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 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.
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.2
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Position
The GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.
Stated by Charing Dale Limited
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Position
The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.
Stated by Charing Dale Limited
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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.
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
Update the Clinical Disengagement/Did Not Attend Policy to require GP engagement before discharge and audit adherence.
Stated by South West London and St George'S Mental Health NHS Trust -
Action
Reinforce GP involvement in discharge decisions through governance meetings and learning dissemination, with reinforcement through the clinical audit cycle.
Stated by South West London and St George'S Mental Health NHS 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
Operational concerns about discharge and communication are the responsibility of the relevant NHS Trust.
Stated by Jackie Doyle-Price MP
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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.
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 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.
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 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.
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 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.
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
Require independent doctors to send final non-attendance letters to patients and relevant professionals, including medication, aftercare, crisis actions and future assistance options.
Stated by Priory Group Healthcare Division -
Action
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.
Stated by Priory Group Healthcare Division -
Action
Require prompt telephone contact with GPs when concerns arise about non-attending patients.
Stated by Priory Group Healthcare Division
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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.
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 notify GPs of hospital admissions
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 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.
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 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.
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
Publish the Information Strategy establishing a framework for recording and securely sharing health and care information using consistent standards.
Stated by Department of Health and Social Care
Data last updated 7 September 2026