Recurring concern

Failure to reliably notify primary care of changes affecting patient care

First to latest report 9 Sep 2013 — 15 Oct 2025

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.

Reports and published responses 21 reports

See individual reports that have raised this concern, and the actions taken in response

  1. Mid Kent and Medway

    AI-generated summary

    Ricky Anderson · 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

    Ricky Anderson was admitted to hospital with command hallucinations and suicidal thoughts, was discharged, and was later found suspended from a tree at Chatham Cemetery on 21 May 2012. Concerns included failures to inform his GP of his hospital admissions, reliance on family information when assessing his wellbeing after discharge, and the lack of contact with the Access team and a care plan before his death.

    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 inform the GP of hospital admissions involving primary care

    Wider context from the report

    “(1) It was established in evidence at the inquest that practitioners from the Kent and Medway NHS and Social Care Partnership Trust did not inform Mr. Anderson's GP of his involvement with primary care on either occasion he was admitted to hospital, resulting in him not being able to obtain a further supply of medication without the intervention of his family ”

    Source location

    Ricky Anderson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026