Incomplete GP Patient Data Transfer
Incomplete transfer of patient data between GP practices, creating significant risks for continuity of care.
Source spread
Where this theme appears
This theme appears across 17 independent accountability sources, so the source mix matters as much as the headline total.
3 inquiry recs
144 PFD reports
10 committee recs
5 CQC actions
23 PPO recs
6 IMB recs
25 IMB reports
2 Scottish FAIs
2 Article 2 learning points
1 detention investigation rec
22 DHR recs
12 PHSO decisions
35 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(3)
IBI-8b — New Patient Registration Screening
Recommendation: As a matter of routine, new patients registering at a practice should be asked if they have had such a transfusion.
Gov response: NHS England is committed to identifying all those infected with a bloodborne disease, however it is transmitted. We would like to reassure the public that evidence shows the likelihood of contracting Hepatitis C via a …
Accepted
IHRD-11 — Patient Transfer Protocol
Recommendation: There should be protocol to specify the information accompanying a patient on transfer from one hospital to another.
Gov response: My Department accepts the recommendations of the O'Hara Report in their entirety.
Accepted
IBI-8a — Pre-1996 Transfusion Testing
Recommendation: When doctors become aware that a patient has had a blood transfusion prior to 1996, that patient should be offered a blood test for Hepatitis C.
Gov response: NHS England is committed to identifying all those infected with a bloodborne disease, however it is transmitted. We would like to reassure the public that evidence shows the likelihood of contracting Hepatitis C via a …
Accepted
Prevention of Future Deaths reports(144)— showing 50 strongest matches
Mone White
Concerns: 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.
Response: • The Department of Health stated that an effective system for communicating guidance was already in place. • The Department of Health indicated that the development of a national flag … (AI summary)
Response (2014 0031Response): • The North West London Hospitals NHS Trust developed a flagging system for patients under the care of specialist hospitals with specialist clinical requirements. • The Trust documented the process … (AI summary)
Responded
Ricky Anderson
Concerns: 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.
Overdue
George Leonard Parkes
Concerns: 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.
Overdue
Simon McAndrew
Concerns: 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.
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
Philip Dean
Concerns: 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.
Response: • The Trust allocated £214,000 to the Home Treatment Team (HTT) to fund nursing posts, and recruitment has commenced. • The Trust will commence a pilot for designated workers in … (AI summary)
Overdue
Graham Darby
Concerns: A specific threat made by Mr Darby to take his own life if evicted, mentioning a knife and rope, was not sufficiently flagged by other agencies to his housing provider, Family Mosaic. This meant Family Mosaic was unaware of the direct threat when making decisions.
Overdue
Hope Evans
Concerns: 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.
Overdue
Anne Whitworth
Concerns: 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.
Overdue
Yaser Saleh
Concerns: 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.
Overdue
Stephen Morris
Concerns: 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.
Response (MDU Services Limited): • The GP will request written confirmation from mental health professionals for any future changes to patient prescriptions. (AI summary)
Overdue
James Stewart
Concerns: 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.
Response (Bedfordshire Clinical Commissioning Group): • Bedfordshire Clinical Commissioning Group (BCCG) has developed a protocol for reconciliation of medications for patients transferring into care homes and registering with a new GP. • The developed protocol … (AI summary)
Responded
Geraldine Kilborn
Concerns: The coroner noted insufficient information sharing from the mental health team with other staff and that mental health input was not always given sufficient weight in ACCT reviews. Concerns were also raised that ACCT review members often did not read relevant documents beforehand.
Response (HM Prison and Probation Service): • An amended arrangement has been put in place to facilitate the presence of a mental health team member at weekend ACCT reviews. • Briefing sessions have been introduced to … (AI summary)
Response (Care UK): • Care UK stated that from April 2015, daily reviews would be undertaken by a mental health team member for patients with mental health issues, and all complex ACCT cases … (AI summary)
Response (Tess Esk Wear Valleys NHS Trust): • The Trust increased Mental Health Team staff availability over weekends to attend ACCT reviews and support prisoners in crisis. • The Mental Health Team Manager attends daily healthcare and … (AI summary)
Responded
Robert Stuart and Darren Hughes
Concerns: The coroner identified insufficient transmission of comprehensive donor information and microbiology reports to the transplant centre. Concerns also included the accepting consultant not using the full electronic system and making unilateral decisions without a team approach.
Response (NHS Blood Transport): • NHSBT approved expenditure for an IT development to change how specialist nurses record and transmit data electronically to transplant centres, with full operation expected by April 2016. • The … (AI summary)
Overdue
Hilda Harris
Concerns: 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.
Response: • A corrective Action Plan for Improvement was developed. • Actions have been implemented by the Primary Community & Localities Directorate. (AI summary)
Overdue
Rita Paton
Concerns: 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.
Overdue
Alec Mathias
Concerns: 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.
Overdue
Colin Moulton
Concerns: Critical information from a paramedic's verbal handover to an A&E triage nurse was lost. Additionally, the Ambulance Trust did not notify the Hospital Trust of their presence within the hospital grounds while searching for the individual, which could have aided communication.
Response (Department of Health): • The Department of Health noted that Fairfield General Hospital had implemented improved handover procedures between paramedics and A&E staff. • The Department of Health stated that all ambulance trusts … (AI summary)
Overdue
Thomas Farrell
Concerns: The care home did not obtain a complete record of prescription drugs from the resident's GP, resulting in some medications not being administered.
Overdue
John Lloyd
Concerns: 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.
Overdue
Suzanne Greenwood
Concerns: 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.
Response (Priory Group): • The organisation reviewed its systems and amended Policy H105: Practising Privileges for Independent Doctors. • The amended policy requires independent doctors to send final letters to patients for repeated … (AI summary)
Responded
Dorothy Cooper
Concerns: 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.
Response: • The Hepatobiliary MDT Co-ordinator re-circulated the updated pathway document, highlighting the need for complete and accurate referral forms. • The clinical team altered MDT reply forms to explicitly state … (AI summary)
Response: • Senior clinical colleagues at the Trust investigated the circumstances of the patient's care. • The process for inter-provider transfer of care for cancer patients in West Yorkshire is being … (AI summary)
Responded
David Baddeley
Concerns: 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.
Response: • NHS England plans for practices to be able to track records and view expected delivery dates from June 2016. • Practices will be reminded to ensure that patients are … (AI summary)
Responded
Harry Mellor
Concerns: The coroner identifies concerns regarding the lack of a legal requirement or reliable system for tracking child GP registration and de-registration. This creates potential safeguarding risks, especially for children with chronic health needs, and specialist teams were not informed of Harry's de-registration.
Response (Department of Health): • The Minister stated an intention to ask the Department of Health and NHS England to review current NHS processes to reduce the possibility of similar incidents. (AI summary)
Response (UK Health Security Agency): • The UK Health Security Agency alerted the relevant NHS England team and the Director of Public Health for Nottinghamshire. • The agency noted that the Nottinghamshire Safeguarding Board had … (AI summary)
Response (GMC): • The GMC discussed the safeguarding concerns with the Royal College of General Practitioners (RCGP). • The GMC reported that work is ongoing to improve clinical guidance for doctors regarding … (AI summary)
Response (CCG): • The CCG has requested assurance from specialist paediatric services regarding the effective implementation of 'Did Not Attend' (DNA) procedures. • The CCG will appoint an independent author to undertake … (AI summary)
Overdue
Alan Ludlow
Concerns: 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.
Overdue
Derek Thomas
Concerns: 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.
Response (HM Prison and Probation Service): • HMP Durham's Head of Operations instructed reception staff to physically check and cross-reference all documentation, obtain signatures, and verbally hand over self-harm warnings and court return information. • A … (AI summary)
Response (HMP Durham): • Nursing staff have been instructed to read and review all documents provided for patients during reception screening. • Staff have been reminded at meetings and briefings about the importance … (AI summary)
Response (Care UK): • Care UK stated it ceased to be the healthcare provider at HMP Durham on 31st March 2015. • Care UK indicated it would forward the coroner's concerns to heads … (AI summary)
Response (GEOAMEY): • Refresher training for escort and court officers on completing the Prisoner Escort Record (PER) is 90.91% complete, with remaining officers scheduled to complete it. • The organisation is undertaking … (AI summary)
Overdue
Irene Pearson
Concerns: 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.
Response (I Pearson): • Takeda reported the matter concerning heat exposure clarity to Johnson and Johnson. • Takeda requested Johnson and Johnson to review the product information for Durogesic. • Takeda confirmed the … (AI summary)
Response (I Pearson Response2): • The Macmillan team confirmed it would not advise patients to use baths to aid patch removal or submerge patches in water. • A 'Trust Alert' was issued to all … (AI summary)
Overdue
Alice Dickenson
Concerns: The GP referral form for the rapid access endoscopy scheme is limited, which may lead to the omission of important past medical history needed by the endoscopist.
Overdue
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 Grant
Concerns: 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.
Response (Black Country NHS): • A MHLS checklist has been developed and shared to prompt review of patient postcodes to avoid incorrect referral routes. • The SPOR duty system has been reviewed to cease … (AI summary)
Responded
Harold Goulding
Concerns: 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.
Response (Orchard Care Homes): • Meetings were held with nursing staff to discuss the incident and identify lessons. • Daily meetings were implemented, and a protocol document was created to improve communication with external … (AI summary)
Responded
Thomas Jordan
Concerns: 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.
Response (Care UK): • Care UK's Head of Healthcare at HMP Leeds discussed the matter with the Clinical Director for Urgent Care at Leeds Teaching Hospital. • The Hospital's Clinical Director agreed that … (AI summary)
Overdue
Rohid Shergill
Concerns: 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.
Overdue
Alfie Rose
Concerns: 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.
Response (University Hospitals Birmingham NHS Trust): • The Trust held a round table meeting at Queen Elizabeth Hospital Birmingham on 10 November 2016 to identify areas for improvement. • A meeting between clinical staff from Russell's … (AI summary)
Response (The Dudley Group NHS Trust): • The Trust held round table meetings with Queen Elizabeth Hospital Birmingham to identify areas of concern regarding communication. • A detailed action plan was developed and agreed by both … (AI summary)
Responded
Gordon Arthur
Concerns: The coroner raised concerns about the absence of policies at the Trust regarding the process for ordering investigative tests and ensuring their results are communicated to the consultant in charge.
Response (Salford Royal NHS Trust): • A joint review of current trust policies for ordering and communicating radiological investigation results was carried out. • Existing protocols for rapid notification of unsuspected pathology and alerting clinicians … (AI summary)
Responded
Matthew Roberts
Concerns: 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.
Response (Sussex Partnership NHS Trust): • The Trust designed and displayed posters to guide staff on managing faxes and requested 100% compliance with Information Governance Training. • New shared standards and guidelines for accepting referrals … (AI summary)
Responded
Raymond Edwards
Concerns: 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.
Response: • The Health Board has begun work to develop the CHAI Ping app. • The app is intended to provide an electronic reporting system to alert requesting clinicians when histology … (AI summary)
Responded
Robert Davidson
Concerns: 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.
Response (Priory Group): • The incident and lessons learned regarding effective communication during resident transfer will be raised in a forthcoming quarterly Safety 1st bulletin. • The requirement for staff to complete Form … (AI summary)
Response (Avery): • Avery stated it has established systems for staff training on emergency procedures and comprehensive documentation for patient information transfer. • Avery confirmed it has robust recruitment and induction processes … (AI summary)
Response (NHS England): • The response noted the introduction of the National Care Certificate, developed jointly by Health Education England, Skills for Health, and Skills for Care. • The National Care Certificate establishes … (AI summary)
Response (CQC): • CQC inspections in March and November 2016 at Aran Court Care Centre identified systems for emergency first aid training for nurses and confirmed staff understanding of 999 call procedures. … (AI summary)
Response (Department of Health): • The Government introduced the Care Certificate in April 2015, which includes standards for basic life support and health and safety. • The Department of Health is investing £12m in … (AI summary)
Responded
Richard Walsh
Concerns: 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.
Response (Virgin Care Limited): • Virgin Care arranged additional ACCT awareness training for all current healthcare colleagues, to be completed by the end of January 2017. • An annual ACCT refresher training programme has … (AI summary)
Response (Department of Health): • The Department of Health brought the coroner's report to the attention of the Health and Care Professions Council (HCPC). • The Department of Health asked the HCPC to respond … (AI summary)
Response (Health Care Professions Council): • The Health Care Professions Council (HCPC) reviewed its criteria for Approved Mental Health Professional (AMHP) training and stated that they continue to set out appropriate requirements. • The HCPC … (AI summary)
Response (Hampshire County Council): • Hampshire County Council and Portsmouth City Council introduced a requirement in November 2016 for Approved Mental Health Professionals (AMHPs) to receive a written medical report from assessing doctors when … (AI summary)
Responded
Doreen Stapleton
Concerns: 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.
Response (Whittington Health NHS): • The Trust stated that its Director of Nursing and Executive Medical Director would write to doctors, senior nurses, and pharmacists to highlight key learning points. • The Trust reported … (AI summary)
Responded
Marian Dale
Concerns: 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.
Overdue
Olive Daynes
Concerns: 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.
Response (United Lincolnshire Hospitals NHS Trust): • The Trust has an electronic system for sending discharge letters to GPs within 24 hours, with compliance improving from 74% to 83%. • The Trust is developing electronic documentation … (AI summary)
Responded
Beryl Foster
Concerns: 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.
Overdue
Johan Pambou
Concerns: 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.
Response (Johan Pambou): • A serious incident group was established, and the merged practice implemented an action plan including dedicated immunisation clinics and improved electronic recording of hospital letters. • NHS England initiated … (AI summary)
Responded
Constance Connolly
Concerns: 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.
Response (The Royal College of Emergency Medicine): • The Royal College of Emergency Medicine recently issued two guidance documents to its Fellows and Members on ensuring test results are followed up. • The College is preparing a … (AI summary)
Response (King's College Hospital NHS Foundation Trust): • The Trust has taken steps to ensure that formal discharge notifications are always sent to a patient's GP, detailing all relevant tests, assessments, and follow-up arrangements, even if the … (AI summary)
Responded
Sarah Poole
Concerns: The coroner noted failures to record the reviewing doctor's name on ECGs and to consider previous abnormal ECG results during paramedic handovers.
Response (The Royal Wolverhampton NHS Trust): • The Emergency Department has instigated a policy requiring all ECGs to be reviewed and signed off by a Senior Decision Maker. • An algorithm for managing abnormal ECGs has … (AI summary)
Responded
Stephen Leven
Concerns: 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.
Overdue
Frances Greenhalgh
Concerns: 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.
Overdue
Mohammad Ashraf
Concerns: 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.
Response (Birmingham Community Healthcare): • The Trust worked with Al-Hijrah school to provide a full response. • The Trust's comments were incorporated into the school's letter. • The Trust responded to concern no.2 within … (AI summary)
Responded
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
Select committee recommendations(10)
#13 — Ensure consistent identifiers alert schools and GPs when children move into temporary accommodation.
Recommendation: 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 …
Response attribution not verified
#9 — Slow progress on data sharing delays essential substance misuse support for prison leavers.
Recommendation: 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 …
Response attribution not verified
#26 —
Recommendation: We welcome the opportunity the Health Transformation Programme presents to improve data sharing and reduce the frequency with which claimants have to submit the same information. We recommend that as well as accessing medical information, the single digital platform should …
Response attribution not verified
#22 — Widespread National Insurance record errors cause multiple underpayments, affecting 10 million Universal Credit claimants.
Recommendation: DWP now reports multiple underpayments relating to issues in the National Insurance record. In addition to the HRP underpayment, DWP has also identified that the National Insurance records for 10 million people claiming Universal Credit have not been updated properly. …
Response attribution not verified
#17 — HMRC faces significant challenges identifying individuals affected by missing Home Responsibilities Protection in records.
Recommendation: We asked HMRC what it is doing to correct the National Insurance record so that DWP can in turn make any back payments of State Pension. HMRC explained that it no longer holds the relevant records and that identifying all …
Response attribution not verified
#16 — Historical State Pension underpayments caused by missing Home Responsibilities Protection have re-emerged despite previous efforts.
Recommendation: When we examined DWP’s 2021–22 accounts, it told us about another category of historical State Pension underpayment caused by gaps in the National Insurance records of women who had previously claimed Child benefit.29 DWP and HMRC explained to us that …
Response attribution not verified
#5 — Assure integrity of National Insurance records and establish early warning system for underpayments.
Recommendation: DWP is not doing enough to assure itself or Parliament that it can rely on National Insurance records to pay State Pension accurately and that it will not find further historic underpayments. The £1.3 billion underpayment of State Pension relating …
Response attribution not verified
#4 — Develop and publish plan with HMRC to correct State Pension underpayments and tax issues.
Recommendation: DWP and HMRC face a significant challenge in making back payments to people who have been underpaid State Pension due to missing Home Responsibilities Protection. In 2021–22, DWP identified underpayments of State Pension due to gaps in the National Insurance …
Response attribution not verified
#7 —
Recommendation: HMRC told us that some young people may have consciously chosen not to claim their savings yet, but The Share Foundation told us that accounts typically go unclaimed because the young person does not know that the money is there …
Response attribution not verified
#5 —
Recommendation: HMRC does not collect the data from providers needed to plan timely action to improve young people’s engagement with their accounts and assess whether its actions are working. HMRC’s understanding of Child Trust Fund accounts that have matured but are …
Response attribution not verified
NCEPOD recommendations(1)
CQC inspection actions(5)
Mount Vernon Cancer Centre
The trust should ensure that there is a comprehensive action place in place to improve discharge summaries being sent to GPs within nationally set timescales.
Should Do
The Sidings Medical Practice
Develop and improve the process to deal with incoming pathology results.
Should Do
Kidderminster Hospital and Treatment Centre
Monitor turnaround times for clinic letters to be issued to GPs to ensure national standards are met.
Should Do
Willow Brook House
A clinical handover sheet was being developed to ensure all nursing staff were fully appraised of each person's health needs which would ensure any deterioration in a person's health would be picked up quickly. At the time of the inspection …
Should Do
Cherished Moments
The service must ensure there is a governance system in place to ensure referrals made to NHS services are followed up.
Must Do
PPO death in custody recommendations(23)
The Head of Healthcare
The Head of Healthcare should ensure staff request prisoners’ community medical records at the earliest opportunity.
The Head of Healthcare
The Head of Healthcare should ensure that healthcare staff read discharge letters fully and complete any required actions promptly.
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, …
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 …
The Head of Healthcare at HMP Onley
The Head of Healthcare at HMP Onley should ensure that healthcare staff routinely and promptly request community medical records for newly arrived prisoners.
Healthcare staff at HMP High Down (Central and Northwest London …
As prisoners are sometimes unwilling to share information or engage during the initial health screen, it would be helpful if healthcare staff routinely review prisoners’ medical records during their initial health screen to identify if there is a history of …
The Head of Healthcare of HMP Bedford
The Head of Healthcare should ensure that prisoners’ GP records are obtained.
The Head of Healthcare
The Head of Healthcare should ensure that there is prompt and effective communication between the GP services and the healthcare team to ensure alerts and triggers for prisoners are monitored appropriately.
The Head of Healthcare and the lead for CGL
The Head of Healthcare and the lead for CGL should ensure that CGL’s records are also recorded on SystmOne so that healthcare staff can access them.
The Head of Healthcare
The Head of Healthcare should ensure that there are robust communication and administrative processes to handover prisoner healthcare information and ensure that all clinical requests are completed in a timely manner.
The Director General of HMPPS
The Director General of HMPPS should ensure that when contracted prisons are transferred between providers data is not lost.
The Heads of Healthcare at Littlehey and Wandsworth
The Heads of Healthcare at Littlehey and Wandsworth should ensure that when a prisoner with complex medical needs transfers to a different prison, relevant medical issues are discussed with the receiving prison.
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that staff manage prisoners at risk of suicide and self-harm in line with PSI 64/2011, including: • that prison and healthcare staff share all information that affects risk and do not …
The Head of Healthcare at Stafford
The Head of Healthcare at Stafford should ensure that where prisoners are already under the care of a hospital consultant when they arrive, staff: • make hospital referrals promptly; • include all relevant information about the stage of treatment and …
The Head of Healthcare
The Head of Healthcare should ensure that PCLDS staff forward mental health assessments and any other pertinent information about a prisoner’s risk to the mental health team’s central mailbox.
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 …
The Head of Healthcare of HMP Liverpool
The Head of Healthcare will want to ensure all healthcare staff ensure continuity of prescribing of all significant and/or critical medicines, after arrival in prison without delay and additionally that doses are not missed due to delays in repeat prescriptions.
The Head of Healthcare and the Head of the Substance …
The Head of Healthcare and the Head of the Substance Misuse Service should ensure that healthcare staff: complete follow up COWS assessments and appointments for prisoners who have previously displayed substance misuse withdrawal symptoms, to ensure continuity of care; and …
The Governor and the Head of Healthcare
The Governor and the Head of Healthcare should ensure that Early Release on Compassionate Grounds applications are completed in line with Policy Framework by: • ensuring that prison staff request a report from Probation staff for the application; and • …
The Governor
The Governor should ensure that prison staff inform healthcare staff when a prisoner asks to see them.
The Governor of HMP Downview and Regional Probation Director
We bring this to the attention of the Governor of Downview and Regional Probation Director to consider whether any improvements could be made to how staff communicate and share information.
The Governor and Head of Healthcare
The Governor and Head of Healthcare should review their information sharing protocol for prisoners with serious medical conditions such as epilepsy.
The Head of Healthcare
The Head of Healthcare should review the current vaccinations process to ensure that if a patient is unavailable, a further appointment is offered.
IMB annual reports(25)
Birmingham (2020)
HMP Birmingham has demonstrated significant improvements in safety, staff-prisoner relationships, and living conditions following an urgent notification in 2018. The Board commended the prison's effective management of the COVID-19 pandemic, which saw reduced violence and enhanced communication, though it also led to a severely restricted regime and mental health challenges. Key concerns include prolonged segregation for mentally unwell prisoners, persistent issues with lost property, and the need to sustain positive changes post-pandemic, particularly regarding staffing and purposeful activity.
PRISON
Key concerns
Wymott (2021)
HMP Wymott largely maintained safety during a challenging Covid-19 reporting year (June 2020-May 2021), seeing reductions in self-harm and violence. While staff efforts and some initiatives were commendable, the pandemic exacerbated long-standing issues, particularly with healthcare provision, the prison estate's infrastructure, property loss, and complaints handling. The restricted regime severely limited opportunities for purposeful activity, education, and resettlement, causing significant frustration among prisoners.
PRISON
Key concerns
Ashfield (2020)
HMP Ashfield continues to be a well-run Category C prison for men serving sentences for sexual offences, known for its safe environment and humane treatment. Despite the significant impact of the COVID-19 pandemic on daily regime and programme delivery, staff were highly commended for their support and resilience. Key concerns include the persistent lack of suitable accommodation for release, issues with property management from other establishments, and the growing backlog for intervention programmes due to COVID-19 restrictions, which could hinder prisoner progression and parole.
PRISON
Key concerns
Woodhill (2021)
HMP Woodhill faced a challenging year dominated by Covid-19 restrictions, which limited prisoner time out of cell to an average of 1.75 hours daily and curtailed visits and activities. Despite successfully preventing a Covid-19 outbreak among prisoners, the Board raised concerns about high levels of violence, a high proportion of inexperienced staff, and issues with long-term segregation and property management. There were also notable delays in mental health transfers and insufficient purposeful activity for progression.
PRISON
Key concerns
Wealstun (2021)
HMP Wealstun, a Category C training and resettlement prison, navigated the reporting year (June 2020-May 2021) under severe Covid-19 restrictions, leading to prisoners being locked up for up to 23 hours daily. The Board commended the prison for maintaining order and a settled environment, with significantly reduced violence and self-harm. Key concerns highlighted include the inadequacy of the daily food allowance, the need for improved body scanner processes and training, and ensuring the full reinstatement of key worker schemes and offending behaviour programmes post-pandemic.
PRISON
Key concerns
Sudbury (2021)
HMP/YOI Sudbury, an open Category D male and young offenders resettlement prison, had a population of 484 in April 2021, operating at an operational capacity of 564. The reporting year, ending May 2021, was significantly impacted by Covid-19 restrictions, limiting the Board's observation and affecting many aspects of prison life, including ROTL, social visits, and purposeful activity. Despite challenges, the prison maintained low self-harm rates and experienced no Covid-19 deaths. However, concerns persist regarding the aging infrastructure, property handling during transfers, and access to offender management support.
PRISON
Key concerns
Warren Hill (2021)
HMP Warren Hill, a Category C adult male prison with an operational capacity of 262, is generally considered safe and treats prisoners with respect, despite the significant challenges of the Covid-19 pandemic during the reporting period (June 2020 – May 2021). The regime was severely curtailed, with reduced time out of cell and suspension of education and therapy, yet staff maintained relationships and prisoner wellbeing was supported. Key concerns include the poor quality of food, delays in property policy reform, and missed opportunities for in-cell technology, though progress was noted on an approved premises and a disabled cell.
PRISON
Key concerns
Thorn Cross (2022)
HMP/YOI Thorn Cross experienced a challenging year due to the pandemic and staffing issues but maintained a safe and humane environment. The Board found the prison's rehabilitative culture and healthcare provision to be strong, with positive staff-prisoner relationships. Key concerns include budget pressures, delays in high-risk transfers, persistent property issues, and the need to improve data collection on protected characteristics and reduce absconds.
PRISON
Key concerns
Swinfen Hall (2022)
HMP/YOI Swinfen Hall, a YOI and Category C training prison, held 583 prisoners during the reporting year. The Board noted positive progress in safety initiatives and equality, diversity, and inclusion. However, significant concerns remain regarding slow responses to prisoner property and complaints, insufficient purposeful activity places, and delays in offender management. Healthcare provision, particularly night cover and mental health staffing, also raises concerns.
PRISON
Key concerns
Stoke Heath (2022)
HMP/YOI Stoke Heath maintained a safe and positive environment during the reporting year ending March 2022, despite ongoing Covid challenges. Key positives included improved in-cell telephony, good routine GP access, and declining use of force. However, significant concerns persist regarding the slow restoration of the key worker scheme, inadequate vocational training and resettlement support, and persistent delays in dental care and access to mental health beds.
PRISON
Key concerns
The Verne (2022)
HMP The Verne, an adult training prison for men convicted of sexual offences, has largely restored its 'core day' regime following COVID-19, maintaining a safe environment with good staff-prisoner relationships and high-quality healthcare. However, the report highlights critical issues, particularly regarding the inadequate 24-hour social care and onsite hospital provision for its growing elderly and frail population. Significant understaffing in the Offender Management Unit continues to undermine resettlement efforts for the substantial number of prisoners released directly from this training prison, alongside concerns about low prisoner pay and a third of the population lacking purposeful activity.
PRISON
Key concerns
Hull (2023)
HMP Hull, a Category B local prison, reported generally safe conditions with violence rates below benchmarks and commendable staff-prisoner relationships. However, significant concerns persist regarding systemic overcrowding, inadequate double-cell accommodation, and insufficient catering budgets impacting food quality. Healthcare provision has improved following a change in contractors, but challenges remain with GP availability and access to specialist mental health care, alongside staffing shortages in other key areas.
PRISON
Key concerns
Hatfield (2023)
HMP/YOI Hatfield is recognised as a very safe and effective Category D open prison, excelling in resettlement with a high percentage of prisoners securing and maintaining employment post-release. The Board commends the positive staff-prisoner relationships and well-managed healthcare, while noting improvements in facilities. Key concerns include the negative impact of prison population pressures on open prisons, the unsuitability of the Lakes site, and delays in completing perimeter fencing to mitigate illicit item drops.
PRISON
Key concerns
Guys Marsh (2023)
The Independent Monitoring Board at HMP Guys Marsh noted positive developments including sufficient organisational support for safety, the appointment of a neurodiversity support manager, and a seamless transition to a new healthcare provider. However, significant concerns remain regarding persistent drug and alcohol use driving violence, ineffective risk management plans, and unacceptably high prisoner-on-prisoner assaults. The Board also highlighted issues with accommodation standards, a long dental waiting list, and underutilised education and work provisions.
PRISON
Key concerns
Foston Hall (2023)
HMP/YOI Foston Hall has shown positive developments in regime provision and some safety initiatives, yet it continues to grapple with persistently high self-harm rates and increased use of force. Staffing shortages have impacted key work and overall experience levels, while healthcare faces challenges with recruitment, missed appointments, and inadequate facilities. The Board highlights significant concerns regarding accommodation decency, delays in parole and mental health transfers, and a lack of analytical focus on protected characteristics, affecting fair treatment and access to services.
PRISON
Key concerns
High Down (2023)
HMP High Down, a Category C training and resettlement prison, experienced significant increases in assaults and illicit item finds during 2023, raising serious safety concerns. Staffing shortages in key work and the Offender Management Unit severely impacted regime delivery and prisoner progression. While improvements were noted in mental health transfer times and family contact, persistent issues with property loss, poor shower conditions, and limited purposeful activity for prisoners, particularly vulnerable ones, remained key challenges.
PRISON
Key concerns
North Sea Camp (2025)
HMP North Sea Camp is a Category D open prison providing a safe and humane environment with a new Governor making positive regime and community engagement changes. While healthcare and education services receive commendations, significant concerns persist around inadequate accommodation standards, particularly for double rooms and dormitories, and the lack of on-site residential healthcare for complex needs. The Board also highlights issues with delayed Offender Assessment System (OASys) completion by Community Offender Managers and the ongoing lack of progress for IPP prisoners.
PRISON
Key concerns
Buckley Hall (2020)
HMP Buckley Hall, a Category C training prison with an operational capacity of 459, received positive HMIP inspection results and was ranked highly among UK prisons. Staff efforts to keep prisoners safe during the COVID-19 lockdown were commended, with minimal positive cases. Key concerns included high rates of cancelled external medical appointments, under-completion of key worker sessions due to staffing pressures, and the lack of in-cell telephones. The regime was significantly restricted during lockdown, causing boredom, though out-of-cell time increased by the reporting year's end.
PRISON
Key concerns
Buckley Hall (2021)
The reporting year at HMP Buckley Hall (Aug 2020 - July 2021) was largely defined by Covid-19, leading to significant operational challenges and a restrictive regime. Despite these difficulties, the IMB judged the prison to be safe, with dedicated leadership and staff, and good healthcare provision. Key concerns persist regarding prisoner progression, funding for new initiatives, and some basic decency issues such as secure in-cell medication storage and shower quality.
PRISON
Key concerns
Warren Hill (2022)
Warren Hill maintained a safe environment despite Covid-19 constraints, effectively managing outbreaks and promoting positive staff-prisoner interactions. The IMB commends the prison's efforts in harmonising regimes and establishing on-site approved premises. However, persistent issues with food provision, the suspension of the ROTL pilot, and challenges related to prisoner property and in-cell telephony remain significant concerns, along with the impact of recent parole changes on prisoner morale and progression.
PRISON
Key concerns
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 transfers, including incomplete assessments and uncontrolled property, and a lack of category D prison places continue to hinder progression and resettlement efforts. The performance of the education provider is also a key concern.
PRISON
Key concerns
Wakefield (2022)
HMP Wakefield, a high-security prison for men, is generally considered safe but experienced increases in assaults and use of force. Key concerns include persistent issues with mental health transfers, a lack of robust healthcare complaints processes, and the absence of in-cell telephony. The Board also highlighted unsatisfactory property management and insufficient purposeful activity for prisoners.
PRISON
Key concerns
Ford (2023)
HMP Ford, a Category D open prison, achieved positive recognition from HMIP for its safe and humane environment, with commendable healthcare and a strong focus on rehabilitation. While the prison effectively supports resettlement and purposeful activity, the IMB raises significant concerns regarding the severe under-maintenance of the estate, slow progress on a planned expansion, and persistent issues with external Probation Service support. Additionally, challenges with external contractors for education and the ongoing problem of inter-prison property transfers continue to hinder prisoner progression.
PRISON
Key concerns
Haverigg (2023)
HMP Haverigg, an open category D prison for PCoSO prisoners, effectively managed a 50% population increase while maintaining low levels of self-harm and violence. The Board noted high standards of humane treatment, robust healthcare provision, and strong focus on education and resettlement. Key concerns remain the inhumane nature of IPP sentences, persistent property loss during transfers, and inconsistencies in sentence management.
PRISON
Key concerns
Frankland (2023)
HMP Frankland, a Category A dispersal prison, operated close to its 852 capacity, maintaining a generally safe environment despite some serious assaults. The IMB noted improvements in healthcare provision, reducing a previous 'enhanced surveillance' status, and a 75% achievement rate in education. Persistent concerns include outdated CCTV, ongoing kitchen equipment breakdowns and heating issues causing lost workdays, and long-standing problems with prisoner property during transfers. The Board also highlighted challenges in mental health provision for complex cases and inadequate facilities for older and disabled prisoners.
PRISON
Key concerns
IMB individual recommendations(6)
Yarl’s Wood (2020)
The Board recommends that upon the release of STHF detainees, their destination addresses are confirmed as a matter of urgency to enable medical records to be forwarded swiftly to their GPs, so allowing access to essential medical care.
Home Office
Lowdham Grange (2024)
Prisoners who have not been recently sentenced are being transferred to HMP Lowdham Grange without a completed or up-to-date offender assessment (OASys). This means the assessment has to be completed at this prison, adding to pressure on the offender management unit (OMU) and putting prisoners at risk until it is completed. Does HMPPS feel it is acceptable that some establishments …
HMPPS
Noted
Oakwood (2024)
The Board approves of Level 2 English and Mathematics being mandatory for those who have not reached this level but is concerned at the inconsistencies in transferring prior attainment information from previous establishments. Can the Director look at ways to resolve this issue?
Governor / Director
Wandsworth (2020)
The Board was surprised to be informed by Novus that individual learning plans did not follow prisoners on transfer to other prisons or outside. Why is this?
Other
Implemented
Isis (2022)
Require prisons receiving prisoners from the courts to complete an OASys report before a prisoner is transferred.
HMPPS
Moorland (2025)
How and when will the Prison Service resolve the issue of delay in transferring PIN numbers when a prisoner moves from a private sector establishment to a public sector one?
HMPPS
Implemented
Health investigations(30)
Independent investigation: Ivy Newman, Tower Hamlets (1998) — Rec 1
Any GPto whom a patient with a psychiatric history presents for the first time, should ensure that they obtain the patient’s records as soon as possible, and there should be systems in place to pick up delays in receipt of such records.
london
Independent investigation: Tracey Baker, Chard (2015) — Rec 11
Somerset Partnership NHS Foundation Trust should undertake an audit of a random sample of patient records to ascertain whether: • consultant psychiatrists are informing a patient’s GP when a Mental Health Act (1983) assessment (including section 136) has been undertaken. • the appropriate manager or duty manager are informing a …
south_west
Independent investigation: Shivani Taneja Kapoor, Northwood (2013) — 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.
london
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: Samantha Ho, St Neots (2015) — 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.
east_of_england
Independent investigation: Nicole TownshendJane Malkin, Leicester (2007) — Rec 3
LPT’s crisis resolution and home treatment service must ensure that its discharge summaries provide complete information to GPs and other relevant mental health teams and agencies. The information provided on the discharge summaries from the CRHT to GPs and other professionals was inadequate in 2007. The management team for crisis …
midlands
Independent investigation: Mary Skerrit (81)Keith Fernandez, Stoke NewingtonPalmers Green — Rec R1
The wider NHS should consider whether, when a patient leaves a GP’s list, that GP should be informed of the patient’s new GP. This would provide the opportunity to communicate any concerns the former GP may have about the patient which may not be apparent from the records.
london
Joint Domestic Homicide Review and independent mental health homicide investigation … — Rec 3
Prison health care providers must ensure that systems are in place to share secondary prison health care consultations and information with GPs on discharge or release.
north_west
Independent investigation: Geraldine Simpson, Birmingham (1997) — Rec 6
the Health Authority and the Primary Care Groups should discuss the procedures enabling GPs to obtain previous notes so that the patient‟s previous history is available as a matter of urgency.
midlands
Independent investigation: Bertha Martin, Cleadon (2008) — Rec 29.
The investigation panel was informed as to an eight day delay in the processing of important information sent by fax to GP 6 by patient E’s Counsellor 1 in January 2008. GPs practices should review internal communication systems to ensure that information is received by the patient’s GP promptly.
north_east_yorkshire
*Mental health homicide investigation legacy report into the care and … — Rec R1
The Kent and Medway NHS and Social Care Partnership Trust should include in its programme of clinical audit a review of the timeliness of completion of hospital discharge summaries and sending them to patients’ GPs and, where appropriate, to other agencies.
south_east
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 inquiry into the care and treatment of Ms … — Rec 8
The Management of Unregistered Patients protocol to be reviewed and amended with further guidance included where required. This protocol should include a method for ensuring registered GP, any temporary registrations and the name of the last GP seen are sought from patients and or their relatives.
south_east
An independent inquiry into the care and treatment of Ms … — Rec 6
Mental Health to send full CPA review reports to GPs every time an assessment is completed.
south_east
Independent investigation into the care and treatment of Mr B — Rec 7
The Trust must ensure that processes are in place to trace the correct GP for clients when a client record indicates that a client is not registered with a GP; and that this must be undertaken within seven calendar days.
Mr B who committed a homicide in 2012. Mr B was in receipt of services from South London and Maudsley NHS Foundation Trust
london
Accepted
An independent investigation into the care and treatment of Jack … — Rec 2
When RDaSH practitioners and clinical staff make a significant entry in a patient’s SystmOne records, such as a risk assessment or a change in the treatment plan, they should alert the patient’s primary care service, by email or telephone, that an entry has been made. Evidence of this being introduced …
Rotherham Doncaster and South Humber NHS Foundation Trust
north_east_yorkshire
Independent investigation: Laura Sturla, Gillingham (2003) — Rec 12
The trust should ensure that discharge summaries are sent to GPs within 24 hours of discharge.
south_east
Independent investigation: Laura Sturla, Gillingham (2003) — Rec 3
The trust should ensure that GPs are informed of a patient’s admission and discharge from inpatient care.
south_east
Independent investigation: Shaun O’Neill, Modbury (2013) — Rec 4
A process should be commissioned to enable GP practices to receive police 121A’s.
south_west
Independent investigation: Paige Shatlock Jones (PS/J), Hucknall, Notts (2003) — Rec 12
Professionals working with families with children in primary care mental health services, should access GP records prior to the commencement of work with the client/family, so that as much information as possible is known to a practitioner from the outset.
midlands
Independent investigation: Leonne Weeks, Dinnington (2017) — Rec 2
When RDaSH practitioners and clinical staff make a significant entry in a patient’s SystmOne records, such as a risk assessment or a change in the treatment plan, they should alert the patient’s primary care service, by email or telephone, that an entry has been made. Evidence of this being introduced …
north_east_yorkshire
Independent investigation: Bertha Martin, Cleadon (2008) — Rec 16.
When a patient is discharged from hospital following an inpatient admission, on the day of discharge there should be a preliminary discharge letter sent to the patient’s GP outlining the discharge medication and follow up arrangements. A full account should be sent to the patient’s GP by the discharging medical …
north_east_yorkshire
*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
Assurance Report reviewing progress against the recommendations detailed in the … — Rec 2.12
Following a CPA review if there are any significant changes in a patient’s risk management, support needs or medication the care coordinator should arrange as soon as possible to meet with the patient’s primary care service so that the patient’s records can be updated and any plans implemented.
Solent NHS Foundation Trust
south_east
An independent investigation into the care and treatment of Mr … — Rec 4
In order to improve information sharing between primary care and Lancashire Care NHS Foundation Trust’s community mental health services consideration should be given to strengthening a joint information sharing protocol. Such a protocol should identify both agencies’ responsibilities for: Information sharing following a patient’s discharge from an acute inpatient …
Mr S . Mr S was convicted of the murder of Mrs S in 2014. At the time of the homicide Mr S was receiving care and treatment from Lancashire Care NHS Foundation Trust
north_west
An independent inquiry into the care and treatment of Ms … — Rec 2
Secondary care to communicate significant events, such as deaths of Mental Health Act Section patients to temporary registered GPs if they have had substantial input with patients
south_east
An independent inquiry into the care and treatment of Mr … — Rec 7
SHFT should continue to ensure that discharge summaries are sent electronically and should consider the option of reintroducing a Part A initial discharge summary to help ensure General Practitioners receive information about medication promptly. This should be completed within 6 months of publication of this report and Implementation should be …
Southern Health NHS Foundation Trust
south_east
Independent investigation into the care and treatment of Mr F: … — Rec 6
Secondary mental health care services should be aware that patients on a methadone programme in this area may be registered with two primary care services. If this is the case, they must ensure that communication is being sent to both services.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
Independent investigation into the care and treatment of Mr F: … — Rec 5
When a patient is registered with two primary health care services, there needs to be improved communication and information sharing between the practices.
Tees, Esk and Wear Valleys NHS Foundation Trust
north_east_yorkshire
An independent investigation into the care and treatment of a … — Rec 11
Cornwall Partnership NHS Foundation Trust must ensure that when a patient is discharged to the care of an originating team a full summary of the patient’s care and treatment whilst in Cornwall is provided to the receiving team.
Mr P in Dorset NHS England has published an independent investigation report into the care and treatment of a Dorset Healthcare University NHS Foundation Trust
south_west
Scottish Fatal Accident Inquiries(2)
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 all times …
John Paul Pratt
I have therefore recommended that the DVLA institute a practice whereby in cases where the examining doctor is not the applicant’s general practitioner that the general practitioner is asked to verify from his records that the applicant has no condition likely to adversely affect his fitness to hold a relevant licence.
Nov 2014
Article 2 learning points(2)
— LP D
Every effort should be made to gain access to a prisoner’s medical records from his GP or local hospital within 24 hours of reception into prison.
PPG
— LP 1
There needs to be much speedier medicines reconciliation, post reception. In prisoners, like Mr Everest, who are prescribed drugs like antidepressants, this needs to be within 24 hours to avoid withdrawal symptoms. There needs to be a robust administration process whereby a summary is acquired from the GP in the …
HMP Altcourse and HMPPS
Partially Accepted
Independent reviews(3)
Selous Review — Rec 64
The Department of Health and Social Care (DHSC) and the Devolved Governments to require GPs to transfer records speedily when Service families are relocated.
Other
Litchfield WCA Review Year 4 — Rec 25
DWP continues to work with BMA to develop and co-design a revised electronic ESA113 with the aim of simplifying the process for GPs and improving the quality of evidence available.
Employment & Work
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(12)
P-002384 — A practice in the Sutton area
Miss I complained her GP practice provided inappropriate care and delayed obtaining medical records, leading to the avoidable loss of her kidney and subsequent health issues.
NHS in England
Dec 2023
P-003153 — A practice in the Oadby and Wigston area
Mr A complained the GP Practice failed to visit his brother after hospital discharge, leading to his death, and recorded incorrect information on the death certificate, causing distress.
NHS in England
Not Upheld
Nov 2024
P-003587 — Royal Cornwall Hospitals NHS Trust
Mrs B complained the Trust discharged her husband, Mr A, while he had a fever and couldn't swallow medication, and failed to provide a discharge summary. His subsequent death caused her distress.
NHS in England
Jun 2025
P-003687 — A practice in the Gedling area
Mrs N complained the Practice failed to process multiple repeat prescription requests, inappropriately changed one prescription, and did not act on requests for eczema/psoriasis creams.
NHS in England
Jul 2025
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-002509 — A practice in the Rochdale area
Mr and Mrs C complained a GP practice delayed confirming a PMDD diagnosis, showed unprofessionalism, and committed a data breach by sending another patient's information.
NHS in England
Mar 2024
P-002576 — A practice in the Rutland area
The Practice delayed her referral to Adult Autism Services, included incorrect information, did not review her medication, and wrongly deregistered her.
NHS in England
Apr 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-003700 — Sussex Partnership NHS Foundation Trust
Ms F complained Dr A discussed her daughter E's needs with another service without consent, lied about disclosures, and about missing records and poor complaint handling.
NHS in England
Jul 2025
P-003740 — A practice in the Cheshire West and Chester …
Miss I complained that three practices removed diagnoses, shared her medical information, tampered with records, and failed to upload them electronically between 1981 and 2005. She alleged this led to her not knowing about a genetic condition.
NHS in England
Aug 2025
P-002356 — Tees, Esk and Wear Valleys NHS Foundation Trust
Mrs E complained she wasn't informed about her son's discharge or care strategies and that the Trust failed to use her requested reasonable adjustments for communication during the complaints process.
NHS in England
Dec 2023
P-003115 — A practice in the Cumberland area
A GP was rude and failed to include crucial patient history in a referral, leading to complications during knee surgery, a bladder infection, and ongoing health issues.
NHS in England
Nov 2024
LGO / SPSO decisions(35)
NIPSO-202003466 — GP
A breakdown in the relationship between a GP Practice and a patient led to her being removed from its Patient List. We welcomed the staff training delivered by the Practice which followed our investigation.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
NIPSO-202003467 — GP
We found a GP Practice treated a man's elbow appropriately. However, we believed that the man's complaint about his treatment prompted the Practice to remove him from its list. We said this was unfair.
NIPSO (NI Public Service…
Health & Social Care
Upheld
Apr 2024
PSOW-202103182 — Hywel Dda University Health Board
Mr A complained to the Ombudsman that in March 2020, due to the pandemic, his orthopaedic operation was cancelled. When he submitted his complaint, he had yet to receive a date for his operation. The Ombudsman accepted that the Health Board’s services had been severely disrupted, and further delays to …
PSOW (Public Services Om…
Health
Oct 2021
PSOW-202403453 — Cardiff and Vale University Health Board
Miss G complained that she had been waiting for five years to undergo surgery, but the Health Board had told her that she was now not fit for surgery. Miss G said that the Health Board had failed to provide her with a proper explanation as to why she was …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202403533 — Betsi Cadwaladr University Health Board
Mr X complained that Betsi Cadwaladr University Health Board (“the Health Board”) had not fully responded to his concerns about the management of his ongoing care and treatment and delays for a surgical procedure. The Ombudsman’s assessment found that the Health Board had not provided Mr X with information regarding …
PSOW (Public Services Om…
Health
Oct 2024
PSOW-202409958 — Aneurin Bevan University Health Board
Ms D complained about the waiting times at Aneurin Bevan University Health Board for a knee replacement for her daughter, Mrs E, who had very sadly since passed away. Ms D said that she had sent a letter to the Health Board but had only received a response via her …
PSOW (Public Services Om…
Health
Jun 2025
PSOW-202501158 — Patient list issues : A GP Practice in …
Mr A complained that the GP Practice failed to recognise or respond appropriately to his needs, leading to him being removed from the patient list. The Ombudsman decided that the Practice had not communicated effectively with Mr A and decided to settle the complaint without an investigation. The Ombudsman sought …
PSOW (Public Services Om…
Health
Aug 2025
201803006 — A Medical Practice in the Tayside NHS Board …
Mr C complained that the practice unreasonably removed him from the patient list. Mr C had been in correspondence with the practice about matters not connected with his NHS treatment. Mr C received a letter from the practice in which the suggestion was made that perhaps it would be for …
SPSO (Scottish Public Se…
Health
Upheld
Feb 2019
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
PSOW-202208013 — Cardiff and Vale University Health Board
Mr S complained that Cardiff and Vale University Health Board failed to pick up a referral for his father. Mr S said that it was only discovered when he contacted the Health Board for an update and an explanation as to why it was missed was not provided. The Ombudsman …
PSOW (Public Services Om…
Health
Jun 2023
PSOW-202302782 — A GP Practice in the area of Swansea …
Ms A complained about how the Practice had off listed her and handled her complaint about that matter. The Ombudsman had previously addressed the Practice’s failure to respond to Ms A’s complaint through an early resolution decision. However, the Ombudsman was concerned that the Practice had failed to demonstrate that …
PSOW (Public Services Om…
Health
Oct 2023
PSOW-202400648 — Betsi Cadwaladr University Health Board
Mrs C complained about the care and treatment she received from Betsi Cadwaladr University Health Board. Specifically, the investigation considered whether it was clinically appropriate that a consultant obstetrician and gynaecologist did not diagnose Mrs C with a cystocele (prolapsed bladder – where the bladder drops and pushes on the …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
PSOW-202400797 — Cwm Taf Morgannwg University Health Board
Ms A complained about the Health Board’s delay in hip surgery for her father, Mr B. Mr B was told that his care had been transferred to a neighbouring health board. However, enquiries revealed he was not on the surgery waiting list at either health board. The investigation considered whether …
PSOW (Public Services Om…
Health
Nov 2025
PSOW-202407678 — Swansea Bay University Health Board
Mr W complained about a delay in receiving a total knee replacement surgery from Swansea Bay University Health Board, which he had been waiting for since August 2019. The investigation considered whether Mr W’s waiting time for surgery was appropriately managed in line with the Welsh Government’s Rules for Managing …
PSOW (Public Services Om…
Health
Nov 2025
PSOW-202501669 — Betsi Cadwaladr University Health Board
Mr A complained about the Health Board’s response to 3 GP referrals for back, hip and side pain since 2019 and the wait to by seen by the Pain Management Team. Mr A further complained about the Health Board’s handling of his complaint. The Ombudsman found that although Mr A …
PSOW (Public Services Om…
Health
Nov 2025
23-006-504f — St. Albans Medical Group (23 006 504f)
Summary: Mrs A complains about the care and treatment of her mother, Mrs B. She also complains about how long North East and North Cumbria Integrated Care Board (the ICB) took to respond to her complaint. We found the ICB took too long to respond to Mrs A’s complaint which …
LGO (Local Government & …
Health
Upheld
Aug 2025
23-006-504e — St. Albans Medical Group (23 006 504e)
Summary: Mrs A complains about the care and treatment of her mother, Mrs B. She also complains about how long North East and North Cumbria Integrated Care Board (the ICB) took to respond to her complaint. We found the ICB took too long to respond to Mrs A’s complaint which …
LGO (Local Government & …
Health
Upheld
Aug 2025
23-006-504d — St. Albans Medical Group (23 006 504d)
Summary: Mrs A complains about the care and treatment of her mother, Mrs B. She also complains about how long North East and North Cumbria Integrated Care Board (the ICB) took to respond to her complaint. We found the ICB took too long to respond to Mrs A’s complaint which …
LGO (Local Government & …
Health
Upheld
Aug 2025
201300401 — A Medical Practice in the Lothian NHS Board …
Miss C complained that she and her elderly mother (Mrs A) were unreasonably removed from the practice's list of patients without any discussion. She had received no prior warning from the practice, nor had she been invited to the practice to discuss this. The practice believed that they had followed …
SPSO (Scottish Public Se…
Health
Upheld
Nov 2013
201302194 — A Medical Practice in the Tayside NHS Board …
Mrs C complained that her medical practice had removed her from their list of patients. She had visited the practice to try to get an emergency appointment. She had a sore throat and had lost her voice so she used a pen and a scrap of paper to communicate with …
SPSO (Scottish Public Se…
Health
Upheld
Mar 2014
201504218 — A Medical Practice in the Tayside NHS Board …
Mrs C was removed from the treatment list of her GP practice following a difficult visit to the practice. Her husband (Mr C) complained about this and Mr and Mrs C were invited to a meeting to discuss the investigation. At the meeting they felt that no investigation had been …
SPSO (Scottish Public Se…
Health
Upheld
May 2016
201604142 — A Medical Practice in the Greater Glasgow and …
Miss C complained that her medical practice unreasonably removed her from the practice patient list because of comments which had been made on her social media site. The practice said that they would not tolerate such comments and that there had been a breakdown in the doctor/patient relationship which meant …
SPSO (Scottish Public Se…
Health
Not Upheld
Mar 2017
201707096 — A Medical Practice in the Grampian NHS Board …
Ms C complained that the practice unreasonably removed her from the patient list. Ms C had had concerns about the treatment which she had received from the practice previously but these had been dealt with under the complaints procedure. Ms C was surprised to subsequently receive a letter from the …
SPSO (Scottish Public Se…
Health
Upheld
May 2018
NIPSO-202005702 — GP
A man complained that shortly before her death his wife’s GP incorrectly diagnosed her with an upper respiratory tract infection. We did not identify any failures in her care and treatment.
NIPSO (NI Public Service…
Health & Social Care
Not Upheld
Feb 2025
PSOW-202205005 — Betsi Cadwaladr University Health Board
Mrs Y complained that her husband, Mr Y, was referred to an NHS Trust outside of Wales (“the English Trust”) in 2017 by Betsi Cadwaladr University Health Board for surgery which had not taken place. The investigation considered whether Mr Y’s surgery was unreasonably delayed and whether the Health Board …
PSOW (Public Services Om…
Health
Upheld
Nov 2024
PSOW-202308117 — Aneurin Bevan University Health Board
Mrs C complained about Aneurin Bevan University Health Board (“the Health Board”) and a registered Residential Care Provider (“the Care Provider”) which the Health Board had commissioned to provide care to her son, Mr A. The investigation looked at whether between November 2021 and October 2022, the Health Board failed …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
PSOW-202400319 — A GP Practice in the area of Swansea …
Miss B complained about the care and treatment provided to her late sister, Miss A, by her GP Practice. The investigation considered whether the decision by Miss A’s GP not to prescribe her with antibiotics, following telephone consultations on 5 and 12 December 2022, was appropriate and whether it was …
PSOW (Public Services Om…
Health
Upheld
Mar 2025
PSOW-202401585 — A GP Practice in the area of Swansea …
Mr C complained about the care provided to his late mother, Mrs D, by her GP Practice (“the Practice”). Specifically, Mr C complained that there was a failure by the Practice in April and May 2023 to identify that Mrs D was at risk of deep vein thrombosis (“DVT” – …
PSOW (Public Services Om…
Health
Not Upheld
Mar 2025
PSOW-202404490 — A GP Surgery in the area of Swansea …
Mrs A complained that the GP Surgery failed to investigate what stage her mother’s, Mrs B’s, COPD was at and identify metastatic cancer. The Ombudsman decided that whilst the overall care provided to Mrs B was appropriate, the Surgery managed 4 COPD exacerbations in a row over the telephone, before …
PSOW (Public Services Om…
Health
Mar 2025
24-003-158b — Quorn Medical Centre (24 003 158b)
Summary: We will not investigate Miss B’s complaint. She has not provided good reasons for approaching us late. Also, Miss B has already appealed the decision to detain her under Section 2 of the Mental Health Act to the First Tier Tribunal (Mental Health).
LGO (Local Government & …
Health
Aug 2024
25-000-897 — London Borough of Enfield
Summary: We will not investigate Mrs X’s complaint that the Council failed to transfer her child’s Education, Health and Care Plan to another Authority. This is because the Council apologised and an investigation is unlikely to achieve any additional outcome, and because we cannot achieve the outcome Mrs X wants.
LGO (Local Government & …
Education
Jul 2025
24-009-211a — Whitemoor Medical Centre (24 009 211a)
Summary: Mrs A complains about the way the Care Home and GP Practice cared for her mother, Mrs B. We will not investigate this complaint because we are unlikely to achieve anything more. This is because the coroner has already looked at the issues, and there has already been an …
LGO (Local Government & …
Health
Nov 2024
201402368 — A Medical Practice in the Greater Glasgow and …
Mrs C complained on behalf of her daughter (Ms A) that a medical practice would not register Ms A because she did not attend a new patient medical consultation. Mrs C also complained that the practice manager did not return Ms A's phone calls when she was trying to explain …
SPSO (Scottish Public Se…
Health
Dec 2014
201401246 — A Medical Practice in the Greater Glasgow and …
When Mrs C joined the medical practice, she met the practice manager and expressed concerns about her experiences with her previous practices. In particular, Mrs C was concerned that the abbreviation 'DNR' was in her medical notes, as she believed that this related to a 'do not attempt cardiopulmonary resuscitation' …
SPSO (Scottish Public Se…
Health
Upheld
Dec 2014
201910147 — A Medical Practice in the Lothian NHS Board …
C was removed from their GP practice patient list. The practice were contacted by Practitioner Services (part of NHS National Services Scotland who support primary care providers) after this and suggested the practice refer C to the board's Challenging Behaviour General Practice (CBGP). The practice referred C to the CBGP. …
SPSO (Scottish Public Se…
Health
Not Upheld
Sep 2021
Domestic Homicide Reviews(22)
Kent — recommendation 3
When GP surgeries change their IT systems they must ensure that the medical records of current and previous patients are transferred from the old system to the new or that the records on the old system are archived in a way that makes them readily available.
NHS England
NHS England
Cornwall — recommendation 11b
That there is a requirement for relevant early history, such as fostering, to be included as an integral part of GP records.
NHS England
NHS England
Cornwall — recommendation 9c
Paper record search to ensure that all relevant information is included on electronic record
Safer Cornwall
Shropshire — recommendation 4
Undertake a review of whether relevant MARAC information is shared with GP Practices across the Partnership; seek to implement a robust process which remedies any gaps identified.
Shropshire Safeguarding Community Partnership
Shropshire — recommendation 8.2a
Ensure all incidents/risks relating to a service user are communicated to their GP within 24 hours.
Shropshire Recovery Partnership (We are with …
East Sussex — recommendation 14
That a Digital Data recovery mechanism needs to be available for patient records that have failed to transfer. NHS England and NHS Digital need to work with General practice information system suppliers to provide a process for migrating and merging records that are fragmented.
NHS England
NHS England
East Sussex — recommendation 8
That the NHS Sussex Integrated Care Board continues to work towards a long term, sustainable solution to the issue of information sharing with GPs.
NHS Sussex Integrated Care Board
NHS Sussex ICB
Kent — recommendation 3
Clinical Commissioning Groups should ensure that when it is known to a GP practice that a patient is a victim of domestic abuse, this is clearly highlighted in their notes if they transfer to another practice.
ICBs in Kent and Medway
Brent — recommendation 6.5.2
That if people are referred from a source other than a GP, then there should be an automatic request to the GP for background information. Information from other sources will be requested depending on individual circumstances.
Camden and Islington NHS Foundation Trust
North London NHS Foundation …
Nottingham — recommendation 10.4g
DART/MARAC Notifications should be forwarded to a Clinical Professional for review & action planning & documentation into the GP clinical records (of Victim and Perpetrator if appropriate) as soon as the information is received by the GP Practice.
Greater Nottingham Clinical Commissioning Partnership
Nottingham — recommendation 10.4f
All DART/MARAC Notifications received by the GP Practice should be entered into the GP Records of the Victim and into the records of the Perpetrator (if the Perpetrator is registered with the same GP Practice as the Victim).
Greater Nottingham Clinical Commissioning Partnership
Ceredigion — recommendation 11.2
General practitioners and Health Boards should review their procedures and ensure that: a. the decision to remove patients from the Severe Mental Illness Register or from recall should be made by the medical practitioner responsible for the patient. The clinician must record the reason for doing so including identifying any …
General practitioners | Health Boards
NHS Wales
Somerset — recommendation 17.1.1
Discussion to be had, with the assistance of the Chair of this review, regarding medical records and how high-level medical history can be shared with a new GP practice as soon after registration has taken place to ensure the continuation of the patient’s care appropriately.
NHS England | Somerset Clinical Commissioning …
NHS England
Manchester — recommendation 5
For patients who have moved practice and the new GP does not have access to full medical records that they contact the previous GP in a timely manner to obtain information especially in circumstances where the patient is vulnerable.
NHS England
NHS England
Walsall — recommendation 8.8
Primary Care Services England should consider how GP2GP record transfers could be improved and the Black Country and West Birmingham CCG should also encourage as best practice direct conversations between GP practices where there are concerns that a vulnerable adult has changed practice.
Primary Care Services England | Black …
NHS Black Country ICB
Colchester — recommendation Recommendation Six
A review into NHS systems and the functionality of information sharing needs to be undertaken. How to transfer medical notes between G.P. practice’s to ensure crucial medical information isn’t lost should be considered.
NHS
NHS
Wolverhampton — recommendation 14
The Safer Wolverhampton Partnership to require the Black Country Partnership Foundation Trust to review its discharge communications to ensure appropriate discharge information is sent to the GP within 48 hours of a patient discharge.
Safer Wolverhampton Partnership
Gwynedd — recommendation 1
That the Acute Mental Health Unit implement processes which ensure that patient assessments are shared with the patient’s GP.
Acute Mental Health Unit
Stoke-on-Trent — recommendation 8
University Hospital North Midlands (UHNM) should ensure that hospital discharge letters sent to GPs include a full account of any disclosures made by patients regarding domestic abuse and any actions taken to explore these.
University Hospital North Midlands (UHNM)
University Hospitals of North …
Leicester — recommendation LPT_R4
Consideration to be given to the reciprocal information sharing agreement with GP’s as part of the development of the ‘RiO’ Electronic Patient Record system
Leicestershire Partnership NHS Trust
Leicestershire Partnership NHS Trust
Bedford — recommendation 3.71.
GP’s are recommended to consider the efficacy of the current GP electronic data entry system and to identify areas where the system could be improved. For example data entries should include clear historical accounts of the patient and detailed documented evidence of patient examinations and contacts.
General Practitioners
Enfield — recommendation 3
The multi-agency risk assessment conference (MARAC) meeting should consider how to share any pertinent information with the relevant GPs
multi-agency risk assessment conference (MARAC)