Unsafe remote clinical consultations for assessment and advice
First to latest report 24 Mar 2014 — 6 Aug 2025
Reports that mention this concern
8
Times this concern has been raised
10
Stated actions linked to this concern
7
What this concern includes
Includes failures of remote clinical consultations, including telephone or virtual consultations, where inadequate assessment, insufficiently thorough questioning, unreliable patient-provided information or failure to check understanding can make clinical advice or decisions unsafe.
What is not included
Excludes face-to-face consultation failures where remote consultation is not the deficient process.
Excludes failures confined to a named pathway, such as telephone mental health assessment, GP appointment triage or emergency call handling, where that named pathway supplies the more specific supported boundary.
Excludes generic communication, documentation or follow-up deficiencies unless they directly impair the safety of a remote clinical consultation.
Excludes failures occurring after a remote consultation has been adequately completed, including subsequent treatment or service-access failures.
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.
Department of Health and Social Care5
NHS England3
Association of Ambulance Chief Executives1
East of England Ambulance Service NHS Trust1
Essex Partnership University NHS Foundation Trust1
Frimley Health NHS Foundation Trust1
Mid and South Essex NHS Foundation Trust1
NHS Greater Manchester Integrated Care Board1
NHS North East Hampshire and Farnham Clinical Commissioning Group1
North East Ambulance Service NHS Foundation Trust1
Royal College of Psychiatrists1
Royal College of Surgeons of England1
Yorkshire Ambulance Service NHS Trust1
Ministerial department5
NHS trust4
Executive non-departmental public body3
Clinical commissioning group1
Health professional body1
Health-sector membership body1
Integrated care board1
Professional body1
Reports and published responses 8 reports
See individual reports that have raised this concern, and the actions taken in response
Inner North London
Concerns raised1
Reliance on unreliable patient-provided heart rate and blood pressure observations in remote consultations
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
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
Prescribers, not the Department, decide whether medicines can be safely prescribed and must account for relevant national clinical guidance.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Suffolk
Concerns raised2
Failure of online prescribers to access patients’ records during consultations
Failure to assess suicidal behaviour or thoughts in online consultations
This report raised 4 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
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
Department of Health and Social Care
If an appropriate organisation requires a standardised suicidal-behaviour question, the GPhC would monitor its inclusion through inspections.
Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Essex
Concerns raised1
Failure to involve children directly in asthma service consultations
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University NHS Foundation 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
Essex Partnership University NHS Foundation Trust
Request to speak with children during consultations and record their views in the electronic patient record.
Essex Partnership University NHS Foundation Trust
Require nurses to speak with sufficiently mature children and record children’s views in electronic patient records.
Manchester South
Concerns raised1
Failure to provide physical examination during telephone GP consultations where clinically needed
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester South
Concerns raised1
Failure of GP consultation arrangements to support effective communication about deteriorating health
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked responses
Department of Health and Social Care
NHS England
NHS Greater Manchester Integrated Care Board
Tameside Borough Council
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.4
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Review patient experience feedback monthly to identify poor primary-care experiences and access inequalities.
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Discuss negative patient feedback with relevant practices to support learning and improvement.
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Introduce six-monthly patient surveys at individual practices from October 2021 to assess primary-care access and delivery.
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
Conduct an individual practice clinician survey in October 2021 to assess primary-care delivery during the pandemic.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3
NHS England
National general practice guidance required remote triage and face-to-face appointments where clinically appropriate, addressing concerns about remote-only care.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
NHS Greater Manchester Integrated Care Board and Tameside Borough Council
The CCG cannot determine how GP consultations are undertaken because it lacks legal powers and is not party to the nationally negotiated contract.
Outside remitThe respondent said that this matter was outside its role or authority.
Department of Health and Social Care
Existing guidance, procedures and resources are considered sufficient to support safe remote general practice consultations alongside face-to-face appointments.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
South Yorkshire (Western)
Concerns raised2
Failure to provide written follow-up of advice from virtual consultations
Failure to assess patients’ understanding of advice during virtual consultations
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
NHS England
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1
NHS England
Routine written follow-up after every remote primary-care consultation is considered disproportionate; follow-up should be based on clinical judgment.
Existing arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
Sunderland
Concerns raised1
Failure to make direct telephone contact with the patient during initial clinical review
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
North East Ambulance Service NHS Foundation 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.1
North East Ambulance Service NHS Foundation Trust
Implement the updated Urgent Ringback Procedure, prioritising direct conversation with patients wherever possible, and communicate it to relevant staff.
Surrey
Concerns raised1
Superficial and perfunctory nurse-led telephone consultations for enhanced recovery after laparoscopic surgery
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.