GP oversight of specialist care
GPs lacking internal systems and a clear monitoring role to assess the quality and outcomes of specialist services.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
Committee recommendation
83match
#3 - 79th Report - Supporting people with frailty outside hospitals
NHS England’s existing oversight arrangements are not improving GPs’ assessment and support of people with frailty. It is not clear exactly who is responsible for improving performance. NHSE considers that ICBs are responsible for commissioning services to meet the needs of their population; and that the service providers must ensure that the services they are commissioned to provide...
Matched on
terms: care, oversight
Inquiry recommendation
67match
IBI-6a(i) - Hepatologist Oversight and Fibroscan Access
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have been diagnosed with cirrhosis at any point should receive lifetime monitoring by way of six-monthly fibroscans and annual clinical review, either nurse-led, consultant-led or, where appropriate, by a GP with a specialist interest in hepatitis
Matched on
terms: care, oversight, specialist
Inquiry recommendation
66match
F123 - Responsibility for monitoring delivery of standards and quality
GPs need to undertake a monitoring role on behalf of their patients who receive acute hospital and other specialist services. They should be an independent, professionally qualified check on the quality of service, in particular in relation to an assessment of outcomes. They need to have internal systems enabling them to be aware of patterns of concern, so...
Matched on
terms: specialist
PFD report
65match
Patricia McAdam
The coroner identified a lack of a robust system to ensure regular assessment of patients who decline contact or care from healthcare providers but continue to receive repeat prescriptions.
Matched on
terms: care
Committee recommendation
62match
#17 - Forty-Fourth Report - NHS backlogs and waiting times in England
We asked about how patients other than the longest waiters and those with the highest clinical priority would be supported while they waited. NHSE&I stated that GPs had a role in managing these patients and that it was also asking secondary care clinicians to ensure patients were clearly informed about their position on waiting lists. NHSE&I explained that...
Matched on
terms: care
PFD report
61match
Michael Uriely
The care management for chronic asthma lacked coordination, long-term planning, and adherence to clinical guidelines. Concerns also included insufficient communication between primary and secondary care, and a failure to refer to a tertiary respiratory service.
Matched on
terms: care
PFD report
61match
Stuart Campbell
The coroner noted that an escalation policy between ADS and Pennine Care was not followed, and ADS workers lacked clear guidance and clinical support. There were also concerns regarding the documentation and facilitation of shared care discussions, especially as the GP had not seen the deceased.
Matched on
terms: care
PFD report
61match
Nathan Cooke
The coroner noted the absence of a formal process for primary care practices to manage patients prescribed medication requiring regular monitoring, particularly when patients do not attend reviews.
Matched on
terms: care
PFD report
61match
Graham Earl
The coroner noted GPs' insufficient understanding of a medication's link to pulmonary fibrosis and their lack of awareness regarding escalation procedures for side effects. Additionally, a GP amended a secondary care prescription without consulting the prescribing physician.
Matched on
terms: care
PFD report
61match
Sharon Reeve
The coroner noted a lack of clear pathways for district general hospital radiologists to obtain direct specialist neuroradiological opinions, leading to inappropriate referrals. Suboptimal communication between the hospitals further delayed accurate diagnosis due to unclear questions, incomplete information, and slow image transfer.
Matched on
terms: specialist
PFD report
61match
Joanna Flynn
The coroner identified a lack of specialised assistance and referral agencies for General Practitioners to help patients wean off addictive prescription opiates. Concerns were also raised about the sufficiency of training and education for GPs in this area of care.
Matched on
terms: care
PFD report
61match
Darren King
The coroner identified gaps in effective follow-up for high-risk patients with learning disabilities who disengage, and a lack of clear escalation processes. A missing structured medication review in care plans also limited staff awareness of compliance and referral routes.
Matched on
terms: care
PFD report
61match
Sam Pringle
The coroner noted that some psychiatrists ask GPs to instigate Lithium prescriptions, contravening the shared care protocol. This practice leads to delays or non-provision of essential medication for mentally ill patients.
Matched on
terms: care
PPO recommendation
61match
The Head of Healthcare
The Head of Healthcare should ensure that GPs conduct a full, documented clinical assessment, in line with relevant guidance, to inform medication reviews and changes.
Matched on
terms: care
PFD report
57match
Jacqueline Allwood
The coroner identified concerns regarding the absence of an agreed protocol for managing calf pain and suspected DVT at the Urgent Care Centre. Additionally, questions were raised about a specific GP's understanding and acceptance of normative diagnostic standards and the adequacy of practice changes.
Matched on
terms: care
PFD report
57match
Phyllis Barnes
The coroner noted a visiting GP did not fully appreciate the patient's serious post-operative condition, and a nurse-led telephone consultation appeared superficial. Additionally, there was no formal opportunity for the patient's daughter to relay her mother's condition to healthcare providers.
Matched on
terms: care
PFD report
57match
Aimee Varney
The coroner noted that the NICE Guidelines for referring a patient with suspected epilepsy to a Specialist Tertiary Centre were not followed.
Matched on
terms: specialist
PFD report
57match
Sadik Miah
The coroner identified a lack of regular consultant physician input for inpatients with physical health problems in psychiatric settings, which led to delays in obtaining specialist medical opinions for conditions such as hyponatraemia.
Matched on
terms: specialist
PFD report
57match
Mary Marshall
The coroner identified a lack of awareness among healthcare practitioners, especially General Practitioners, regarding the significance of GDH positive results for Clostridium Difficile risk and future antibiotic prescriptions. Concerns were also raised about the absence of consistent procedures in hospitals nationwide for communicating these results to primary care providers.
Matched on
terms: care
PFD report
57match
Violet Nelson
The coroner noted insufficient oversight by consultant radiologists for ultrasonography reports and a potential lack of awareness among general practitioners regarding the implications of supra-renal aortic aneurysm findings for thoracic aortic aneurysms.
Matched on
terms: oversight
PFD report
57match
Keith Harwood
The coroner is concerned that medical staff may lack access to urgent specialist advice when faced with unfamiliar conditions, potentially leading to families needing to educate staff about their condition's implications.
Matched on
terms: specialist
PFD report
57match
Stuart Clarke
The coroner noted the absence of national guidelines for referring patients with known valve disease from primary to secondary care, or secondary to tertiary care.
Matched on
terms: care
PFD report
57match
Jake Perry
Variations in parenteral nutrition management and communication were identified for patients with medical conditions overseen by other hospitals. The coroner noted the need for a named local consultant and for specialist departments to be consulted upon admission.
Matched on
terms: specialist
PFD report
57match
Rory Attwood
The coroner noted that the patient's General Practitioner was not involved in the serious untoward incident investigation, despite the patient being under community care. This raised concerns about learning opportunities and better partnership working in such reviews.
Matched on
terms: care
Committee recommendation
56match
#15 - GP advice and guidance scheme demonstrates significant growth in specialist input
NHSE said that it had made progress in some areas, partly where necessity during the Covid 19 pandemic had driven the adoption of technology. NHSE highlighted the advice and guidance scheme, which allows GPs to request specialist input without going through a full referral. This scheme had seen continued growth with 1.1 million requests expected to go through...
Matched on
terms: specialist
Committee recommendation
56match
#4 - 79th Report - Supporting people with frailty outside hospitals
NHS England has overloaded GPs, who have limited capacity, with new and expanding priorities. NHSE has prioritised improving patients’ access and digital access to general practice. It recognises that pushing to improve one aspect of care inevitably causes consequences to appear elsewhere, in this case, support for people with frailty.NHSE is looking at interventions that could be done...
Matched on
terms: care
PFD report
53match
Lisa Webb
The coroner raised concerns about a general practitioner's suboptimal asthma management, citing insufficient respiratory assessment and monitoring. Additionally, the prescription of Diazepam for anxiety was noted as poor treatment, especially with sleep apnoea or respiratory distress.
Matched on
classifier match
PFD report
53match
Paul Hyde
Concerns were raised regarding the advice provided by Community Mental Health Services to a GP, who sought guidance on a patient's deteriorating condition, to re-refer the patient to the Assessment and Treatment Service.
Matched on
classifier match
PPO recommendation
53match
The Head of Healthcare and the Lead GP (HMP Oakwood)
The Head of Healthcare and the Lead GP should review the terms of reference of the multi-professional complex case clinic/conference (MPCCC) process to ensure that: • crucial information is appropriately reviewed and shared at meetings, and • patients receive continuity of care.
Matched on
terms: care
PHSO casework decision
53match
P-001511 - A healthcare provider in the Nottingham area
Mr D complained about a delayed urgent dermatology appointment due to an administrative error and a consultant prescribing medication for vasculitis without prior examination or biopsy.
Matched on
terms: care
Inquiry recommendation
52match
18 - Role of general practitioners
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.
Matched on
terms: specialist
Inquiry recommendation
51match
IBI-6a(ii) - Specialist Hepatology Centre Access
All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have fibrosis should receive the same care
Matched on
terms: care, specialist
LGO / SPSO decision
50match
PSOW-202401069 - Cardiff and Vale University Health Board
Miss C complained about the care and treatment she received from the Health Board, specifically; • Whether the Commissioning Team appropriately considered requests received on her behalf between 2022 and 2023 • Whether it was clinically appropriate that she was repatriated to the Spinal Team in June 2022 and whether this decision was communicated to her appropriately and...
Matched on
terms: care, specialist
PFD report
49match
Amna Umer Ahmed
The coroner noted a potential low awareness of Sudden Arrhythmic Death (SAD) in general practice, alongside an apparent lack of, or awareness of, guidelines for GPs regarding urgent referrals for patients vulnerable to SAD.
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classifier match
PFD report
49match
Jonathan Thorpe
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.
Matched on
classifier match
PFD report
49match
Lucy Goulding
Concerns were raised regarding the lack of consultant supervision for on-call paediatric trainees admitting emergency patients and the absence of independent consultant assessment for paediatric admissions at Worthing Hospital. The report also noted a lack of national guidelines for assessing and investigating headaches in children.
Matched on
classifier match
PFD report
49match
Yuki Ivy Norman-Knight
The coroner identified concerns regarding St Stephens Gate Medical Practice's systems for practice nurses to access patient medical history, a lack of guidelines for nurses to refer patients to doctors, and no triggers for receptionists to book doctor's appointments, particularly for young children or babies.
Matched on
classifier match
PFD report
49match
Michael Tarratt
The coroner raised concerns about the infrequent communication between the Drug and Alcohol team and the GP, and the lack of routine information exchange between services regarding patient prescriptions.
Matched on
classifier match
PFD report
49match
Brian Francis
Concerns were raised about the reliability of a 'tick in the box' system for consultant attendance and the impact of unavailable community medical records at the time of hospital admission.
Matched on
classifier match
PFD report
49match
Jorge Castro
The coroner noted a lack of systems at Springfield Medical Centre to identify uncollected prescriptions, particularly for vulnerable patients needing anti-epileptic medication. This meant General Practitioners were not alerted when the patient did not collect vital medication, despite prior consultant concerns about adherence.
Matched on
classifier match
PFD report
49match
Grant Richards
The coroner noted the GP surgery's failure to action a recommended chest clinic follow-up from an A&E discharge summary, alongside a lack of contingency systems and poor attention to documents, including faxes from mental health agencies.
Matched on
classifier match
PFD report
49match
Jamie Elliott
The coroner raised concerns that mental health clinicians did not contact external providers when a patient was receiving treatment elsewhere, and that a worsened patient's condition did not trigger a prompt consultant psychiatric assessment.
Matched on
classifier match
PFD report
49match
Michael Halfpenny
The coroner raised concerns about a GP's incorrect referral for vascular screening and a lack of a hospital system to direct such requests, leading to refusal. Issues also included GP uncertainty regarding the screening programme criteria.
Matched on
classifier match
PFD report
49match
Rita Taylor
The coroner identified failures in the appropriate management of hyponatraemia, including a lack of adherence to national guidelines for treatment and monitoring serum sodium levels. Concerns were also raised about inadequate medical planning, poor documentation, and an insufficient understanding of hyponatraemia management by some consultants.
Matched on
classifier match
PFD report
49match
Michelle Roach
The coroner identified a need for a GP to review knowledge of venous thromboembolism signs and symptoms and record-keeping practices, and for the practice to improve its system for investigating unexpected deaths. Concerns were also raised regarding the hospital trust's level of medical registrar cover at night.
Matched on
classifier match
PFD report
49match
Sylvia Mitchell
The coroner identified inadequate communication between the Trust and GP advising on the urgent removal of a pessary. Concerns were also raised regarding insufficient follow-up, routine cleansing, and monitoring of vaginal integrity during pessary use.
Matched on
classifier match
PFD report
49match
Miriam Tighe
The coroner noted a lack of awareness between GPs and a psychiatrist regarding medication decisions, leading to continued prescribing of a drug after it was advised to be stopped, and subsequent over-sedation.
Matched on
classifier match
PFD report
49match
Brenda Drew
The coroner noted a lack of formal GP review for repeat Oramorph prescriptions and raised concerns that pharmacists requested repeat medications from GPs without confirming the patient's wishes.
Matched on
classifier match
PHSO casework decision
48match
P-002632 - Royal Devon University Healthcare NHS Foundation Trust
Mr H complained the Trust's paediatrician mismanaged his grandson's medication and lacked leadership, causing his mental health to deteriorate.
Matched on
terms: care
PHSO casework decision
48match
P-002594 - Imperial College Healthcare NHS Trust
Mr E complained the Trust wrongly stopped his ambulatory oxygen prescription in February 2023, causing low oxygen saturation, restricted activity, and potential organ damage.
Matched on
terms: care