GP oversight of specialist care
GPs lacking internal systems and a clear monitoring role to assess the quality and outcomes of specialist services.
Source spread
Where this theme appears
This theme appears across 7 independent accountability sources, so the source mix matters as much as the headline total.
7 inquiry recs
91 PFD reports
11 committee recs
4 CQC actions
8 PPO recs
69 PHSO decisions
12 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(7)
F123 — Responsibility for monitoring delivery of standards and quality
Recommendation: 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 …
Gov response: The government published "Hard Truths: the Journey to Putting Patients First" (Cm 8777) on 19 November 2013, responding to all 290 recommendations of the Francis Report. This followed an initial response "Patients First and Foremost" …
Accepted
IBI-6a(vi) — Commissioning Hepatology Services
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those bodies responsible for commissioning hepatology services in each of the home nations should publish the steps they have taken to satisfy …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
IBI-6a(v) — Consultant Hepatologist Access
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Those who have had Hepatitis C which is attributable to infected blood or blood products should be seen by a consultant hepatologist, …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
IBI-6a(iv) — Fibroscan for Liver Imaging
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Fibroscan technology should be used for liver imaging, rather than alternatives
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
IBI-6a(iii) — Uncertainty About Fibrosis
Recommendation: All patients who have contracted hepatitis via a blood transfusion or blood products should receive the following care: Where there is any uncertainty about whether a patient has fibrosis they should receive the same care
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
IBI-6a(ii) — Specialist Hepatology Centre Access
Recommendation: 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
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted in Part
IBI-6a(i) — Hepatologist Oversight and Fibroscan Access
Recommendation: 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 …
Gov response: UK Government We accept this recommendation but will balance its implementation against NHS England’s role to promote equitable access for all, the principle that patients should receive the same treatment irrespective of how the disease …
Accepted
Prevention of Future Deaths reports(91)— showing 50 strongest matches
Amna Umer Ahmed
Concerns: Low awareness of Sudden Arrhythmic Death (SAD) among GPs and a lack of clear guidelines for urgent referral of at-risk patients contribute to missed diagnoses.
Response (Royal College of General Practitioners): The Royal College of General Practitioners acknowledges the concerns, describes its role in GP training and standards, and references existing curriculum and resources related to cardiovascular disease and sudden adult …
Overdue
Jonathan Thorpe
Concerns: A GP failed to consult or refer a known self-harmer to Mental Health Services, prescribing medication without adequate assessment of his ongoing mental health needs.
Overdue
Lucy Goulding
Concerns: There was insufficient consultant supervision and independent assessment for emergency paediatric admissions. A lack of national guidelines for assessing headaches in children was also identified.
Response (Womens Childrens Division): The Trust strengthened consultant involvement in shift handovers, including direct supervision of the afternoon handover and telephone contact with the night team. They will audit handover practices in June 2014, …
Overdue
Jacqueline Allwood
Concerns: The urgent care center lacked an agreed protocol for DVT management, and a consulting GP failed to meet normative practice standards for diagnosis, risking future missed DVT cases.
Response (NHS England): NHS England has requested that the GP in question undertake a reflective report, attend a course on medical record keeping, and complete an audit of his medical record keeping, with …
Overdue
Yuki Ivy Norman-Knight
Concerns: Concerns include fragmented patient record access, lack of clear guidelines for practice nurse referrals to doctors, and insufficient triggers for receptionists to book doctor appointments for young children and babies.
Response (St Stephens Gate): St Stephens Gate has reviewed and reinforced the need for all clinicians to check patient past clinical history at each appointment. They are arranging laminated copies of the NICE Traffic …
Responded
Michael Tarratt
Concerns: There was an unacceptable 18-month lapse in communication between the drug and alcohol team and the GP. Services failed to exchange information on inappropriate prescriptions for an opiate-dependent patient.
Response (Leicestershire Partnership NHS Trust): An urgent memo was sent to the Drug & Alcohol team regarding GP communication standards (minimum every 3 months). Standard GP letter templates have been reviewed to ensure detailed updates …
Responded
Phyllis Barnes
Concerns: A visiting GP failed to recognise the seriousness of the patient's condition. Post-operative telephone follow-ups were inadequate, and there was no effective communication channel for family concerns.
Overdue
Rosemary Oladejo
Concerns: A critical lack of communication between the GP and responsible clinician led to unauthorized and unrecorded changes in the patient's medication, including incorrect dosing and administration times for amitriptyline.
Response (Hillingdon Commissioning Group): Hillingdon CCG will review current processes for recording and communicating medication information by August 2014. They will discuss the possibility of developing one standard letter/form for use across all sectors …
Response (Central North West London NHS Trust): Central North West London NHS Trust will circulate a Clinical Risk Alert referencing this case in an anonymised form in the next few weeks to remind staff of the importance …
Responded
Lisa Webb
Concerns: Sub-optimal asthma management by the GP involved failure to assess asthma history, unrecorded vital signs, lack of objective measurements (peak flow/oximetry), and an inappropriate Diazepam prescription.
Response (Basildon Road Surgery): The GP now ensures that during consultations with significant problems, they check past reviews and previous consultations. They also check to see if any reviews are outstanding, and either complete …
Overdue
Aimee Varney
Concerns: NICE Guidelines for referring patients with suspected epilepsy to a Specialist Tertiary Centre were not followed, risking delayed or inappropriate specialized care.
Response (Luton Dunstable University Hospital): Luton and Dunstable University Hospital are commissioning a further report from an independent general neurologist to assess whether the individual clinician's practice regarding NICE guidelines on epilepsy referrals fell outside …
Responded
Sadik Miah
Concerns: Inadequate physical health monitoring for psychiatric inpatients, including inconsistent ECG review for antipsychotic risks and significant delays for urgent non-emergency medical opinions, creates ongoing patient safety risks.
Overdue
Paul Hyde
Concerns: Concerns arose regarding the effectiveness and timeliness of the mental health referral pathway for a patient with a deteriorating condition, despite anxieties being raised by community mental health workers.
Response (Sussex Partnership NHS): The trust recruited an additional administrator to the Triage team. GPs have been allocated named Consultant Psychiatrists and meetings have been arranged. Mr. Hyde's experience has been shared (anonymously) with …
Overdue
Phyllis Barlow
Concerns: Widespread ignorance among GP practices of NICE guidelines means patients on warfarin with head injuries are not being admitted to hospital for CT scans as required.
Response (NHS Wales): Welsh Government officials are developing a Patient Safety Notice to raise awareness of NICE guideline 176 regarding head injuries in patients on warfarin, which will be issued to all local …
Responded
Brian Francis
Concerns: A flawed consultant attendance logging system meant a patient was not reviewed. Lack of access to community medical records at admission delayed critical anti-coagulation therapy.
Response: The Health Board provided an action plan prior to the inquest and has updated it in response to concerns. Actions include enhanced senior clinician review of emergency medical patients, reinforced …
Overdue
Mary Marshall
Concerns: A general lack of awareness among hospital staff and GPs about the importance of GDH positive results, which indicate Clostridium Difficile vulnerability, risks inappropriate antibiotic prescribing.
Response (Department of Health1): NHS England will work with partners to explore ways to develop a wider understanding of C. diff testing and the implications of the results, including GDH testing. NHS England will …
Responded
Jorge Castro
Concerns: A vulnerable patient missed crucial anti-epileptic medication due to uncollected prescriptions, which GPs failed to review during multiple consultations. The surgery lacked a system to highlight uncollected prescriptions, especially for dependent patients.
Response (Springfield Medical Centre): Springfield Medical Centre has implemented an alert system in patient records for compliance issues, amended the IT system to highlight overdue prescriptions, created a register of patients on weekly prescriptions, …
Responded
Michael Uriely
Concerns: Inadequate chronic asthma management, lack of coordinated care, and poor inter-service communication led to a failure to follow guidelines and recognise deteriorating patient condition.
Response (Uriely): NHS England will share learning and support tools developed by the Healthy London Partnership, communicate up-to-date asthma guidelines to CCGs and GPs, and explore commissioning mechanisms to incentivise improved commissioning …
Response (Uriely Response2): NICE has produced a quality standard on asthma and is developing further guidelines on diagnosis, monitoring and management of asthma, to be published in October 2017, which will inform updates …
Overdue
Grant Richards
Concerns: The GP surgery failed to act on A&E follow-up recommendations and mental health team faxed documents, revealing systemic management control issues and a lack of suitable procedures for processing critical patient information.
Overdue
Jamie Elliott
Concerns: Mental health clinicians failed to contact external providers when patients received treatment elsewhere. There was also a lack of timely, face-to-face consultant psychiatric assessments for patients with worsening conditions, despite identified concerns.
Response (East London NHS Trust): The Trust distributed a memo to clinical staff in City and Hackney regarding contact with external providers. A policy has been updated to include referrals to the Home Treatment team …
Responded
Michael Halfpenny
Concerns: A GP referral for vascular screening was sent to the wrong department and refused, with no follow-up. Both GP practice and hospital screening teams lacked awareness and proper systems for managing screening referrals.
Response (Glenfield Surgery): The surgery will raise the case as a discussion point in a practice meeting, make all doctors aware of self-referrals, and produce posters to put up in the waiting room …
Response (University Hospitals of Leicester NHS Trust): The Trust has reviewed the process for rejecting imaging referrals and is strengthening the relevant guideline to include a clear statement of why the rejection was made. A new system …
Response (East Leicestershire and Rutland Clincial Commisioning Group): The CCG has enclosed the signed final report regarding the Serious Incident investigation into this case and confirmed that they have contacted the family to share the report.
Responded
Dean Rowland
Concerns: Delays in accessing GP appointments for antidepressant review and premature discharge from community mental health services, despite previous serious suicide attempts, posed significant risks.
Response (South Staffordshire and Shropshire Healthcare): The Trust states that the CMHT conducted a sufficiently detailed assessment of Mr. Rowland's needs and appropriately discharged him, providing resources for future support and contact information.
Response (Peel Medical Practice): Peel Medical Practice has instituted a duty doctor and telephone triage system to improve access for patients needing appointments or telephone consultations sooner than routine appointments.
Responded
Violet Nelson
Concerns: Lack of consultant oversight for ultrasound reports and GPs' unawareness that supra-renal aortic aneurysms indicate larger thoracic aneurysms led to delayed diagnosis. Education and clearer report recommendations are needed.
Response (NHS Engalnd): NHS England will ensure that the NICE lead for the Abdominal Aortic Aneurysm guideline is aware of the coroner's concerns and will ensure the report is considered by the working …
Response (Royal College of General Practitioners): The RCGP agrees GPs are unlikely to be aware that a supra-renal aortic aneurysm should raise concerns about the possibility of a thoracic aortic aneurysm; they rely on secondary care …
Response (SoR): The Society of Radiographers will communicate to radiology services the need for sonographers to have clear processes for arranging onward referral.
Responded
Stuart Campbell
Concerns: Inadequate guidance and clinical support for ADS workers, coupled with a failure to follow escalation protocols and properly document shared care discussions, contributed to unmet patient needs.
Response (Addiction Dependency Solutions): ADS has re-negotiated with Pennine Care NHS Trust for clinical advice and supervision, and has commissioned Applied Suicide Intervention Skills Training (ASIST) for shared care staff.
Responded
Keith Harwood
Concerns: Medical professionals struggle to access urgent specialist advice for unfamiliar conditions despite Trust policies, potentially delaying appropriate care and requiring families to educate staff.
Response: The Trust will issue an internal alert reminding staff of the importance of timely management of patients with Parkinson's disease and timely referral to the Parkinson's Specialist Team and the …
Responded
John Worthington
Concerns: A&E made a borderline decision not to investigate a significant head injury, and the GP failed to take full observations for persistent back pain, delaying a pneumonia diagnosis.
Response (MDDUS): The doctor involved has reflected on the case and will be more aware of documenting a full set of observations and considering x-rays for older patients after trauma. She is …
Overdue
Rita Taylor
Concerns: Inadequate management of hyponatraemia, including a consultant's failure to seek expert advice and non-adherence to national guidelines, resulted in a lack of a coherent patient care plan.
Response (Epsom and St Helier University Hospitals NHS Trust): The Trust has revised its procedures and processes to ensure that all patients with hyponatraemia will have a clear treatment plan to correct their sodium in line with recognised guidance. …
Overdue
Daniel Young
Concerns: GP surgeries lack routine monitoring for psychiatric patients collecting antipsychotic medication, increasing the risk of relapse and harm to themselves or others.
Response (Department of Health Social Care): NHS England is developing a framework for community mental health services to improve joint working between primary and secondary services. They will also write to GP practices about monitoring antipsychotic …
Responded
Michelle Roach
Concerns: GP's knowledge of VTE symptoms and record-keeping were inadequate. The GP practice lacked a robust system for learning from unexpected deaths, and hospital night-time medical registrar cover was insufficient.
Overdue
Robin McEwan
Concerns: Disconnected communication between private therapy and GPs, lack of guidance on self-help resources, and insufficient involvement of family support for suicidal patients were identified.
Response (Harrogate CCG): The CCG will review the primary care referral process for private counselling, look at developing Mental Health & Psychological First Aid within Primary Care and the CCGs, and further develop …
Responded
Ursula Keogh
Concerns: Inconsistent and contradictory advice from GPs and schools regarding CAMHS referrals, exacerbated by a school lacking the necessary Psychology Team, highlighted poor communication between health and education professionals.
Response (Department of Health and Social Care): The Department of Health and Social Care highlights national initiatives like 'Future in Mind' and the Suicide Prevention Workplan. They also mention plans to set up 24/7 crisis care for …
Response (Calderdale CCG): Calderdale CCG and Calderdale Council have reviewed and revised processes and identified new actions related to CAMHS referrals and communication between professionals, overseen by the multi-agency Open Mind Partnership. Calderdale …
Responded
Sylvia Mitchell
Concerns: Inadequate communication between the Trust and GP regarding the urgent removal of a pessary, and insufficient follow-up for pessary use, led to heightened infection risks.
Response (Sandwell and West Birmingham NHS Trust): Every person attending for pessary insertion now receives an information leaflet. Processes have been amended to tighten follow up, including letters and offering a further appointment if there is no …
Response (Oaks Medical Centre): The GP provides a summary of the patient's medical history and care, noting cancelled appointments and home visits.
Response (Sandwell and West Birmingham Hospital NHS Trust): The hospital acknowledges the patient cancelled her appointment and asks the GP to inform them when she is ready to reschedule.
Responded
Megan Jones
Concerns: A lack of formal policy or protocol for GP surgeries to monitor patients prescribed Clozapine, specifically regarding QTc recording and when exceeding BNF limits, poses a safety risk.
Overdue
Nathan Cooke
Concerns: There's no robust system to manage patients prescribed medication requiring regular monitoring, potentially endangering welfare if they don't attend reviews.
Overdue
Miriam Tighe
Concerns: Lack of communication and awareness between GPs and psychiatrists led to unsafe, duplicate prescribing and over-sedation of a care home resident with conflicting medications.
Overdue
Graham Earl
Concerns: GPs lacked understanding of medication links to pulmonary fibrosis, failed to seek specialist guidance before amending prescriptions, and were unaware of side effect escalation procedures.
Overdue
Kaiya Campbell
Concerns: GP and midwifery staff failed to seek urgent neurology guidance for a high-risk epileptic mother on anticonvulsant medication, resulting in inadequate management of fetal abnormality risks.
Overdue
Sharon Reeve
Concerns: A lack of clear pathways for specialist referrals and suboptimal communication between hospitals led to inappropriate referrals, delayed diagnoses, and wasted time for complex cases.
Overdue
Stuart Clarke
Concerns: The lack of national guidelines for timely referral of patients with valve disease between primary, secondary, and tertiary care leads to significant patient deterioration before intervention.
Response (Department of Health and Social Care): The Department of Health and Social Care acknowledges the concerns and notes that NICE is developing a clinical guideline on heart valve disease in adults, while the Manchester University NHS …
Response (NHS Eng and NHS Imp): The Greater Manchester Cardiac Network will review how they can support and extend work at MFT to improve the heart care pathway for quicker diagnosis and treatment of patients requiring …
Response (National Institute for Health and Care Excellence): NICE references existing guidelines on chronic heart failure and notes the development of a clinical guideline on heart valve disease presenting in adults, which will consider referral indications, and the …
Response (BCIS): BCIS will contact its members to review local referral pathways for TAVI procedures to expedite treatment and prevent delays, and supports moves to ensure adequate capacity for TAVI candidates.
Overdue
Joanna Flynn
Concerns: There is a significant lack of specialised assistance, referral agencies, and adequate training for General Practitioners to help patients safely wean off addictive prescription opiates.
Response (NHS England): NHS England/Improvement acknowledges the need for national-level guidance and support, highlighting a review group established in response to the PHE review. They note the complexity of patients with addiction to …
Response (the Department of Health and Social Care): The Department of Health and Social Care highlights the PHE report on prescription drug dependence and the review of overprescribing led by Dr Keith Ridge. The Mid-Essex CCG will implement …
Response (Mid Essex CCG): Mid Essex CCG details plans for a Local Enhanced Service for substance misuse, joint guidance for de-prescribing, and a session on Opioids and Safe Prescribing at the CCG's Time to …
Overdue
Brenda McWilliams
Concerns: Medical practitioners failed to consistently prescribe VTE medication post-discharge, and an interpretation of NICE guidance may leave high-risk community patients unassessed and untreated, despite recognized serious risks.
Overdue
Brenda Drew
Concerns: The deceased received unrequested, repeat prescriptions for high-dose Oramorph. The GP surgery failed to formally review this potent medication for several months, raising concerns about prescribing oversight.
Response (RPS): The RPS highlights existing guidance for pharmacy teams covering prescription requests to GPs, published in 2015 and available on their website. They also updated and published a Prescribing Competency Framework …
Responded
Anita Loi
Concerns: Repeated GP and family referrals for leg wound management were unaddressed by community nursing teams, who also failed to engage in case review meetings, highlighting systemic referral and response failures.
Response (Central London Community Healthcare NHS Trust): Central London Community Healthcare NHS Trust outlines ten planned actions to improve communication and management of referrals between Tissue Viability Nurses and District Nurses, including establishing clearer processes for reviewing …
Responded
Darren King
Concerns: There was a lack of effective follow-up for high-risk patients with learning disabilities who disengage, an unclear escalation process for unaddressed risks, and no structured medication review within care plans.
Overdue
Jake Perry
Concerns: Issues include varied parenteral nutrition protocols and communication breakdowns. Patients with specialist conditions managed by other hospitals require a named local consultant and consultation with the overseeing hospital's specialist department upon admission.
Response (Birmingham Women and Childrens NHS Trust): Birmingham Women and Childrens NHS Trust has ensured that national guidance such as that the best practice guidance on Homecare medicines, issued in 2011 and known as ‘the Hackett Report’ …
Response (Wye Valley NHS Trust): The Trust has developed and implemented a standard operating procedure for both the medical and surgical divisions to ensure patients with medical conditions overseen by another hospital have a named …
Responded
Natasha Abrahart
Concerns: NICE guidelines for monitoring patients starting antidepressants, particularly those under 30 or at increased suicide risk, were not followed by the mental health trust or GP.
Response (AWP): The trust issued a "Red Top Alert" to medical personnel regarding NICE guidelines for prescribing anti-depressants (CG90), including communication with primary care and documentation. It will also be discussed at …
Response (University of Bristol): The University practice now books appointments to review patients starting SSRIs within one week, and clinicians ideally book the next appointment before the patient leaves, with a message to alert …
Response (the Department for Health and Social Care): The Department acknowledges the concerns and highlights existing guidelines and initiatives, including updated NICE guidelines on antidepressant prescription and various government-funded projects to improve student mental health support and reduce …
Responded
Patricia McAdam
Concerns: The GP practice lacked a system to regularly assess vulnerable patients who refused care, despite continuing repeat prescriptions, posing a risk that deteriorating conditions would go unaddressed.
Overdue
Sam Pringle
Concerns: Psychiatrists are circumventing shared care protocols by asking GPs to prescribe Lithium, causing delays or non-provision of this critical medication to mentally ill patients, with potentially fatal consequences.
Response (Greater Manchester Medicines Management Group NHS Stockport Clinical Commission Groupw): Stockport CCG, Pennine Care NHS Foundation Trust, and the Greater Manchester Medicines Management Group (GMMMG) are jointly reviewing shared care protocols, including Lithium, to prevent delays in prescribing. Proposed actions …
Responded
Katie Corrigan
Concerns: There is no national system for circulating patient alerts to pharmacies or GPs regarding inappropriate opiate prescriptions. This allowed the deceased to improperly obtain lethal quantities of medication.
Response (CQC): CQC has inspected registered online providers identified from the inquest and taken regulatory action where needed. They are investigating unregistered providers and are exploring ways to strengthen regulation of online …
Response (Dept of Health and Social Care): The Department of Health and Social Care is working with healthcare and professional regulators to strengthen the regulation of independent online prescribers. NHS England and Improvement are implementing recommendations from …
Responded
Andrew Biddlecombe
Concerns: The deceased was not advised about medical conditions impacting driving ability or the legal requirement to notify the DVLA, and the practice failed to inform the DVLA.
Response (Emsworth Surgery): Emsworth Surgery has reviewed templates for chronic disease reviews to ensure they include questions about driving status. They have written to patients on Epilepsy and Parkinson's registers to remind them …
Responded
Rory Attwood
Concerns: The patient fell between gaps in primary, acute, psychiatric, and social services. GPs are rarely involved in serious incident reviews, which limits learning and partnership working for community-supervised patients.
Response (Aneurin Bevan University Health Board): Aneurin Bevan University Health Board has reviewed its practices regarding GP involvement in Serious Incident Reviews and devised a process and pro forma to ensure GPs are invited to participate. …
Responded
Select committee recommendations(11)
#3 —
Recommendation: 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 …
Gov response: The government agrees with the Committee’s recommendation. the public and support them to make green choices. This includes ensuring that green choices are affordable and easier to make. In summer 2022 government launched a comprehensive …
Response Pending
#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 …
Gov response: The government agrees with the Committee’s recommendation. ensuring the whole of government works effectively to achieve it. The government has established arrangements for coordinating the main departments including the Domestic and Economic Affairs (Energy, Climate …
Response Pending
#14 —
Recommendation: NHSE&I was not responsible for managing any local variations and did not challenge local clinical decisions.28 DHSC has told us that NHSE&I and NHS Digital considered that ultimately additions were a decision for local clinicians. It noted that the approach …
Gov response: 3: PAC conclusion: Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. 3: PAC recommendation: Within …
Accepted
#3 —
Recommendation: Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. As well as NHS Digital using national data to identify clinically vulnerable …
Gov response: agree with the conclusion that there was huge local variation. NHS Digital and DHSC have already written to the Committee with an initial analysis of the local variation in growth of the Shielded Patient List …
Under Consideration
#17 —
Recommendation: 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 …
Gov response: 4.1 The government agrees with the Committee’s recommendation. Target implementation date Spring 2023 4.2 Delivery of the Elective Recovery Plan, and the initiatives deployed to achieve it, will be closely monitored by both the department …
Accepted
#15 —
Recommendation: NHS Digital told us that for the people whom it had identified and added centrally to the list, in line with the clinical criteria set by the chief medical officers, there is very little variation by area.30 DHSC acknowledged that …
Gov response: 3: PAC conclusion: Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. 3: PAC recommendation: Within …
Accepted
#83 —
Recommendation: If a review concludes that it is inadvisable to make GPs’ engagement with the firearms licensing process mandatory, we recommend that statutory guidance emphasise the strong expectation that GPs who object conscientiously to engaging with the firearms licensing process will …
Gov response: The GP role in firearms licensing The Committee made recommendations for changes to the GP role in firearms licensing, specifically around the GP medical marker, making their role mandatory in the process and their involvement …
Under Consideration
#15 — GP advice and guidance scheme demonstrates significant growth in specialist input
Recommendation: 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 …
Gov response: 3.1 The government agrees with the Committee’s recommendation. Target implementation date: October 2026 3.2 Both NHSE and DHSC recognise the importance of incorporating monitoring and evaluation from the outset of policy development, supported by a …
Accepted
#13 —
Recommendation: NHSE&I asked GPs and hospital doctors to add or remove people from the list, based on their clinical judgement, and as their patients’ conditions or treatments changed over time.26 However, the extent to which the list grew between 12 April …
Gov response: 3: PAC conclusion: Huge local variation strongly suggests that GPs were inconsistent when judging who was clinically extremely vulnerable and should therefore be advised to shield and be eligible for support. 3: PAC recommendation: Within …
Accepted
#11 —
Recommendation: As well as NHS Digital using patient data to add people to the shielding list, GPs and hospital doctors were asked to review the list and use their clinical judgement to add or remove people. GP and hospital doctors’ additions …
Gov response: 2.2 Whilst the government agrees with the Committee’s recommendation, it does not agree with the conclusion that DHSC and NHS Digital took too long to identify all clinically extremely vulnerable people. Given the data available …
Not Accepted
#73 —
Recommendation: GPs’ involvement is key to the firearms licensing process. For example, Superintendent Steven Duncan, Head of National Firearms and Explosives Licensing for Police Scotland, told us: “We are quite clear that if your GP practice is not willing to put …
Gov response: The Committee made recommendations for changes to the GP role in firearms licensing, specifically around the GP medical marker, making their role mandatory in the process and their involvement in suggested interim checks during the …
Under Consideration
CQC inspection actions(4)
Charlton House Medical Centre
Although the practice had introduced a formal programme of clinical meetings there was no evidence of links with multidisciplinary teams to adequately review treatment and monitoring of patients with complex medical issues this continued to place patients at risk of …
Must Do
Gillmoss Medical Centre
Continuetoundertakemedicationreviewsforpatientsprescribedrepeatmedicines.
Should Do
Reside at Southwood
people's nutrition and hydration needs were not being met. Advice from health care professionals was not always sought or followed up, to ensure people received care in a safe way.
Must Do
Oakleigh House Nursing Home
The care and treatment of service users did not always meet their medical needs appropriately, by discussing the service users' treatment choices with a competent health care professional or other competent person to manage the service users care and treatment. …
Must Do
PPO death in custody recommendations(8)
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 …
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.
The Head of Healthcare
The Head of Healthcare should ensure that patients with long-term conditions undergo reviews and receive treatment as outlined in NICE guidelines.
The Head of Healthcare
The Head of Healthcare should ensure that long-term conditions, such as diabetes, are managed in line with national guidance.
The Head of Healthcare
The Head of Healthcare should ensure that specialist advice is sought to manage long-term conditions such as diabetes.
The Head of Healthcare
The Head of Healthcare should review the GP triage process to ensure prisoners are placed on the correct waitlist depending on their need.
The Head of Healthcare and the provider’s Lead GP (HMP …
The Head of Healthcare and the provider’s Lead GP must be assured that all staff are fully aware of the local operating procedure related to “GP referrals to hospital” and that this is followed at all times.
The Head of Healthcare
The Head of Healthcare should ensure that: • newly arrived prisoners are seen by a GP if they are referred for a GP assessment; and • if a prisoner is not seen, the GP records the reason in the prisoner’s …
PHSO casework decisions(69)
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.
NHS in England
Partly Upheld
Jul 2022
P-002669 — A practice in the Suffolk area (the Surgery)
Mrs A complained multiple NHS organisations provided inadequate care to her late mother, including delayed cancer treatment, poor follow-up, and communication failures.
NHS in England
Jun 2024
P-003710 — A practice in the Croydon area
Mr F complained the Practice failed to communicate blood pressure test results and delayed GP appointments following a lung health check and cardiology letter, causing distress.
NHS in England
Jul 2025
P-003932 — A practice in the Exeter area
Miss B complained the Practice failed to arrange timely specialist support for her mother, and a GP was unprofessional and rude. She also complained about the Practice's poor complaint handling.
NHS in England
Partly Upheld
Sep 2025
P-004074 — A practice in the West Berkshire area
Mrs H complained her brother's GP failed to monitor his Atorvastatin use and blood pressure, and did not refer him for persistent UTIs, contributing to his death.
NHS in England
Sep 2025
P-004272 — A practice in the Cotswold area
Mr M complained his GP failed to refer him for a hip replacement in November 2022, leading to prolonged pain and financial hardship from private treatment.
NHS in England
Nov 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-004309 — Manchester University NHS Foundation Trust
Miss N complained a podiatrist failed to see her father in person or properly check his condition, leading to early discharge and delayed care, which she believes contributed to his death.
NHS in England
Nov 2025
P-004721 — A practice in the Stratford-on-Avon area
Mrs A claimed GPs failed to consider and refer her for ADHD diagnosis, inappropriately managed anxiety, and provided ineffective referrals, causing delayed diagnosis and prolonged symptoms.
NHS in England
Jan 2026
P-004722 — Wirral University Teaching Hospital NHS Foundation Trust
Mr F complained the Trust wrongly decided he was ineligible for an insulin pump, arguing he meets the criteria due to his inability to self-inject and reliance on family support.
NHS in England
Jan 2026
P-001347 — NHS Devon Clinical Commissioning Group
Miss T complained about delayed GP referrals by NHS Devon CCG, a hospital declining a rheumatology appointment, and the CCG refusing to address complaints older than a year.
NHS in England
Mar 2022
P-001320 — Barts Health NHS Trust
Ms U complained about inadequate care for a skin condition, unnecessary antidepressant prescription, and significant delays by Barts Health NHS Trust in handling her complaint.
NHS in England
Mar 2022
P-001605 — A medical practice in the Cambridgeshire area
Mrs P complained the GP failed to refer Mr P to the neurological rehabilitation team for Botox injections, causing a significant delay and severe deterioration of his arm.
NHS in England
Nov 2022
P-001765 — Mid Yorkshire Hospitals NHS Trust
Ms G complained the Trust missed a meningioma on a 2017 MRI scan and failed to arrange follow-up, leading to its growth and requiring urgent surgery in 2021.
NHS in England
Jan 2023
P-001698 — The Royal Wolverhampton NHS Trust
Mrs O complained a locum consultant mismanaged her mother's treatment and The Royal Wolverhampton NHS Trust failed to implement Root Cause Analysis report recommendations.
NHS in England
Partly Upheld
Jan 2023
P-001739 — A practice in the Worcestershire area
Mrs O complained her son's GP dismissed health concerns and mishandled blood tests, delaying his severe haemophilia A diagnosis, affecting treatment and subsequent family planning.
NHS in England
Jan 2023
P-001699 — A practice in the Lancashire area
Miss B complained her uncle's GP practice failed to properly assess and diagnose his condition, made an incorrect ambulance request, and mishandled her complaint.
NHS in England
Jan 2023
P-001718 — A GP practice in the Gateshead area
Mrs R alleged her GP practice failed to conduct a face-to-face assessment or hospital referral for her husband's serious symptoms, leading to his death from cardiac arrest.
NHS in England
Jan 2023
P-001839 — A practice in the Hertfordshire area
Mrs I alleged an out-of-hours GP missed diagnosing her mother's perforated colon, peritonitis, and sepsis due to inappropriate conduct and incomplete examination, leading to her death.
NHS in England
Jan 2023
P-001700 — University Hospitals Birmingham NHS Foundation Trust
Clinicians at the Trust did not take Mrs I's endometriosis seriously, delayed treatment, and advised her to 'persevere', causing ongoing pain and affecting potential fertility.
NHS in England
Jan 2023
P-001728 — A practice in the Liverpool area
The Practice misdiagnosed Mrs A with plantar fasciitis, offered inappropriate pain treatment, and refused referrals until private treatment was sought, causing pain and anxiety.
NHS in England
Jan 2023
P-001878 — The Newcastle Upon Tyne Hospitals NHS Foundation Trust
Mrs B complained the Trust did not recommend a stomach-lining medication with her anti-inflammatory drugs, causing an ulcer. She also alleged delayed treatment for her arthritis.
NHS in England
Mar 2023
P-003897 — A GP practice in the Wirral area
Ms E alleged misdiagnosis of her skin condition, inappropriate treatments, and delayed dermatology referral by GPs, causing suffering and financial strain.
NHS in England
Sep 2023
P-002260 — A GP practice in the Cornwall area
A patient complained a GP practice refused a urology referral and a GP used inappropriate language in her records, causing pain, bladder weakness, and distress.
NHS in England
Oct 2023
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.
NHS in England
May 2024
P-002599 — A practice in the Wigan area
Mr E complained the Practice failed to assess his father's severe pain and weight loss, leading to a delayed cancer diagnosis and death. Complaint handling was also poor.
NHS in England
Upheld
May 2024
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.
NHS in England
May 2024
P-002761 — A practice in the Hackney area
Miss P complained the Practice abruptly stopped her mother's medication without review, and then lied in its complaint response, which she believes led to her mother's death.
NHS in England
Jul 2024
P-002812 — A practice in the Oldham area
Mr O complained the Practice cancelled his monthly prescription, leaving him without medication for five days, which caused severe pain, asthma attacks, and suicidal thoughts.
NHS in England
Not Upheld
Jul 2024
P-002838 — A practice in the North West London area
Miss A complained about inadequate care for her mother's chesty cough and poor communication, leading to delayed diagnosis of pneumonia and lung cancer.
NHS in England
Aug 2024
P-002883 — A practice in the Solihull area
Miss A complained the Practice failed to identify her breast cancer or refer her for relevant tests, despite her feeling a lump.
NHS in England
Aug 2024
P-002896 — A practice in the Tameside area
Miss H complained the Trust and Practice failed to diagnose her son's pyloric stenosis, dismissed her concerns, and delayed hospital referral.
NHS in England
Aug 2024
P-002853 — A practice in the City of Bristol area
A complainant alleged a GP misdiagnosed her mother's symptoms and failed to suspect an aneurysm, denying treatment and preventing the family from saying goodbye before her death.
NHS in England
Aug 2024
P-002927 — A practice in the Northumberland area
Mr O complained the Practice failed to make correct referrals or treat his spine symptoms since 2019, resulting in permanent damage, weakness, and chronic pain.
NHS in England
Sep 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-003235 — A practice in the Croydon area
Mrs T complained the Practice failed to adequately manage her mother's conditions, including delayed UTI referrals and poor follow-up on specialist recommendations, impacting her mother's suffering and cancer diagnosis.
NHS in England
Partly Upheld
Dec 2024
P-003592 — A practice in the North East Derbyshire area
Mrs A complained a GP practice failed to perform a physical examination for her severe pain, refused pain relief, and omitted crucial information from a neurosurgery referral, causing prolonged suffering and delayed diagnosis.
NHS in England
Jun 2025
P-003622 — Mid Yorkshire Teaching NHS Trust
Mr E complained Mid Yorkshire Teaching NHS Trust failed to action a rheumatology referral, blamed the GP, and provided false information to the PHSO, causing an eight-month delay in diagnosis and pain.
NHS in England
Jun 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-003709 — North Middlesex University Hospital NHS Trust
Mrs B complained the Trust wrongly discharged her husband instead of referring him to oncology, believing it was a missed opportunity for earlier treatment or a better outcome.
NHS in England
Partly Upheld
Jul 2025
P-003691 — A practice in the Teignbridge area
Ms R complained the Practice did not appropriately respond to her blood test results, failing to refer her to a nephrologist, which she believes led to her stroke.
NHS in England
Not Upheld
Jul 2025
P-003648 — Royal Devon University Healthcare NHS Foundation Trust
Mr A complained the Trust failed to consider all his symptoms, monitor his blood appropriately, and follow an appropriate medication plan for his complex hypothyroidism, leading to distress.
NHS in England
Jul 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-004733 — A practice in the Lambeth area
Mr S complained the Practice failed to provide updates on his funding request, caused delays, arranged unnecessary appointments, ignored medical record requests, and failed to ensure online record accuracy.
NHS in England
Jan 2026
P-001729 — A practice in the Hertfordshire area
Mr H complained the Practice misdiagnosed his father with gallstones, which was actually stage four cancer, failed to refer him, and did not provide a care plan, leading to pain.
NHS in England
Jan 2023
P-001827 — Liverpool University Hospitals NHS Foundation Trust
Ms A complained the Trust prescribed medication to her mother without explaining risks, failed to order a fibroscan, and didn't communicate abnormal test results, possibly causing her liver failure and death.
NHS in England
Feb 2023
P-002033 — A practice in the Leeds area
Mrs B complained the Practice failed to refer her to gynaecology for a prolapse in 2018, despite a GP promising a referral.
NHS in England
Jun 2023
P-002399 — A practice in the Essex area
Mrs E complained her husband's GP practice failed to refer him to a specialist promptly for a persistent cough, missing a chance to diagnose lung cancer sooner.
NHS in England
Jan 2024
P-002522 — Walsall Healthcare NHS Trust
Miss B complained the Trust declined to consider a second opinion for her superior mesenteric artery blood clot in January 2022, resulting in ongoing pain and illness.
NHS in England
Mar 2024
P-002664 — Sheffield Teaching Hospitals NHS Foundation Trust
Mrs J complained about a lack of diagnosis, unnecessary epilepsy medication, delayed/missed follow-up appointments, and slow communication of medication changes to her GP.
NHS in England
Partly Upheld
Jun 2024
LGO / SPSO decisions(12)
PSOW-202106438 — A GP Practice in the area of Aneurin …
A complainant complained about the delay in an agreed complaint meeting taking place, and the fact that the Medical Centre did not retain telephone recordings, which the complainant considered would provide evidence in support of their complaint. The complainant also complained that the Medical Centre made reference to highly sensitive …
PSOW (Public Services Om…
Health
Mar 2022
PSOW-202004634 — A GP Practice in the area of Swansea …
Mr Y complained that a GP Practice in the area of Swansea Bay University Health Board (“the Practice”) incorrectly removed him for its patient list at the end of 2020. He said the Practice failed to give him a written warning, failed to give him a reason for the decision …
PSOW (Public Services Om…
Health
Upheld
Jan 2022
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-202202134 — A GP Practice in the area of Betsi …
Ms X complained about the poor service she had received from a GP Practice in the area of Betsi Cadawaladr University Health Board. In making enquiries with the Practice, the Ombudsman was concerned that it had not formally responded to Ms X’s complaint despite receiving a complaint in writing from …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202201703 — A GP Practice in the area of Cardiff …
Miss A complained that she was experiencing communication issues with the Practice. She wanted a further assessment with a specific GP for her ongoing health problems. The Ombudsman was concerned because Miss A had not contacted the Practice in two months for a GP appointment. She contacted the Practice to …
PSOW (Public Services Om…
Health
Jul 2022
PSOW-202202071 — A GP Practice in the area of Cardiff …
Mr X complained that despite putting a complaint to his GP regarding issues with his prescription, he had yet to receive a response or resolution to his complaint. The Ombudsman was concerned that Mr X had yet to receive a response from the GP and therefore contacted the GP. As …
PSOW (Public Services Om…
Health
Jul 2022
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 …
PSOW (Public Services Om…
Health
Upheld
Apr 2025
201001207 — A medical practice, Ayrshire and Arran NHS Board
Ms A started to feel unwell while working abroad. She attended a hospital there for scans before returning to Scotland. Ms A attended her GP and explained the problems she was experiencing. She gave him the scans and medical reports, but as these were not in English, he was unable …
SPSO (Scottish Public Se…
Health
Partly Upheld
Jun 2011
PSOW-202304622 — A GP Practice in the area of Aneurin …
Mrs N complained that Aneurin Bevan University Health Board (“the Health Board”) failed to provide her with appropriate care while she received blood transfusions and discharged her inappropriately after the transfusions were complete. Mrs N also complained that the GP Practice failed to appropriately assess and treat Mrs N’s symptoms …
PSOW (Public Services Om…
Health
Upheld
Jun 2024
PSOW-202309518 — A GP Practice in the area of Hywel …
Mrs A complained that from October 2022 to March 2023 a GP Practice in the Hywel Dda University Health Board area (“the Practice”) failed to provide appropriate care and treatment for her late mother in respect of her presenting symptoms, condition and past medical history (aortic heart valve replacement in …
PSOW (Public Services Om…
Health
Not Upheld
Sep 2024