Recurring concern
Failure to reliably notify primary care of changes affecting patient care
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Request correctionFirst reported 9 Sep 2013•Latest report 15 Oct 2025
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
- Individual concerns
- 22
- Date range
- 2013–2025
- Stated actions
- 18
Distinct published reports
A report can raise multiple concerns
First to latest report issue date
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.
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.
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Concerns raised1
Failure to alert relevant services, the GP, or family about a high-risk patient’s departure
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Embed documented carer-contact prompts in the Liaison Psychiatry departmental handover board before discharge.
Stated by South London and Maudsley NHS Foundation Trust
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Family contact may not be possible if a capacitated patient refuses permission, although the refusal should be documented.
Stated by South London and Maudsley NHS Foundation Trust
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Concerns raised1
Failure to communicate discharge actions to the GP
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Send patient contact details and highlighted actions to GPs through administrative support.
Stated by Essex Partnership University NHS Foundation Trust
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Concerns raised1
Failure to inform the GP of declined attendance for medication
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Share qualifying mental-health reports with GPs, explain the reasons, and request follow-up and identification of social-care needs.
Stated by Oxfordshire County Council -
Action
Escalate urgent concerns by contacting GPs immediately or referring cases to the Professional Support Team for evaluation and decision.
Stated by Oxfordshire County Council
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Concerns raised1
Failure to update prescribing GPs about medication non-adherence and stockpiling risks
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 concernsEach statement is shown once, even when linked to more than one concern.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
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Position
Existing medication-review procedures and subsequent GP notification were considered sufficient; no additional GP communication was expected before the review.
Stated by North London NHS Foundation Trust
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Concerns raised1
Failure to inform referring GPs when referrals to secondary services are rejected
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Establish effective working relationships and clarify referral processes between mental health services and general practice.
Stated by NHS Birmingham and Solihull Integrated Care Board
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Concerns raised1
Delays in sending discharge notifications to GPs
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 concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to communicate reductions in clinic attendance and dressing changes to the GP
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Improve communication from secondary care to primary care with colleagues across specialties.
Stated by Royal College of General Practitioners -
Action
Work with NHS England and NHS Improvement to improve communication links between primary and secondary care.
Stated by Royal College of General Practitioners
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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Position
GP communication was unnecessary because there was no significant change in management, dressing frequency or foot condition.
Stated by King'S College Hospital NHS Foundation Trust
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Position
The Home disputes that the GP was unaware of the reduced clinic attendance or wound-dressing changes, stating the GP was informed.
Stated by Tower Bridge Care Centre
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Concerns raised1
Failure to inform appropriate clinical and social care services of pressure injuries
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
No linked response statementsNo respondent-stated action or position is linked to these concerns in the published data.
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Concerns raised1
Failure to routinely notify GPs of non-attendance with HATS
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Provide weekly administrative support to identify all DNA cases.
Stated by Sussex Partnership NHS Foundation Trust -
Action
Notify GPs when patients are discharged from Horsham ATS because of repeated non-attendance or non-engagement.
Stated by Sussex Partnership NHS Foundation Trust
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Concerns raised1
Failure to inform the GP of patient deterioration
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 concernsEach statement is shown once, even when linked to more than one concern.
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
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Action
Implement a rescue-antibiotics policy requiring parents to contact the practice on the first treatment day.
Stated by and the Sydenham Green Group Practice -
Action
Bring together professional colleges to develop standards promoting connectivity, proactive care, and communication for children with ongoing health needs.
Stated by Royal College of Paediatrics and Child Health -
Action
Publish a position on information sharing and consistent identifiers for children to support professionals’ access to information and care coordination.
Stated by Royal College of Paediatrics and Child Health
Data last updated 7 September 2026