesbrough (2003) — Rec 4
Patients who are being treated in the community should receive regular reviews in psychiatric outpatients (which in the case of well stabilised patients could be limited to three or four appointments per year). Contact in the context of CPA reviews or other larger meetings is no substitute for a psychiatric …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 13
The panel recommends that the question of continuity of care is addressed; where possible, care should follow the patient, and where a patient moves within a reasonable distance, there should be no undue haste to enforce changes of service provider.
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 5
Care coordinators may leave their posts at short notice. The panel accepts that this, and difficulties in replacing staff, may militate against good handovers between care coordinators. However, trusts should ensure that transfers of care are agreed to in writing, that the new care coordinator accepts that he/she is taking …
north_east_yorkshire
Independent investigation: Maurice Hilton, Peterlee (2006) — Rec 2
Trusts should ensure that all patients subject to CPA have a designated care coordinator who should be responsible for following the patient throughout stays in hospital whether locally or further afield, within the NHS or within the private sector. It should be the responsibility of the treating hospital to ensure …
north_east_yorkshire
Independent investigation: Karen Leonard, Middlesbrough (2009) — Rec 2
Patient 2009/3245 was transferred on numerous occasions to different treating Consultants. The Panel considered that continuity of mental health care would have been greatly improved had there been in use a comprehensive standardised transfer summary by the clinical staff treating Patient 2009/3245. The inquiry, therefore recommends the introduction of a …
north_east_yorkshire
Independent investigation: Joan Smythe, Rainham (but SE Coast patient) (2002) — Rec 20.3.a
We list below some of the communication issues that have been raised in this report. We recommend that the Mental Health Trust consider gathering data and identifying solutions to the following problems: Primary health care. We were told that it was sometimes difficult for a GP to obtain feedback if …
south_east
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 8
All GPpractices should meet with staff from their local CMHTs in order to review operational and clinical arrangements. As a minimum, these should ensure that patients with severe mental illness are regularly reviewed and that there is easy and effective communication between primary care and the CMHT.
london
Independent investigation: Ian LawsonSimon Richardson, Sunderland — Rec 4
The inquiry panel recommends that the commissioners of primary care services utilise appropriate clinical governance arrangements to promote detailed record keeping in general practice so as to facilitate continuity of patient care.
north_east_yorkshire
Independent investigation: Asiya Khatun, Newham (2000) — Rec 4
East London and The City Mental Health NHS Trust, the London Borough of Newham and Newham Primary Care Trust should review Care Programme Approach policies and procedures to ensure they reflect the importance of full participation by GPs in care planning, particularly where the GP will carry responsibility for monitoring …
london
Independent investigation: Valerie Sexton, Gosport (2000) — Rec 5.3
We recommend that whenever a consultant psychiatrist has seen a patient, and following the consultation will be retaining clinical responsibility, a follow-up appointment should be made for the patient.
south_east
Independent investigation: Sean Hand, Basildon (2003) — Rec 105.4
That the Trust also be asked to confirm that all professional staff are aware of the need to keep General Practitioners fully informed of all matters affecting, or likely to affect, the care and treatment of their respective patients, particularly where any such matter has repercussions for the care and …
east_of_england
Independent investigation: Sarah Lawson, Worthing (2000) — Rec 5
Regular and patient-focused GP practice meetings would provide a forum for peer group advice and support thereby making it more difficult to form collusive, and potentially detrimental, alliances.
south_east
Independent investigation: Sandra Crawford, St Albans (2010) — Rec 12
GP surgeries should ensure that even when such specialist care is received by patients with long term conditions, regular, yearly visits to the primary care team should be maintained.
east_of_england
Independent investigation: Kenneth Light, Leeds (2005) — Rec 2
Although the response rate from GPs to the survey questionnaire circulated to all GP practices in Leeds (150 practices approximately 300 GPs) was very disappointing (13%), a number of key issues emerged from the responses that were received. These were: That 50% of respondents to the survey said that they …
north_east_yorkshire
Independent investigation: Keith Bevis, Portsmouth (2013) — Rec 1
For patients on Enhanced CPA when there has been a significant change in either their risk factors or medication, which have been made at their CPA review or during an inpatient admission, their care coordinator should discuss with the GP the future management of the patient.
south_east
Independent investigation: Karina Menzies, Cardiff (2012) — Rec 8
The Welsh Government should consider the benefit of having named doctors at General Practices for patients with mental health conditions.
wales
Independent investigation: Joanne Butler, East Shilton, Leics (2006) — Rec R6
NHS Leicestershire County and Rutland PCT should review the support available to GPs who act as the main contact for people with mental health problems (B).
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 26
The practice of changing the Community Link Nurse every 3 months should be reconsidered.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 25
It is important to strengthen the role of the Community Link Nurse with Ward Q so as to establish continuity of care compatible with the Care Programme Approach.
midlands
Independent investigation: Gwendoline SmithDavid Smith, Sandiacre (1995) — Rec 21
The Consultant should ensure that the patient's G.P. receives notice of the discharge as soon as possible and his medical and social details as necessary to ensure continuity of care.
midlands
Independent investigation: Geraldine Simpson, Birmingham (1997) — Rec 4
the Health Authority and Primary Care Groups should agree a protocol which gives guidance on the issuing of medical certificates by GPs when patients first register with them.
midlands
Independent investigation: Colin Ricketts, Laindon, Essex (2009) — Rec R2
We recommend that Basildon CMHT review with their referring GPs what improvements to partnership working may be needed and how they might be implemented.
east_of_england
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 14
Specifically, the trust should review its systems for the organisation of outpatient clinics. Where a patient attends outpatient clinics over a long period, arrangements should ensure that the patient is not seeing a succession of inexperienced junior doctors without mandatory periodic (at the least annual) review by a consultant psychiatrist. …
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 13
The trust should review how, in all clinical contexts – for example CMHTs and outpatient clinics – patients who do not present with crises, but in whom untreated or undertreated conditions may become chronic and ingrained, may have the benefit of longitudinal reviews which consider the whole of the patients’ …
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 6
GPs and the relevant secondary mental health services should agree procedures which enable each party to notify the other promptly about prescription changes, so that the possibility of confusion, and under or over prescribing is minimised. It is not safe for clinicians to be several weeks out of date, nor …
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 5
Where GPs continue to see and prescribe for patients who are under the care of hospital psychiatrists, GPs should take responsibility for ensuring either that they prescribe in accordance with the decisions made by the psychiatrists, or that where prescriptions are different, this is immediately notified to the psychiatrists.
north_east_yorkshire
Independent investigation: Colin Anderson, Newcastle (2006) — Rec 3
GPs making referrals to secondary mental health services should review, with their patients, whether the referral has been acted upon by those services, and taken up by the patient. This is particularly important where avoidance may be part of the patient’s condition. When GPs are notified by secondary mental health …
north_east_yorkshire
Independent investigation: Chris Poole, Eastbourne (2012) — Rec 5
The final outcome of contact with secondary mental health services should always be communicated to the service users’ GP. The CCG and Trust should agree the routes of communication between secondary mental health services and GPs, and embed these into practice.
south_east
Independent investigation: Harry Messenger, Faversham (2017) — Rec 5
The Trust needs to further assure itself, by way of audit, that GPs, patients and referring teams are being informed of a CMHT decision to not accept a patient.
south_east
Independent investigation: Harry Messenger, Faversham (2017) — Rec 4
The template for ‘Referral not accepted’ should include a signpost to copy the GP into the letter in instances when the GP was not the original referrer.
south_east
Independent investigation: Bertha Martin, Cleadon (2008) — Rec 28.
GPs surgeries should consider the viability of instituting a ‘usual doctor’ system whereby a patient is assigned to a particular GP within the practice to assist in the continuity of care and communication with external agencies.
north_east_yorkshire
Independent investigation: Beata Slomiana, Finchley (2010) — Rec R3
The trust should examine whether a route for direct consultation by GPs with consultants is needed and whether this can be offered without undermining the general referral processes.
london
William Mead – Root Cause Analysis Investigation Report — Rec c)
That a SW initiative is developed for best practice in primary care on safety-netting advice.
south_west
*Mental health homicide investigation legacy report into the care and … — Rec 3
The Trust should ensure there are clear standards in place detailing what information should be sent to GP’s when a service user is discharged back to their sole care, and ensure there are processes in place to ensure ongoing compliance with this.
south_east
*Mental health homicide investigation legacy report into the care and … — Rec 3
The Trust should ensure there are clear standards in place detailing what information should be sent to GP’s when a service user is discharged back to their sole care, and should continue to audit ongoing compliance with this.
south_east
*Mental health homicide investigation legacy report into the care and … — Rec 2
The Trust should ensure there are clear standards in place detailing what information should be sent to GP’s when a service user is discharged back to their sole care, and ensure there are processes in place to ensure ongoing compliance with this.
south_east
Independent report into the care of patient T: December 2015 — Rec 1
The outcome of primary care referrals should always be communicated back to the service user’s GP, and the GP should be kept informed of plans of care and progress through mental health services.
Hertfordshire Partnership NHS Foundation Trust
east_of_england
*Independent investigation into the care and treatment of Patient G: … — Rec 17
GPs should ensure that opportunities exist within their practice to undertake case reviews. This is particularly important when patients are being managed by other professionals on their behalf and there is a regular flow of information arriving from those agencies. There are also opportunities within primary care for counselling and …
Northumberland, Tyne and Wear NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr S — Rec R5
The Trust should consider how GPs are kept up to date about the progress of clients they have referred. In particular, clients who are moving through a number of care pathways and being supported by different teams.
Mr S who committed a homicide in November 2012. Mr S had previously received treatment from Central and North West London NHS Foundation Trust
london
Accepted
Independent investigation into the care and treatment of Mr S — Rec R4
The Trust should undertake a review of GPs understanding of the current team structures and service line arrangements and if needed put in place a communication strategy to improve their understanding.
Mr S who committed a homicide in November 2012. Mr S had previously received treatment from Central and North West London NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of mental … — Rec 5
The Trust must ensure a service user’s plan of care remains continuous if admitted to an inpatient ward from the community, with appropriate liaison and engagement with the community team and other services as required.
Mersey Care NHS Foundation Trust
north_west
An independent investigation into the care and treatment of a … — Rec 4
Cambridgeshire and Peterborough Clinical Commissioning Group must implement a set of standards for reviewing the notes when a new patient with a secondary mental health history is accepted at a GP surgery.
Sally. He had a long and complex mental health history and had previously had contact with mental health services at Northamptonshire Healthcare NHS Foundation Trust
east_of_england
An independent investigation into the care and treatment of a … — Rec 5
The Trust should ensure that GPs receive regular updates on mental health care provided by the Trust, including timely discharge letters. Adherence to this expectation should be audited and monitored to ensure compliance
south_east
An independent inquiry into the care and treatment of JK: … — Rec 1
The Trust’s care pathways should give due prominence to the importance of having one or two key members of staff who can provide continuity of care for a long-term service user.
Southern Health NHS Foundation Trust
south_east
Accepted
Key findings and action plan – Final report: Norfolk and … — Rec 4
The EIT Clinical Team Leader (CTL) to provide assurances and evidence that systems are in place to ensure a named case manager/care coordinator is provided for each service user under the care of the EIT.
Norfolk and Suffolk NHS Foundation Trust
east_of_england
Key findings and action plan – Final report: Norfolk and … — Rec 1
CRHTT to review their approach to patient allocation with the aim of reducing the number of staff involved with an individual service user and providing greater continuity of care for service users.
Norfolk and Suffolk NHS Foundation Trust
east_of_england
Independent investigation report into the care and treatment of Mr … — Rec 9
The Trust must ensure that the correct registered GP details are held on file, regularly checked and updated (where required) and present on discharge documentation.
midlands
Independent investigation report into the care and treatment of Mr … — Rec 13
The GP practice must ensure that prior to removing a patient from a surgery list, the surgery has considered all information in their possession regarding the possible whereabouts of that patient and that they clearly document in the records the basis or rationale for that removal with details and/or a …
midlands
Independent investigation report into the care and treatment of Mr … — Rec 12
The GP practice must ensure that when the practice is informed that a patient has been admitted to hospital, a review of that patient’s appointments and repeat medications is undertaken.
midlands
Independent reviews(7)
Selous Review — Rec 69
The Clinical Commissioning Groups in England to be required through the Armed Forces Covenant to ensure timely access to CAMHS and paediatric services and that children and young people maintain their relative place on waiting lists when their parents are required to relocate to another area.
Other
Selous Review — Rec 68
The DHSC in England and national health services across the UK to ensure that family members of Serving personnel are able to retain their relative place on waiting lists when they move to another area, and that GPs and other healthcare professionals support their transition from one area to another, …
Other
Selous Review — Rec 67
The Ministry of Defence to continue to work with the national health services across the UK to ensure that an Armed Forces Family Code articulates what is required to deliver appropriate continuity of care for Service families as they move around the UK, and to ensure that information is available …
Other
Darzi Review — Rec 6
People are struggling to see their GP. GPs are seeing more patients than ever before, but with the number of fully qualified GPs relative to the population falling, waiting times are rising and patient satisfaction is at its lowest ever level. There are huge and unwarranted variations in the number …
Health & Social Care
Darzi Review — Rec 5
How long people wait, and the quality of treatment, are at the heart of the social contract between the NHS and the people. The NHS has not been able to meet the most important promises made to the people since 2015. From access to GPs and to community and mental …
Health & Social Care
Selous Review — Rec 70
The Ministry of Defence to take account of the healthcare needs of military families when posting Service personnel to a new area.
Other
Selous Review — Rec 65
The NHSEI, NHS Scotland, NHS Wales and Health and Social Care Northern Ireland to require GPs to: • reinforce the veteran-friendly GP practice accreditation scheme to include Serving military families • routinely ask whether adults and children are members of a Serving military family • identify previous GP/dental practices for …
Other
PHSO casework decisions(62)
P-003330 — A practice in the Dorset area
Mrs T complained the Practice denied her husband a home visit, delayed a telephone consultation, and failed to arrange an agreed home visit, questioning if this contributed to his death from sepsis.
NHS in England
Feb 2025
P-003664 — A practice in the Forest of Dean area
Mrs N complained a receptionist failed to review her husband's medical history or seek clinical advice for foot pain, advising him to call NHS 111, which delayed his cellulitis diagnosis.
NHS in England
Jul 2025
P-001352 — A medical practice in the Oldham area
Mr H complained the Practice wrongly cancelled his appointment, falsely accused him of abusive behaviour, removed him from its patient list, and mishandled his complaint.
NHS in England
Partly Upheld
Apr 2022
P-004554 — A practice in the Wokingham area
A son complained the Practice denied his hard-of-hearing father face-to-face appointments and had poor communication regarding a blood test.
NHS in England
Dec 2025
P-002891 — A practice in the North Tyneside area
A patient alleged a practice failed to refer her to neurology for arm dysfunction and weight loss, delaying her Motor Neurone Disease diagnosis for several years.
NHS in England
Aug 2024
P-003160 — A practice in the West Northamptonshire area
The GP Practice allegedly refused home visits for Ms B's deteriorating father, leading to a delayed hospital admission for a fatal infection.
NHS in England
Upheld
Nov 2024
P-003538 — A practice in the Birmingham area
Ms P complained her mother couldn't contact the Practice, had delayed callbacks, no face-to-face appointment, and an incorrect diagnosis, leading to her death.
NHS in England
May 2025
P-003704 — Oxford University Hospitals NHS Foundation Trust
Mrs T complained the Trust inadequately considered evidence when declining an immunology referral for her daughter, whose recurring infections and seizures remain uninvestigated.
NHS in England
Jul 2025
P-003714 — A practice in the Oldham area
Mrs A complained the Practice failed to provide her mother with face-to-face GP appointments in September 2023, causing distress and forcing her to change practices.
NHS in England
Jul 2025
P-003984 — A practice in the City of Nottingham area
Ms P complained the Surgery refused her required HRT dose, reduced it without notice, and failed to communicate with other organizations to support her prescription needs.
NHS in England
Sep 2025
P-004538 — A practice in the Norwich area
Miss M complained her practice failed to investigate ongoing menstrual symptoms adequately, delayed a gynaecology referral, and dismissed her concerns as "normal."
NHS in England
Dec 2025
P-004667 — A practice in the North Yorkshire area
Mr T complained a practice dismissed his wife's symptoms and failed to investigate her tongue/jaw issues, leading to a private diagnosis and a 12-month NHS wait.
NHS in England
Jan 2026
P-004579 — A practice in the Broadland area
The Practice refused GP appointments, instructed walk-in centres, declined a urine sample, and would not provide antibiotics for Mr H's pain and undiagnosed condition.
NHS in England
Jan 2026
P-001826 — A practice in the Calderdale area
Mrs A complained the Practice poorly communicated and repeatedly misdiagnosed her mother over the phone, leading to her death from an undiagnosed infection.
NHS in England
Feb 2023
P-001872 — A practice in the Derbyshire area
Mrs A complained the Practice failed to identify and diagnose her arterial arteritis despite clear symptoms, leading to significant suffering and adverse health impacts.
NHS in England
Mar 2023
P-001869 — A practice in the Warwickshire area
Mrs V complained a medical practice failed to urgently refer her for a scan for post-menopausal bleeding, delaying her cancer diagnosis and making the tumour inoperable.
NHS in England
Mar 2023
P-001964 — A practice in the Stockton-on-Tees area
Mrs O complained the Practice ignored her requests for an emergency appointment for excruciating back pain, provided unsuitable information, and caused her emotional stress leading to emergency surgery.
NHS in England
Apr 2023
P-002455 — A practice in the Lancashire area
Mrs H complained the Practice gave incorrect information to the coroner, failed to chase a referral, and missed a home visit for her late father.
NHS in England
Feb 2024
P-002521 — A practice in the Stockport area
Mr O complained the Practice and Trust failed to diagnose his stroke in October and November 2021, leading to permanent physical weakness and speech difficulties.
NHS in England
Mar 2024
P-002495 — A practice in the Devon area
Mrs R complained GP doctors missed multiple opportunities from early 2022 to spot signs of cancer in her father, leading to a delayed diagnosis and his subsequent death.
NHS in England
Mar 2024
P-003224 — A practice in the Manchester area
Miss Q complains the Practice delayed referring her to a long COVID clinic and for dyslexia support, and failed to monitor her blood pressure.
NHS in England
Dec 2024
P-003417 — A practice in the Sheffield area
Miss A complained about delayed registration, unprofessional staff, and lack of medical and mental health support, which she said worsened her spine condition and anxiety.
NHS in England
Mar 2025
P-003515 — A practice in the Leeds area
Miss T complained the Practice delayed her father's cancer diagnosis, mismanaged referrals, incorrectly diagnosed sleep apnoea, and mishandled data requests and complaints.
NHS in England
Mar 2025
P-003773 — A practice in the Solihull area
Mr P complained the Practice failed to appropriately refer his wife for a cardiology echocardiogram and follow up, which he believes contributed to her avoidable death.
NHS in England
Upheld
Aug 2025
P-004488 — A practice in the Wigan area
Ms E complained a doctor failed to prescribe antibiotics for a viral infection with a high temperature, leading to her condition deteriorating significantly and hospitalisation with pneumonia.
NHS in England
Dec 2025
P-004494 — A practice in the Braintree area
Mrs L complained her husband's GP Practice failed to implement a care plan, was unaware of his severe illness, and did not test for type 2 diabetes before his death.
NHS in England
Dec 2025
P-004521 — A practice in the Croydon area
Miss K complained the Practice caused delays in her receiving a medical exemption certificate, leading her to go without necessary medication for three weeks, causing physical pain and distress.
NHS in England
Dec 2025
P-004682 — A practice in the Leeds area
Mrs A complained her father, Mr R, received inadequate care from the Practice and Trust, including a lack of face-to-face consultation and misdiagnosis, leading to his suffering and death.
NHS in England
Jan 2026
P-004683 — Royal Devon University Healthcare NHS Foundation Trust
Mrs S complained the Trust incorrectly discharged her from spinal care, provided insufficient discharge information, gave vague explanations, and failed to process a GP referral, causing distress and affecting her health.
NHS in England
Jan 2026
P-004698 — A practice in the Canterbury area
Mrs D complained a GP did not fully investigate her mother's symptoms, provide correct treatment, or urgently refer her for further investigation in April 2024, leading to her death.
NHS in England
Jan 2026
P-001801 — A practice in the Worcestershire area
Mrs U complained the Practice refused B12 injections for her son, delayed specialist referrals, denied online record access, and failed to respond to her complaint letters.
NHS in England
Feb 2023
P-001820 — A practice in the Derbyshire area
Ms R complained about poor clinical care for her father, including an inadequate telephone assessment, lack of follow-up for serious symptoms, and poor complaint handling.
NHS in England
Feb 2023
P-001928 — A practice in the Essex area
Ms U complained about issues with medication prescriptions (missing items, no verbal requests), unsupportive GP care for suicidal feelings, lack of specialist referrals, accessibility problems, and various treatment failings.
NHS in England
Apr 2023
P-003823 — A GP practice in the Doncaster area
A GP practice allegedly refused to provide routine aftercare following Mrs C's private surgery, causing her anxiety about her recovery.
NHS in England
Sep 2023
P-002397 — A practice in the Telford and Wrekin area
Mr H complained his GP failed to recognise and inform him of bisoprolol's mental health side-effects and that remote appointments hindered diagnosis, causing him years of suffering.
NHS in England
Jan 2024
P-002658 — A practice in the Manchester area
Miss L complained about a lack of hair loss treatment and specialist referrals from the Practice, and that the Practice removed her from their patient list.
NHS in England
Jun 2024
P-002663 — A practice in the Leicestershire area
Mrs I complained the Practice prescribed incorrect medications and failed to physically examine her husband's penile cancer symptoms, delaying his terminal diagnosis.
NHS in England
Jun 2024
P-002670 — A practice in the Hartlepool area
Mrs E complained about an incorrect referral to gastroenterology instead of ENT and being wrongly removed from the Practice's patient register, causing distress.
NHS in England
Jun 2024
P-003005 — A practice in the Exeter area
Miss O complained the Practice delayed timely specialist support for her mother, that a doctor was unprofessional, and that the complaint was improperly handled, contributing to her mother's deterioration and death.
NHS in England
Sep 2024
P-002918 — A practice in the Hartlepool area
Miss R complained the Practice did not provide blood pressure checks or follow-up for HRT. She alleged they failed to offer medication changes for side effects and were difficult to contact, causing suffering and poor mental health.
NHS in England
Sep 2024
P-003031 — James Paget University Hospitals NHS Foundation Trust
Mrs A complained about delays in referral, diagnosis, and treatment for her late husband, alleging medical negligence contributed to his suffering and avoidable death, seeking admission of liability.
NHS in England
Oct 2024
P-003023 — A practice in the Stratford-on-Avon area (GP Surgery …
Removal from GP lists and restricted access to Trust services impacted her son’s care, putting his health at risk and causing Ms E distress and financial difficulties.
NHS in England
Oct 2024
P-003258 — Royal Free London NHS Foundation Trust
Mr K complains the Practice failed to admit his mother to hospital promptly, and the Trust delayed treatment, communication, and placed a COVID-positive patient in her room.
NHS in England
Dec 2024
P-003483 — A practice in the Leeds area
Mrs O complained the Practice delayed investigating her husband's symptoms, leading to a late diagnosis of terminal spinal lung cancer. She believed an earlier diagnosis could have altered his prognosis.
NHS in England
Apr 2025
P-003789 — A practice in the Fenland area
Mr E complained a GP ignored correspondence, failed referrals, made an unqualified diagnosis, accused him of fabricating symptoms, and concealed medical records.
NHS in England
Aug 2025
P-003809 — A practice in the Wirral area
Mr B complained the Practice communicated poorly about his registration, first registering and then de-registering him, which delayed his compensation claim.
NHS in England
Aug 2025
P-003748 — A practice in the North Tyneside area
Mrs E complained a GP failed to investigate her husband's cancer symptoms, causing pain and distress. She questioned if earlier treatment could have prolonged his life.
NHS in England
Aug 2025
P-003735 — A practice in the Bromsgrove area
Mrs T complained her severe back pain was not taken seriously by the Practice, despite her spinal condition. She believes this contributed to declining mobility and needing a knee replacement.
NHS in England
Aug 2025
P-004293 — A practice in the Stockport area
Mr A complained the GP practice delayed referring him for tests despite symptoms and a seizure, leading to a delayed diagnosis of temporal lobe epilepsy and a brain lump.
NHS in England
Nov 2025
P-004326 — A practice in the Shropshire area
Dr A complained a GP Practice failed to identify his daughter was being bullied despite emotional and physical symptoms, and lacked consistent clinician care, severely impacting her wellbeing.
NHS in England
Nov 2025
LGO / SPSO decisions(317)
PSOW-202501595 — A GP Practice in the area of Betsi …
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 …
PSOW (Public Services Om…
Health
Jan 2026
PSOW-202303749 — Aneurin Bevan University Health Board
Mrs B complained about the advice her husband Mr B received from an Advanced Nurse Practitioner (ANP) employed by the Out of Hours GP service, shortly before he was admitted to hospital and sadly died of neutropenic sepsis. Mrs B said that a home visit she requested should have been …
PSOW (Public Services Om…
Health
Upheld
Mar 2024
PSOW-202402918 — Betsi Cadwaladr University Health Board
Mr B complained that the Health Board had not responded to all the questions that he had raised with the GP Practice. He also was unhappy with the Health Board’s handling of his complaint, including the time taken to provide a response. He referred to the effect this had on …
PSOW (Public Services Om…
Health
Aug 2024
PSOW-202405171 — A GP Practice in the area of Hywel …
Mr A complained about how the Practice dealt with his complaint, how he was de-listed from the Practice, and the clinical treatment he received from the Practice. After assessment, the Ombudsman found that the Practice had not responded to Mr A’s complaints under the Putting Things Right process. The Ombudsman …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202407040 — Betsi Cadwaladr University Health Board
Ms C complained that she was unable to make an appointment with a GP Practice in the area of Betsi Cadwaladr University Health Board, which resulted in delays in reviewing her medication and issuing prescriptions The Ombudsman decided that the Practice had failed to recognise that the patient had made …
PSOW (Public Services Om…
Health
Feb 2025
PSOW-202408569 — A GP Practice in the area of Swansea …
Mr C complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) had not ensured that his father, Mr A’s, prescriptions were processed correctly and in a timely manner. He further complained that the Practice had not handled his complaints in accordance with the …
PSOW (Public Services Om…
Health
Upheld
Nov 2025
201902987 — A Medical Practice in the Lanarkshire NHS Board …
C attended the practice to collect prescriptions and had a brief discussion with a member of staff. Subsequently, C received a letter from the practice informing them their registration with the practice had been terminated due to inappropriate behaviour. C considered the practice’s actions to be unreasonable. We found that …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2020
NIPSO-29583 — Lurgan Medical Practice
We found that a medical assessment performed during a home visit was carried out in line with good medical practice, but that the GP should have recorded what had been discussed with the patient and her family, and what they should do if her symptoms did not improve.
NIPSO (NI Public Service…
Health & Social Care
Dec 2020
NIPSO-gp-practice-addresses-appointment-booking-system-after-patients — GP
NIPSO (NI Public Service…
Health & Social Care
Apr 2021
NIPSO-201916274 — GP
We investigated whether an increase in a man’s prescription caused him to attend hospital the following day. We found the Practice’s increase in the dose fell within the prescribed limits.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Mar 2024
NIPSO-202004023 — GP
A woman complained that her GP failed to uphold a commitment to monitor her mental health problems. We partially upheld the complaint.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Mar 2025
NIPSO-202006812 — GP
A man complained that his GP should have provided him with medication following a private ADHD diagnosis.
NIPSO (NI Public Service…
Health & Social Care
Upheld
May 2025
NIPSO-202400471 — GP
A patient’s daughter complained he should not have had to wait for the results of blood tests before being sent to hospital. We found his GP acted appropriately.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Dec 2025
PSOW-202103895 — Betsi Cadwaladr University Health Board
Mrs X complained that she was admitted to hospital for 3 weeks due to a lack of treatment by a GP practice, which is managed by the Health Board, for a chest infection, which resulted in fluids subsiding to her heart and resultant breathing difficulties. She also complained about a …
PSOW (Public Services Om…
Health
Oct 2021
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 …
PSOW (Public Services Om…
Health
Not Upheld
Oct 2021
PSOW-202108137 — A GP Practice in the area of Aneurin …
Miss X complained that the Surgery changed the frequency of her prescriptions from monthly to fortnightly without explanation. The Ombudsman decided that the Surgery should provide Miss X with a “Putting Things Right” (the formal NHS complaints process in Wales) compliant written response (within 3 weeks) which should explain the …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202106424 — A GP Practice in the area of Aneurin …
Mrs H complained that her GP Practice failed to manage her diabetes appropriately and that it removed her from its patient list after she submitted a formal complaint. The Ombudsman considered that there was insufficient evidence of harm to justify investigating Mrs H’s clinical complaint. However, having considered advice from …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202200063 — A GP Practice in the area of Cardiff …
Mr X complained that despite making a formal complaint to the GP Practice in November 2021 about his medical records not being transferred, he had not received a response . The Ombudsman was concerned that Mr X had yet to receive a response to his concerns and contacted the GP …
PSOW (Public Services Om…
Health
Apr 2022
PSOW-202200632 — A GP Practice in the area of Aneurin …
Mr X complained that the Practice failed toappropriately change his pain relief medication as instructed by the hospitaland failed to issue a repeat prescription. The Ombudsman found that whilst the Practice responded to Mr X’s concerns, it had done so verbally. It had not offered its response in writing in …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202005677 — A GP Practice in the area of Hywel …
Mr X complained about the care provided to his mother, Mrs Y, by her GP Practice. He complained that: • There was a delay in providing Mrs Y with a clear and accurate diagnosis. • Mrs Y was not advised that the reason for a scan she received in January …
PSOW (Public Services Om…
Health
Upheld
Jul 2022
PSOW-202103875 — Cwm Taf Morgannwg University Health Board
Mr A complained about the treatment given to his mother, Mrs B, by the Practice. He stated that Mrs B had repeatedly raised concerns for 15 months before she was diagnosed with ovarian cancer, and if the Practice had responded appropriately, including offering her face-to-face consultations rather than telephone ones, …
PSOW (Public Services Om…
Health
Upheld
Aug 2022
PSOW-202200229 — A GP Practice in the area of Swansea …
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 …
PSOW (Public Services Om…
Health
Aug 2022
PSOW-202202701 — A GP Practice in the area of Cardiff …
Miss X complained that although she had raised her concernswith the GP Practice, she had not yet received a final response despitepromises that it would be issued to her. The Ombudsman was concerned that Miss X was yet to receive aresponse to her concerns and therefore contacted the GP Practice. …
PSOW (Public Services Om…
Health
Aug 2022
PSOW-202202532 — Betsi Cadwaladr University Health Board
Mr X complained about problems making appointments at his GP Practice (managed by the Health Board) and he said that staff were “awkward”, “demanding” and “argumentative” when returning his telephone calls. He also alleged that staff do not believe anything is wrong with him. He further raised concerns about the …
PSOW (Public Services Om…
Health
Aug 2022
PSOW-202104963 — A GP Practice in the area of Aneurin …
Ms A complained about her diagnosis and treatment by the GP Practice while she was going through a mental health crisis. The investigation considered whether the appointments provided to her were suitable, whether the Practice’s communication with Ms A regarding her requests for appointments was appropriate, whether the medications prescribed …
PSOW (Public Services Om…
Health
Not Upheld
Nov 2022
PSOW-202203324 — A GP Practice in the area of Hywel …
Mr S complained that the Surgery de-registered him from the practice due to him submitting a complaint. He further complained that despite him submitting his complaints, he had not received a full response. The Ombudsman was concerned that Mr S had not yet received a response to his concerns and …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202203494 — A GP Practice in the area of Betsi …
Mr X complained about his experience with the Practice, who he considered to be transphobic. The Practice refused to prescribe hormones, requested by the local gender team, without seeking further clarification, but he had not received any update or response regarding this. Mr X was dissatisfied with the complaint response …
PSOW (Public Services Om…
Health
Nov 2022
PSOW-202202905 — A GP Practice in the area of Betsi …
Mrs A complained that the GP Practice’s management and care of her late father Mr B’s deteriorating kidney function in 2022 was not to an appropriate standard. The Ombudsman’s investigation found that most of the appointments and interactions relating to Mr B’s care, together with the medication management of his …
PSOW (Public Services Om…
Health
Upheld
Sep 2023
PSOW-202202309 — A GP Practice in the area of Betsi …
Mrs A complained about the care and treatment that her late mother, Mrs B, received during the final weeks of her life while she was a resident in a care home in the area of Betsi Cadwaladr University Health Board. Mrs A complained that the Care Home failed to appropriately …
PSOW (Public Services Om…
Health
Upheld
Jan 2024
PSOW-202204525 — Aneurin Bevan University Health Board
Mrs C complained about the care and management her late husband, Mr A, received from the GP Surgery (“the Surgery”) between May and November 2021. The Ombudsman investigated whether there were unacceptable delays in making appointments and telephone consultations for Mr A between May 2021 and 23 November 2021, and …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2024
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 …
PSOW (Public Services Om…
Health
Not Upheld
Feb 2024
PSOW-202301750 — Cwm Taf Morgannwg University Health Board
Mr B complained that the Practice failed to provide appropriate care and treatment to his mother, Mrs B, shortly before she sadly died. Mr B complained that the Practice failed to call an ambulance or inform his sister, Mrs A, that their mother needed to be admitted to hospital. Mr …
PSOW (Public Services Om…
Health
Upheld
Feb 2024
PSOW-202307376 — A GP Practice in the area of Betsi …
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 …
PSOW (Public Services Om…
Health
Feb 2024
PSOW-202308473 — A GP Practice in the area of Cardiff …
Ms N complained that a GP surgery in the Cardiff and Vale University Health Board area (“the Surgery”) failed to address her concerns that it issued a letter containing medical information to her shared home address without an addressee. The Ombudsman found that the Surgery omitted to address this aspect …
PSOW (Public Services Om…
Health
Feb 2024
PSOW-202106970 — A GP Practice in the area of Betsi …
Mrs B complained about the care and treatment provided to her by a GP Practice (“the Practice”) in the area of Betsi Cadwaladr University Health Board. The investigation considered whether the Practice misdiagnosed Mrs B’s symptoms, which led to a delay in the diagnosis of laryngopharyngeal reflux/silent reflux (when stomach …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2024
PSOW-202108288 — A GP Practice in the area of Swansea …
The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2024
PSOW-202208529 — Velindre University NHS Trust
The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202306840 — Health Education and Improvement Wales
The Ombudsman investigated a complaint from Mr Y about the way that a trainee GP at the Practice had managed the care of his late wife, Mrs Y, when she had contacted the Practice complaining of a history of 10 days constipation and abdominal pain. A telephone appointment was arranged …
PSOW (Public Services Om…
Health
Upheld
Mar 2024
PSOW-202308039 — Cwm Taf Morgannwg University Health Board
Messrs A & B complained that the Practice had decided not to investigate and provide a substantive response to the complaint they had made to it. The Ombudsman was concerned that the Practice had unfairly decided that the complaint to it was out of time and that it had declined …
PSOW (Public Services Om…
Health
Mar 2024
PSOW-202302575 — Aneurin Bevan University Health Board
Mrs A complained about the care and treatment provided by a GP Practice to her late mother, Mrs B, in July and August 2022. The Ombudsman investigated whether antibiotics should have been prescribed at or following a home visit on 25 July 2022, whether home visits should have been carried …
PSOW (Public Services Om…
Health
Not Upheld
Apr 2024
PSOW-202309245 — A GP Practice in the area of Cardiff …
Miss H complained that Whitchurch Road Surgery failed to address her concerns about alleged malpractice and malicious referrals in its complaint response. The Ombudsman found that whilst the Surgery had issued a complaint response it had failed to adequately address her concerns. She said that this caused frustration and uncertainty …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202310284 — A GP Practice in the area of Cardiff …
Mrs A complained about the care provided to her late sister by Cardiff and Vale University Health Board and a GP Practice. The Ombudsman found that Mrs A complained to the Health Board in 2022, but she had not received a formal response to her complaints under the Putting Things …
PSOW (Public Services Om…
Health
Apr 2024
PSOW-202302967 — A GP Practice in the area of Hywel …
Mr A’s complaint centred on the alleged delay by a GP Practice in the area of Hywel Dda University Health Board (“the GP Practice”) in October 2021 with diagnosing his father, Mr D, with spinal issues and kidney cancer. The Ombudsman did not find an undue delay in the GP …
PSOW (Public Services Om…
Health
Not Upheld
Jun 2024
PSOW-202309223 — A GP Practice in the area of Powys …
Ms A complained about the care and treatment that her late father, Mr B, received from the Practice, including that it did not adequately treat her father’s anaemia. The Ombudsman decided that although the Practice prescribed one month’s folic acid, no further investigation of Mr B’s folate level were carried …
PSOW (Public Services Om…
Health
Jun 2024
PSOW-202400818 — A GP Practice in the area of Aneurin …
Mr A complained about the GP Practice’s complaint response about his mother’s management and care in February 2024. Mr A also complained about a later period of care (in April ) that the GP Practice had not had an opportunity to consider. The Ombudsman exercised her discretion and decided to …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202401942 — A GP Practice in the area of Hywel …
Mrs B complained to her GP Practice about care and treatment she had received. This included concerns about a letter she had received from a GP, concerns about her pain management, incorrect information in hospital referrals and access to her medical records. Mrs B complained to the Ombudsman that the …
PSOW (Public Services Om…
Health
Jul 2024
PSOW-202309554 — A GP Practice in the area of Powys …
Mr A complained that a GP Practice in the Powys Teaching Health Board area (“the Practice”) failed to provide appropriate care and treatment in relation to his presenting symptoms. Mr A was later diagnosed with polymyalgia rheumatica. Mr A was particularly concerned that it was unreasonable for the Practice to …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
PSOW-202402868 — A GP Practice in the area of Cardiff …
Ms P complained that between June and August 2023, her wounds were not appropriately cared for by nursing staff at the Surgery and the risk of infection was not addressed. She also complained that nursing staff did not seek additional input at appropriate times. Ms P said that her wounds …
PSOW (Public Services Om…
Health
Not Upheld
Dec 2024
PSOW-202303356 — A GP Practice in the area of Aneurin …
Ms D complained about the care and treatment provided to her grandmother, Mrs F. Specifically, the investigation considered whether, between June 2021 and June 2022, Mrs F’s GP Practice failed to take appropriate action which would have resulted in an earlier diagnosis of her bladder cancer. My investigation found that …
PSOW (Public Services Om…
Health
Jan 2025
PSOW-202309579 — Swansea Bay University Health Board
Mr F complained about the care provided to his late mother Mrs G. The investigation considered whether the action taken by the Acute Clinical Team in respect of his late mother’s blood test results between 25 May and 2 June 2023 was clinically appropriate. The investigation found that Mrs G’s …
PSOW (Public Services Om…
Health
Upheld
Jan 2025
Domestic Homicide Reviews(148)— showing 50 strongest matches
Bury — recommendation 4.
GP Practice 2 to explore if there are practical ways of maximising relationship continuity using this case as a significant event. The RCGP toolkit for Continuity of Care provides a useful guide of how to do this.
North Manchester Clinical Commissioning Group
Kent — recommendation 4
The threshold for GP summary referrals should be reviewed and due consideration given to including attendance at domestic abuse and/or alcohol dependent patients.
SECAmb
South East Coast Ambulance …
Kent — recommendation 2
GPs practices should ensure they have robust processes in place to ensure that when information from other agencies directs an action for primary care that these requests can be promptly actioned. This should include the acknowledgement to referring agencies when a requested action cannot be met due to non-engagement.
Kent and Medway ICB
NHS Kent and Medway …
Cheltenham — recommendation GCCG.1
Make efforts to ensure continuity of care with a “usual GP” for patients who are known to be vulnerable.
Gloucestershire Clinical Commissioning Group
Gloucestershire Clinical Commissioning Group
Manchester — recommendation 7
The Manchester CSP, with the support of the ICB, issues a briefing note to all Partners outlining the national policy regarding ‘temporary residence’ when registering with a general practitioner and the implication of temporary residence on the opportunity to receive all commissioned services for that GP catchment; The Manchester CSP …
Manchester Community Safety Partnership | Integrated …
Greater Manchester Mental Health …
Kent — recommendation 7
In exercising their responsibility in assisting young adults leaving care, Social Services should endeavour to ensure such individuals are registered with a GP, (none of the Rose Brothers were registered with a GP at the time they attacked Joyce).
Kent and Medway Social Services
Coventry — recommendation 7.1.1
Implementation of the IRIS project in GP Primary Care
Coventry and Rugby Clinical Commissioning Group
NHS Coventry and Warwickshire …
West Berkshire — recommendation 2
It is recommended that across the CCG GP Practices to hold clinical meetings to share patients with vulnerabilities (defined as patients in whom symptoms are not resolving despite usual treatment) amongst colleagues so that any GP who might consult this group of patients is fully briefed (in addition to the …
Newbury & District Clinical Commissioning Group …
Chiltern — recommendation Panel Recommendation
To ensure follow up letters to GP practices are sent and recorded.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Chiltern — recommendation STARS Recommendation
Inclusion services to develop processes to inform the client’s GP of involvement with services.
South Staffordshire and Shropshire Healthcare Trust …
Cornwall — recommendation 9b
GPs undertake an agreed formal process to identify thresholds that trigger joint multi professional assessments of particular cases.
Safer Cornwall
Cardiff — recommendation 2
General Practitioner’s should make any referral on to appropriate services and should not expect family to make contact with services themselves.
Cardiff & Vale University Health Board
Cardiff and Vale University …
Cardiff — recommendation 5
In line with Cardiff & Vale Dementia Strategy, Cardiff & Vale University Health Board will encourage GP surgeries in Cardiff and the Vale of Glamorgan to become designated ‘Dementia Friendly’ and provide literature, awareness and guidance on dementia to patients and members of the public
Cardiff & Vale University Health Board
Cardiff and Vale University …
South Gloucestershire — recommendation 42
Practices to be encouraged to consider implementing a system of identifying and allocating known drug users to a specific GP who should co-ordinate their care, with flagging of records to indicate which GP they should be directed to.
South Gloucestershire Clinical Commissioning Group (ICB)
NHS Gloucestershire ICB
Herefordshire — recommendation CCG5
The CCG should utilise the Map of Medicine care pathways approach to support GPs in their work re alcohol abuse and the links between alcohol misuse and domestic abuse
Herefordshire ICB
NHS Herefordshire and Worcestershire …
Harlow — recommendation 15.2.5
Where there are concerns raised, every effort should be made for the patient to have continuity of care and be seen by the same midwife.
Princess Alexandra Hospital
The Princess Alexandra Hospital …
Norfolk — recommendation 3
An in-house process introduced for Practices, for communication regarding disengaging patients in primary care by notification to the Safeguarding Lead GP for the Practice, or the responsible GP for the patient.
Norfolk and Waveney Integrated Care Board
NHS Norfolk and Waveney …
East Sussex — recommendation 7
That all GP practices should assure themselves that they have a complex care mechanism for co-ordinating the care of high risk and vulnerable patients, with a way of identifying and tracking this cohort of patients.
NHS Sussex Integrated Care Board | …
NHS Sussex ICB
Solihull — recommendation BSCCG-GP3-1
The practice to improve knowledge and skills with regard to identification of domestic abuse by IRIS refresher training
Birmingham and Solihull Clinical Commissioning Group
NHS Birmingham and Solihull …
Solihull — recommendation BSCCG-GP1&2-2
Practices to review systems of receiving information, and the progression of information which gives rise for safeguarding concerns to be discussed, either within the Practice or multi-agency forum.
Birmingham and Solihull Clinical Commissioning Group
NHS Birmingham and Solihull …
Solihull — recommendation BSCCG-GP1&2-1
The practice to improve knowledge and skills with regard to identification of domestic abuse by becoming an IRIS accredited practice
Birmingham and Solihull Clinical Commissioning Group
NHS Birmingham and Solihull …
Solihull — recommendation 2
Safer Solihull Partnership shares this report with Solihull Health and Well-Being Board in order to support the extension of the IRIS Programme across all GP practices and to support the provision of domestic abuse pathways incorporating Independent Domestic Violence Advisors across all Emergency Departments in the area.
Safer Solihull Partnership | Solihull Health …
Cornwall — recommendation 8
We recommend that a process and protocol be put in place to guide practitioners and managers about how best to ensure continuity of care provisions, most notably, continuity of worker. Recognising the constraints of workforce capacity and workload, it is nevertheless important to place emphasis on the need to provide …
NHS Kernow | Cornwall Partnership NHS …
NHS Kernow
Sunderland — recommendation SCCG-1
To recommend that GPs ensure that patients with complex medical health issues are offered face-to-face appointments.
Sunderland Clinical Commissioning Group
Telford and Wrekin — recommendation 11
A return to primary face to face appointments
The GP Practice
Somerset — recommendation 7.1.3
All referrals into their service for temporary accommodation should be advised to bring identification with them and at least one month’s supply of medication (If medically safe) or a record of the medication in order that support can be ascertained from the new local GP practice for assistance to prevent …
Torbay Domestic Abuse Service
Somerset — recommendation 7.1.1
This agency should link with the local GP practices in close proximity to their safe houses/refuge and build a rapport with the practice in order that the domestic abuse service can become more familiar with the practice. The aim is also so that the GP practices can assist new arrivals …
Torbay Domestic Abuse Service | Somerset …
Sheffield — recommendation a
in cases of ongoing mental ill-health, good practice would be for a patient to be seen by the same General Practitioner
Sheffield Clinical Commissioning Group
Sheffield Clinical Commissioning Group
Braintree — recommendation 5.4
That all health agencies are reminded of the significance of information sharing with primary care services (GPs) to ensure clarity of information and continuity of care. It would be helpful if GPs are made aware when patients do not attend (DNA) appointments with other services.
EPUT | Mid Essex Clinical Commissioning …
Essex Partnership University NHS …
Braintree — recommendation 5.3
That NHS England and CCGs remind primary care services to complete a transfer summary in the electronic medical records (regarding patients with mental issues) when a surgery becomes aware that a patient is moving to a new locality.
NHS England | Mid Essex Clinical …
NHS England
Nottingham — recommendation 20.5.4
DART workers should contact the survivor’s GP when a survivor has been assessed as ‘High-risk’ and telephone contact has been unsuccessful, to request that contact details of Adult Services and Women’s Aid are provided at the patient’s next consultation.
Nottingham City Council Adult Services
Nottingham City Council
Ealing — recommendation 2
London North West University Healthcare NHS Trust Community 0 – 19 Service should look at issues arising from this case to establish if the lack of continuity of health professionals has impacted on the quality of care
London North West University Healthcare NHS …
Basildon — recommendation 13
That all agencies commit to support the current care coordination roles of the G.P. so that the G.P’s are aware of all mental health concerns identified by other health professionals, even if no formal diagnosis is identified.
All agencies | General Practitioners
Bournemouth — recommendation 9.5
All GP practices across Dorset, Bournemouth and Poole to identify a lead for domestic abuse within the surgery and to embed the RCGP domestic abuse pathway. Michelle’s pattern of seeking emergency appointments meant that the GP practice that Michelle attended could not offer a consistent GP in her care. Managing …
Dorset Clinical Commissioning Group
Dorset Clinical Commissioning Group
Isle of Wight — recommendation 4
That NHS England, supported by the Isle of Wight Clinical Commissioning Group, develop robust mechanisms to assure that the contractual requirements regarding the function of named and accountable GPs are adhered to fully so that this cohort of potentially vulnerable people receive co-ordinated and tailored health care which meets their …
NHS England | Isle of Wight …
NHS England
Wolverhampton — recommendation 15
The Safer Wolverhampton Partnership to require the Black Country Partnership Foundation Trust to demonstrate that it actively encourages all patients with severe and enduring mental ill-health to register with a local GP.
Safer Wolverhampton Partnership
Northampton — recommendation 4
NHFT to review the discharge procedure following an admission under Section 2 Mental Health Act, ensuring a more robust system of communication with GPs to avoid delay and therefore potential loss of timely information as well as providing continuity of care provision.
NHFT
Oxford — recommendation 4
We recommend that a robust and clear process for communicating with GPs should be devised, in consultation with primary care colleagues and implemented as swiftly as possible so that the management of patients who are temporarily registered with a GP or do not have a GP can be improved.
Oxford Health NHS Foundation Trust
Oxford Health NHS Foundation …
Liverpool — recommendation A1.2
Emergency Department to review process for communicating with GPs particularly around patients who leave the department before their treatment has been concluded.
St Helens & Knowsley Teaching Hospitals …
Mersey and West Lancashire …
Tendring — recommendation 3
The GP surgery should recognise their role and responsibility in relation to the case management of patients with dementia and those with complex needs.
Anglian Community Enterprise
Anglian Community Enterprise
New Forest — recommendation 1
The General Practices referred to in this Review, with the support of the CCG and NHS England where appropriate, to ensure that frequent attenders are identified and flagged, and develop of a set of options to be considered when a frequent attender is identified. Options could include the patient seeing …
General Practices | West Hampshire Clinical …
NHS England
Kirklees — recommendation 10
To ensure that Locala clinicians and Lifeline staff have access to an up to date list of walk-in centres in Kirklees so they can identify when patients access NHS services as opposed to the services of their regular General Practitioner.
Locala | Lifeline
Gwynedd — recommendation 8
Future revisions to the protocol to include general practitioners as consultees / representation as a member of the working group.
CMHT | General Practice
Dental Practice Board
Gwynedd — recommendation 7
General Practice to understand the mechanisms used by CMHT to assess GP referrals to them in the knowledge of the protocol and key sections.
General Practice
Stoke-on-Trent — recommendation UHNM_R5
Where a patient discloses Domestic Abuse the discharge letter to the GP will reflect the level of abuse and any actions taken.
University Hospitals of North Midlands NHS …
University Hospitals of North …
Huntingdonshire — recommendation 3
That CPFT and the CCG work together to ensure that all GP surgeries have absolute clarity over referral routes and the terminology to be used when prioritising cases.
CPFT | Cambridgeshire and Peterborough ICB
Cambridgeshire and Peterborough NHS …
Central Bedfordshire — recommendation 13
Bedfordshire CCG to work with GPs to monitor the impact of the changes to the discharge notifications from local hospitals and ensure that this GPs take follow up action if required.
Bedfordshire Clinical Commissioning Group
Bedfordshire Clinical Commissioning Group
Doncaster — recommendation 1
The partnership should explore ways of improving the care received by looked after children under 18 when there is evidence of non-attendance and who at times are not registered with a GP or/and dentist.
Safer Doncaster Community Safety Partnership
Middlesbrough — recommendation 19.16
GPs to input into the frequent attenders at Emergency Departments.
South Tees Clinical Commissioning Group
Cornwall — recommendation 8
We recommend that a process and protocol be put in place to guide practitioners and managers about how best to ensure continuity of care provisions, most notably, continuity of worker. Recognising the constraints of workforce capacity and workload, it is nevertheless important to place emphasis on the need to provide …
NHS Kernow | Cornwall Foundation Partnership …
NHS Kernow