Recurring concern

Failure to reliably notify primary care of changes affecting patient care

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First reported 9 Sep 2013•Latest report 15 Oct 2025

Definition

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.

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
21

Distinct published reports

Individual concerns
22

A report can raise multiple concerns

Date range
2013–2025

First to latest report issue date

Stated actions
18

Described in published responses

Reports over time

Reports 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.

Aneurin Bevan University LHB2
Department of Health and Social Care2
London Ambulance Service NHS Trust2
Birmingham and Solihull Integrated Care System1
Birmingham and Solihull Mental Health NHS Foundation Trust1
Care Quality Commission1
Charing Healthcare Ltd1
Cricket Green Medical Practice1
Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust1
Cwm Taf Morgannwg University Local Health Board1
Essex Partnership University NHS Foundation Trust1
Kent and Medway Mental Health NHS Trust1
King's College Hospital1
Lewisham and Greenwich NHS Trust1
Litch Care Services Limited1

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.

  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
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Data last updated 7 September 2026