Incomplete GP Patient Data Transfer
Incomplete transfer of patient data between GP practices, creating significant risks for continuity of care.
Strongest theme matches
Mixed across source types and ranked by classifier confidence plus text match strength.
PFD report
85match
Hope Evans
The coroner noted important patient history, including ESBL E. coli acquisition abroad, was not captured or shared between hospitals, impacting treatment and infection control. Additionally, All Wales Inter Hospital Transfer documentation was incomplete and requires revision.
Matched on
terms: incomplete, patient, transfer
PFD report
77match
David Baddeley
Incompatible electronic patient record systems and delays in reviewing paper records during transfers between medical practices meant a patient's serious psychiatric illness and lack of medication were not identified during health checks.
Matched on
terms: patient, transfer
PFD report
73match
Alfie Rose
Poor communication between hospitals resulted in missed opportunities for patient transfer and treatment. The coroner noted a need for better education and guidance for clinicians in outlying hospitals on making neurological referrals.
Matched on
terms: patient, transfer
PFD report
69match
Teresa Lonergan
The general practice did not monitor the patient's consumption of controlled drug prescriptions, leading to a significant accumulation of medication. This situation was exacerbated as the care worker administering the drugs did not report medical instructions.
Matched on
terms: patient
PFD report
69match
Dorothy Cooper
The coroner raised concerns regarding insufficient information transfer during hospital referrals, specifically noting a lack of clear procedures for junior doctors completing forms and for receiving teams to proactively address incomplete clinical information.
Matched on
terms: incomplete, transfer
PFD report
65match
Philip Dean
The coroner noted insufficient funding and under-resourcing of the Home Treatment Team and Liaison Psychiatry, which affected continuity of care, accurate patient assessments, and the availability of qualified staff for section recommendations. Gaps were also identified in recording pertinent information and providing interim patient support.
Matched on
terms: patient
PFD report
65match
Irene Pearson
The coroner raised concerns about the clarity of Matrifen leaflet warnings regarding hot baths and Macmillan Nurses' advice on patch removal. There were also identified gaps in liaison between Macmillan Nurses and the GP practice, alongside unclear GP patient notes.
Matched on
terms: patient
PFD report
65match
Olive Daynes
The coroner noted a significant delay in communication between the hospital and the GP surgery, leading to the GP being unaware of critical information regarding medication changes and increased INR levels for the patient.
Matched on
terms: patient
PFD report
65match
Beryl Foster
The coroner raised concerns that endoscopy discharge summaries were posted rather than emailed to GP practices, causing delays in GPs receiving critical patient information and potentially impacting patient care.
Matched on
terms: patient
Inquiry recommendation
65match
IHRD-11 - Patient Transfer Protocol
There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Matched on
terms: patient, transfer
PFD report
61match
Mone White
The coroner identified a need for a system to ensure that advice regarding the clinical care of patients with special requirements in specialist hospitals is communicated to all treating clinicians.
Matched on
terms: patient
PFD report
61match
Anne Whitworth
Incompatible computer systems prevented out-of-hours doctors from accessing the patient's full medical records, impacting treatment decisions and leading to a missed opportunity for escalation of care.
Matched on
terms: patient
PFD report
61match
Stephen Morris
The coroner noted a limited exchange of mental health information between professionals in Cheshire and Blackpool, meaning Blackpool staff lacked a detailed understanding of the patient's recent presentation and risks upon his return.
Matched on
terms: patient
PFD report
61match
James Stewart
A lack of a system for new GP practices to verify medication details for nursing home patients led to critical omissions. The coroner also noted concerns regarding unqualified staff confirming prescriptions, highlighting the need for a robust system from the Clinical Commissioning Group.
Matched on
terms: patient
PFD report
61match
Robert Davidson
Healthcare staff lacked training in basic emergency procedures, including 999 calls and CPR, and Health Care Assistants had insufficient foundational training for their role. The deceased's PICA behaviour was also not highlighted during care home transfer.
Matched on
terms: transfer
PFD report
61match
Stephen Leven
The coroner identified a lack of secondary care access to GP records, such as a patient's haemophilia diagnosis, which risks future deaths if critical medical information is unavailable.
Matched on
terms: patient
PFD report
61match
Frances Greenhalgh
The surgery lacked adequate systems for processing and recording notifications from external healthcare professionals, leading to a General Practitioner being unaware of a treatment plan and insufficient communication with the patient.
Matched on
terms: patient
PFD report
61match
Ernest Smith
Concerns persist regarding the system for considering GP correspondence, including medication review requests, which remains unchanged. Additionally, there is no clear system for updating GPs on patient progress or disengagement when care is led by non-medical multidisciplinary teams.
Matched on
terms: patient
Inquiry recommendation
61match
IBI-8b - New Patient Registration Screening
As a matter of routine, new patients registering at a practice should be asked if they have had such a transfusion.
Matched on
terms: patient
PFD report
57match
George Leonard Parkes
A patient with an abdominal aortic aneurysm was lost to follow-up, leading to a rupture and death. The coroner noted the absence of a specialist nurse clinic and a dedicated procedure database as factors requiring attention.
Matched on
terms: patient
PFD report
57match
Yaser Saleh
The EMIS computer system for GPs only flags patients for review if they are on current regular prescriptions, meaning those with chronic diseases who have stopped treatment are not identified for necessary monitoring. This poses a risk of preventable deaths for patients with conditions like asthma and epilepsy.
Matched on
terms: patient
PFD report
57match
Hilda Harris
The coroner identified an unreliable booking system for community INR testing, which led to appointments not being transferred, and an unreliable notification system for such omissions.
Matched on
terms: transfer
PFD report
57match
Rita Paton
The coroner raises concerns about the lack of a system to ensure requested blood tests are reported to GPs, and insufficient processes for patients lacking capacity to attend appointments. There is also a noted lack of readily available past medical and medication history for emergency crews.
Matched on
terms: patient
PFD report
57match
Alec Mathias
Discharge letters noting a dangerous side effect were not sent to the patient's GP, and the hospital's internal records were not updated with vital drug sensitivity information.
Matched on
terms: patient
PFD report
57match
John Lloyd
The coroner identified frequent failures in UHW's system for notifying GPs of patient admissions, despite an electronic system being in place. Concerns were also raised about providing adequate management support to overhaul this notification process.
Matched on
terms: patient
PFD report
57match
Suzanne Greenwood
The coroner identified a lack of systems at The Priory Hospital, Altrincham, for contacting patients who repeatedly miss appointments, informing GPs about non-attendance or discharge, and ensuring appropriate review before medication changes are made.
Matched on
terms: patient
PFD report
57match
Ryan Singh Bhogal
The coroner identified a lack of continuity of care at the GP practice and suggested a review of "Red Flag" identification for children. Concerns were also raised regarding the hospital's policy for reviewing GP medical records during young children's admissions.
Matched on
classifier match
PFD report
57match
Richard Grant
A patient's mental health referral was sent to the incorrect team and experienced an unexplained delay, while communication regarding the assessment outcome was not sent to the GP in a timely manner.
Matched on
terms: patient
PFD report
57match
Matthew Roberts
The coroner identified an absence of policies for logging and scrutinising faxed referrals, and for the EI team to read all information before initial risk assessment. This meant patient needs were not fully understood, and an organizational review of the death was delayed.
Matched on
terms: patient
PFD report
57match
Raymond Edwards
The coroner noted a lack of a reliable system or protocol for disseminating histology results to the named consultant, especially after patient discharge. This could lead to delays in diagnosis and treatment of serious conditions.
Matched on
terms: patient
PFD report
57match
Doreen Stapleton
The coroner noted insufficient emphasis on discharge advice, specifically the lack of explicit communication to the patient and family about the critical importance of follow-up medication and the absence of a contact number for the district nursing team.
Matched on
terms: patient
PFD report
57match
Marian Dale
Concerns were raised regarding the District Nursing Team's record-keeping system, where patient notes were held solely at the patient's address with no central contemporaneous record, leading to difficulties in evidence provision and post-death retrieval.
Matched on
terms: patient
PFD report
57match
Constance Connolly
The coroner identified gaps in follow-up for a critical scan, insufficient communication with the general practitioner regarding ongoing investigations, and procedural issues that led to the cancellation of an essential outpatient appointment.
Matched on
terms: patient
PPO recommendation
56match
The Head of Healthcare at HMP Lowdham Grange
The Head of Healthcare at HMP Lowdham Grange should ensure that prisoners with significant health needs are transferred in line with national instructions, including that: • significant health information is shared with the receiving prison, including about significant diagnoses, recent emergency hospital admission and hospital follow up appointments; and • all critical prescribed medications are transferred with prisoners...
Matched on
terms: transfer
PFD report
53match
Simon McAndrew
The coroner raised concerns about poor communication between different NHS Trusts, noting that important information regarding Mr McAndrew's psychiatric care was not effectively shared or accessed, leading to an inappropriate referral.
Matched on
classifier match
PFD report
53match
Harold Goulding
Communication broke down between the anti-coagulation clinic, the GP, and the care home regarding a resident's new GP details. Additionally, the General Practitioner did not consider the Medication Administration Record held by the home during new resident reviews, indicating a lack of a system for medication approval.
Matched on
classifier match
PFD report
53match
Thomas Jordan
The coroner identified that medication continued to be administered in prison despite hospital advice to discontinue it, owing to a communication breakdown between the hospital and prison, and discharge correspondence not being immediately available or reviewed by prison healthcare staff.
Matched on
classifier match
PFD report
53match
Richard Walsh
The coroner noted significant gaps in communication and information-sharing processes between custodial, health, police, court, and prison services. This led to crucial mental health information being lost or distorted, particularly due to a lack of automatic sharing for Mental Health Act assessments between agencies.
Matched on
classifier match
PFD report
53match
Mohammad Ashraf
The coroner identified inadequate and delayed allergy care plans for pupils, ineffective communication between the school and caterer, and an unsafe allergy identification system. Crucially, the Local Authority did not communicate safety recommendations to the school.
Matched on
classifier match
Committee recommendation
52match
#13 - Ensure consistent identifiers alert schools and GPs when children move into temporary accommodation.
Currently, schools are not always notified when a pupil becomes homeless or changes school due to a move into temporary accommodation. This prevents schools from offering additional support which those children may require. Similarly, GPs are often unaware that families are experiencing homelessness, leaving an incomplete picture of the health impacts of homelessness on children. (Conclusion, Paragraph 64)...
Matched on
terms: incomplete
Committee recommendation
51match
#9 - Slow progress on data sharing delays essential substance misuse support for prison leavers.
In 2017 this Committee recommended that HMPPS and NHS England (NHSE) improve information-sharing arrangements between health, prison and probation staff following concerns that healthcare records do not follow patients as they enter or leave prisons.18 The NAO found that HMPPS and NHSE have been slow to improve the collection and sharing of prison leavers’ data, limiting their ability...
Matched on
terms: patient
IMB annual report
51match
Stocken (2022)
HMP Stocken generally provides a safe and humane environment, with strong efforts in safer custody and no deaths in custody this year. However, the Board highlights significant challenges including chronic understaffing across various departments, persistent delays in staff vetting, and a critical shortage of secure mental health provision, leading to unsuitable placements within the prison. Issues with prisoner...
Matched on
terms: incomplete, transfer
PFD report
49match
Ricky Anderson
The coroner noted that Mr. Anderson's GP was not informed of his hospital admissions, leading to issues with medication supply. Furthermore, after an early discharge, there was over-reliance on family for information, and no care plan was established to assess his needs.
Matched on
classifier match
PFD report
49match
Thomas Farrell
The care home did not obtain a complete record of prescription drugs from the resident's GP, resulting in some medications not being administered.
Matched on
classifier match
PFD report
49match
Alan Ludlow
The coroner raises concerns about insufficient information exchange during assessments for residential and nursing placements, noting a new care home was not provided with critical past incident details about a resident.
Matched on
classifier match
PFD report
49match
Derek Thomas
The coroner noted that procedures for identifying suicidal intent failed under demanding conditions due to insufficient support for inexperienced staff. There was also a lack of clarity and communication between GEOAmey and prison reception staff regarding the handover of critical SASH forms.
Matched on
classifier match
PFD report
49match
Rohid Shergill
The coroner noted issues with ensuring parental competence for nasogastric tube (NGT) feeding and inadequate staff training on pH testing before NGT medication. Concerns also included insufficient information sharing between trusts.
Matched on
classifier match
PFD report
49match
Johan Pambou
The GP practice's system for monitoring and actioning hospital letters was insufficient, leading to missed vaccinations. Concerns were also raised about the availability of the pneumovax23 vaccine and GPs' understanding of how to access it.
Matched on
classifier match
Scottish FAI
49match
Declan Hugh Hainey
I am unclear as to whether a ‘lead individual’ is identified at the same time as ‘the lead agency’. If this is not the case, then it is recommended that it should be, and that all councils adopt this system. Management must ensure that there is regular and ongoing assessment of the staffing levels necessary to achieve at...
Matched on
classifier match
PPO recommendation
48match
The Head of Healthcare
The Head of Healthcare should meet with the appropriate person or department at the Princess Royal Hospital and the Royal Sussex County Hospital to ensure there is an understanding of the limits of nursing care that a prison can provide, and to highlight the importance of information sharing namely discharge summaries on the discharge of a patient to...
Matched on
terms: patient