Recurring concern
Failure to reliably notify primary care of changes affecting patient care
- Reports that mention this concern
- 21
- Times this concern has been raised
- 22
- Stated actions linked to this concern
- 18
What this concern includes
Includes failures of dedicated notification arrangements to a patient's GP or outgoing primary-care practice about material changes affecting responsibility, access, admission or continuity of the patient's care, including care transfers, hospital admissions and non-engagement with referred services.
What is not included
- Excludes generic inter-agency communication or information-sharing failures where the notification is not specifically to primary care about a material change affecting patient care.
- Excludes clinical information, medication details or discharge information unless the reported unsafe condition is failure to notify primary care of the relevant care-status change.
- Excludes failures to notify patients, families, coroners, emergency services or other recipients where primary care is not the relevant notification recipient.
- Excludes routine administrative updates that do not affect responsibility, access, admission or continuity of patient care.
Trends
Reports over time
Reports mentioning this concern, over time
Reports about this concern issued each year.
* 2026 is projected from reports observed to 7 Sep 2026.
Most frequent recipients
Most frequent recipients
Reports about this concern sent to each recipient.
Reports and published responses 21 reports
See individual reports that have raised this concern, and the actions taken in response
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Concerns raised1
Failure to inform attending GPs of falls before clinical attendance
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Charing Dale Limited
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
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Charing Dale Limited
The GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.
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Charing Dale Limited
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
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Concerns raised1
Failure to coordinate pre-discharge handover and transition with the GP surgery
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
- Jackie Doyle-Price MP
- South West London and St George'S Mental Health NHS Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2
-
South West London and St George'S Mental Health NHS Trust
Update the Clinical Disengagement/Did Not Attend Policy to require GP engagement before discharge and audit adherence.
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South West London and St George'S Mental Health NHS Trust
Reinforce GP involvement in discharge decisions through governance meetings and learning dissemination, with reinforcement through the clinical audit cycle.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
-
Jackie Doyle-Price MP
Operational concerns about discharge and communication are the responsibility of the relevant NHS Trust.
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Concerns raised1
Failure to notify the GP or ambulance service after reported or observed falls
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to provide the GP with contemporaneous notification of discharge and the assessment leading to discharge
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to notify the outgoing practice when a new practice takes over patient care
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to notify General Practitioners and other continuing-care professionals of missed appointments and hospital discharge status
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Priory Group Healthcare Division
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3
-
Priory Group Healthcare Division
Require independent doctors to send final non-attendance letters to patients and relevant professionals, including medication, aftercare, crisis actions and future assistance options.
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Priory Group Healthcare Division
Require independent doctors to send discharge letters to GPs and relevant professionals after final non-attendance contact, copying patients and including medication, aftercare and crisis actions.
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Priory Group Healthcare Division
Require prompt telephone contact with GPs when concerns arise about non-attending patients.
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Concerns raised1
Failure to inform the GP when a welfare check request is downgraded
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to notify GPs of hospital admissions
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised1
Failure to implement notification of failed attendance for INR testing
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
-
Concerns raised2
Failure to inform the GP of hospital discharge
Failure to inform the GP of hospital admission
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
- Department of Health and Social Care
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1
-
Department of Health and Social Care
Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Data last updated 7 September 2026