Recurring concern

Unreliable clinical correspondence from healthcare services to GPs

Get email alerts

Request correction

First reported 12 Sep 2013•Latest report 17 Aug 2022

Definition

What this concern includes

Includes failures in preparing, quality-checking, dispatching or timely delivering clinical letters and comparable correspondence from healthcare services to GPs when the correspondence contains information needed for assessment, treatment, referral, medication management or continuity of care.

Not included

Excludes failures to review or act on correspondence after it has been reliably received by the GP practice; those belong to incoming-correspondence handling concerns.
Excludes discharge summaries and patient-facing discharge information where those named processes provide the more specific supported boundary.
Excludes generic communication, record-keeping or staffing deficiencies unless they directly impair outgoing clinical correspondence to GPs.
Excludes correspondence to non-GP recipients unless the assertion explicitly supports the same GP-facing clinical-correspondence process.

Reports: 13
Individual concerns: 14
Date range: 2013–2022
Stated actions: 18

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Department of Health and Social Care4

Ashfield House Surgery1

Association Of British Neurologists1

Betsi Cadwaladr University LHB1

Birmingham Women'S and Children'S NHS Foundation Trust1

Black Country Healthcare NHS Foundation Trust1

Bournemouth, Christchurch and Poole Council1

College of Policing1

Cornerstone Family Practice1

Dorset County Council1

Dorset Healthcare University NHS Foundation Trust1

Dorset Police1

Greater Manchester Health and Social Care Partnership1

Kent and Medway Mental Health NHS Trust1

Maidstone and Tunbridge Wells NHS Trust1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

6 Mar2015
Manchester West
Concerns raised1
1. Failure of hospitals to inform General Practitioners of GDH positive results
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Explore methods to support local health communities in reporting and sharing patients’ C. difficile status.
  Stated by Department of Health and Social CareStated planned
2. Action
  Develop hospital-to-primary-care information sharing on patient discharge, informed by local best practice and consultation with relevant partners and experts.
  Stated by Department of Health and Social CareStated in progress
AI-generated summary

Mary Magdalene Marshall · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Mary Magdalene Marshall died in hospital after admission with an incarcerated inguinal hernia and small bowel obstruction, later developing pneumonia and confirmed Clostridium Difficile infection. The principal concerns were limited awareness of GDH-positive results among healthcare practitioners, communication of those results to primary care, and their significance when prescribing antibiotics.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure of hospitals to inform General Practitioners of GDH positive results
Wider context from the report
“ii. The evidence indicated that there was a lack of awareness, in general, of the importance of GDH positive results in relation to the future prescription of antibiotics and the risk of the development of Clostridium Difficile infection. Furthermore there is a lack of awareness amongst General Practitioners in relation to GDH positive results. iii. The evidence indicated that there were Hospital Trusts in the North West that did not inform General Practitioners of GDH positive results and it is believed that a similar problem may exist Nationwide. ”
Source location
Mary Magdalene Marshall · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Explore methods to support local health communities in reporting and sharing patients’ C. difficile status.

Verbatim wording from the response
“Methods to support local health communities in the reporting and sharing of information in relation to a patient’s CDI status will also be explored. More widely, NHS England is already working on ideas for improving the provision of information between hospitals and primary care upon patient discharge. This will be informed by examples of best practice implemented locally and by consulting with relevant partners and subject matter experts to determine how information should be disseminated.”

Source location
2015-0084-Response-by-Department-of-Health1
Page 3 · response
Published 6 March 2015
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop hospital-to-primary-care information sharing on patient discharge, informed by local best practice and consultation with relevant partners and experts.

Verbatim wording from the response
“Methods to support local health communities in the reporting and sharing of information in relation to a patient’s CDI status will also be explored. More widely, NHS England is already working on ideas for improving the provision of information between hospitals and primary care upon patient discharge. This will be informed by examples of best practice implemented locally and by consulting with relevant partners and subject matter experts to determine how information should be disseminated.”

Source location
2015-0084-Response-by-Department-of-Health1
Page 3 · response
Published 6 March 2015
Open published response
19 May2014
Mid Kent and Medway
Concerns raised1
1. Delays in hospital and mental health trust documentation reaching GPs
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Trial electronic discharge notifications to send GPs immediate discharge information, resolving technical issues before wider rollout.
  Stated by Kent and Medway Mental Health NHS TrustStated in progress
2. Action
  Audit compliance with the existing written discharge-notification procedure, including GP feedback.
  Stated by Kent and Medway Mental Health NHS TrustStated in progress
3. Action
  Implement the Electronic Discharge Summary to improve timely information reaching patients’ GPs.
  Stated by Maidstone and Tunbridge Wells NHS TrustStated in progress
Respondent positions 1
1. Position
  Technical issues prevent wider rollout of electronic discharge notification until they are resolved.
  Stated by Kent and Medway Mental Health NHS TrustUnable to act
AI-generated summary

Peter Franklin · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Peter Franklin, who had longstanding mental health difficulties and increasingly frequent hospital attendances, died after jumping from a motorway bridge following an attempted jump earlier that day. The concerns included unclear communication about whether a referral, advice or assessment was required, relevant information not being passed on, and delays in sharing information with his GP.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Delays in hospital and mental health trust documentation reaching GPs
Wider context from the report
“(3) Mr. Franklin’s GP would have initiated a multidisciplinary team meeting to address the increasing frequency of attendances at hospital had he been aware of the recent hospital admission, the subsequent involvement with the mental health team and the attendances at A&E. The documentation from both hospital and mental health trusts was subject of significant delays such that none of the letters to the GP sent by either trust from July onward arrive[d] with the GP before Mr. Franklin died ”
Source location
Peter Franklin · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Trial electronic discharge notifications to send GPs immediate discharge information, resolving technical issues before wider rollout.

Verbatim wording from the response
“This summer KMPT began the trial of an electronic discharge notification system. By this notification of discharge is sent to GPs electronically immediately upon discharge. It”

Source location
2014-0230-Response-by-Kent-Medway-NHS-Trust
Page 2 · response
Published 19 May 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit compliance with the existing written discharge-notification procedure, including GP feedback.

Verbatim wording from the response
“KMPT is continuing to use the existing practice of a Written Discharge Notification being faxed to the GP within 24 hours of discharge including details of medication on the day of discharge. We are implementing an audit to ensure that this procedure is being followed which will include GPs. We recognise however that further improvement can be made and in this regard the following steps are in hand.”

Source location
2014-0230-Response-by-Kent-Medway-NHS-Trust
Page 3 · response
Published 19 May 2014
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Implement the Electronic Discharge Summary to improve timely information reaching patients’ GPs.

Verbatim wording from the response
“5 (3) In the matter of discharge summaries and timely information reaching the patients GPs, the Trust is working towards implementing the Electronic Discharge Summary in line with the rest of the Trust. This is being coordinated by the Head of IT and Information Governance. This will be in place by October 2014. In the meantime all paper discharge summaries are signed and sent by post.”

Source location
2014-0230-Response-by-Tunbridge-Wells-Hospital
Page 2 · response
Published 19 May 2014
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Technical issues prevent wider rollout of electronic discharge notification until they are resolved.

Verbatim wording from the response
“includes full information including diagnosis and details of medication. Unfortunately some technical issues still need to be finally resolved before wider roll out can be implemented.”

Source location
2014-0230-Response-by-Kent-Medway-NHS-Trust
Page 3 · response
Published 19 May 2014
Open published response
12 Sep2013
Norfolk
Concerns raised1
1. Failure to draft letters to general practitioners appropriately
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Develop and implement an agreed general-practitioner letter template presenting key information clearly.
  Stated by Norfolk and Suffolk NHS Foundation TrustStated in progress
AI-generated summary

Matthew Christopher Dunham · Prevention of Future Deaths report

This summary was generated using AI from the published report. Please read the original report for the complete account.

Report summary

Matthew Christopher Dunham, who was receiving mental health services and had recently expressed suicidal ideation, leapt from the fifth floor of a shopping mall in Norwich and was pronounced dead at the scene. The concerns included delays in responding to an emergency referral, uncertainty about referral responsibilities, insufficient response to signs of suicide risk, inappropriate correspondence, and poor coordination and information sharing between mental health professionals.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to draft letters to general practitioners appropriately
Wider context from the report
“d) A letter sent to Mr Dunham's general practitioner from the advice and assessment team was not drafted appropriately. This raises the issue of the need for specific guidance to be given about how such letters should be drafted within a template structure. ”
Source location
Matthew Christopher Dunham · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop and implement an agreed general-practitioner letter template presenting key information clearly.

Verbatim wording from the response
“The Trust's internal investigation identified that whilst all of the information was within the letter to the GP it was presented in a way that key aspects were not readily visible. To address this, the AAT have been working with general practitioners to develop a template that provides information in a manner to meet their needs. The agreed template is due to be implemented from the 18th November 2013”

Source location
Response
Page 2 · response
Published 26 January 2014
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure of hospitals to inform General Practitioners of GDH positive results

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Delays in hospital and mental health trust documentation reaching GPs

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to draft letters to general practitioners appropriately

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Actions described in response 2

Actions described in response 3

Respondent positions 1

Actions described in response 1