Recurring concern

Unreliable coordination and information sharing between primary and secondary care

First to latest report 1 Nov 2013 — 23 Sep 2025

Reports that mention this concern
18
Times this concern has been raised
22
Stated actions linked to this concern
28

What this concern includes

Includes failures in coordination, communication, clinical-information access or information sharing specifically between primary care and secondary care providers where the deficiency can impair safe patient care, including inaccessible records, unshared messages, unclear interaction arrangements and inadequate coordination of mental-health or other clinical care.

What is not included
  • Excludes failures confined to communication within primary care or within secondary care when the cross-interface condition is not identified.
  • Excludes generic inter-agency or inter-service communication failures without a primary-to-secondary healthcare interface.
  • Excludes deficiencies in the underlying clinical assessment, treatment or referral decision when coordination and information sharing between primary and secondary care operated reliably.
  • Excludes failures belonging to a more specific named pathway or system, such as radiology follow-up, mental-health referrals or electronic-record authentication, when that narrower concern is the supported boundary.

Reports and published responses 18 reports

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

  1. Inner North London

    AI-generated summary

    Stephen Leven · 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

    Stephen Leven, who had haemophilia, developed a headache and visual-field changes and was later found to have a large intracerebral haemorrhage. He died on 13 December 2016; the principal concern was that hospital clinicians lacked access to GP information about his haemophilia, which could contribute to deaths in similar future circumstances.

    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

    Lack of secondary care access to GP records

    Wider context from the report

    “I am concerned that, in different circumstances, the lack of access to GP information regarding Mr Leven’s diagnosis of haemophilia, could have caused or contributed to his death. As such, I am concerned that deaths could occur in future similar circumstances if further action is not taken to facilitate secondary care access to GP records. ”

    Source location

    Stephen Leven · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Avon

    AI-generated summary

    David Lee BIRTWISTLE · 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

    David Lee Birtwistle died from a pulmonary embolism after being diverted from an accident and emergency assessment two days before his death, meaning further tests were not carried out. Concerns included the absence of NHS 111 referral information for the front door or emergency department and the need for NHS 111 to share information with emergency departments in a user-friendly format.

    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

    Lack of integrated front-door ED streaming by primary and secondary care clinicians

    Wider context from the report

    “1. Streaming of the front door of ED should be an integrated function run by both primary and secondary care clinicians. This should include at least a basic set of physiological measurements. ”

    Source location

    David Lee BIRTWISTLE · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  3. Inner West London

    AI-generated summary

    Michael Uriely · 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

    Michael Uriely had asthma from early childhood, which deteriorated and was uncontrolled in the seven months before his death. The report identified missed opportunities in the management of his asthma, including a lack of coordinated overall responsibility and long-term care planning, failure to assess and optimise treatment consistently, poor communication between services, and failure to refer him to a specialist respiratory service.

    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

    Lack of effective communication between primary and secondary care

    Wider context from the report

    “7) Two further areas of concern presented, inter related but independently significant and critical in this matter: A) Michael’s mother readily presented her child for care in and out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment. B) Evidence was also received of the failure to refer this child to a tertiary respiratory service which may have resulted in a different approach to his treatment which may have prevented his death, by: i) The general practitioners who failed to recognise the severity of his condition and that referral to a tertiary unit could have been considered. ii) The A&E and inpatient service at the local hospital. ”

    Source location

    Michael Uriely · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Create and endorse the London paediatric asthma toolkit with guidance, care pathways, role definitions, inhaler-technique support and an online learning hub.

    Verbatim wording from the response

    “9. The London paediatric asthma toolkit¹⁰ has been created to support healthcare professionals, schools, parents, carers and children and young people to improve care across the system. It advises on access, evidence, defines roles and responsibilities, techniques, plans and pathways. It also includes an online learning hub for pharmacists’ to assess support including actively promoting good inhaler techniques, which can support direct referral from primary care into community pharmacy and to enable care reviews. The tool has been endorsed by the Royal College of General Practitioners (RCGP), Royal College of Paediatrics Child Health (RCPCH) and by Asthma UK.”

    Source location

    Uriely-Response
    Page 4 · response
    Published 22 March 2017

    Open published response

  4. Cheshire

    AI-generated summary

    Charles Ray Woodward · 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

    Charles Ray Woodward underwent surgery to remove a sigmoid colon tumour and was discharged home after an apparently uneventful recovery. His health then declined, and he died from peritonitis caused by a leaking anastomosis following surgery. The principal concerns were inadequate communication and liaison between the hospital, community care providers and the family, together with insufficiently robust monitoring of his condition after discharge.

    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

    Inadequate communication and liaison between hospital and community care providers after discharge

    Wider context from the report

    “There was inadequate communication and liaison between the hospital on the one hand and on the other hand the deceased’s GP practice and district nurses in the community who, following the deceased’s discharge from hospital, would be responsible for the deceased’s ongoing care. Further, monitoring of the deceased’s condition from Leighton Hospital was insufficiently robust and relied upon oral contact rather than ensuring the physical presence of a medical attendant, be that attendant hospital or community based. The evidence suggested that there was miscommunication between the hospital and the deceased’s family with the result that the deceased’s worrying decline in health was not appreciated by the hospital. ”

    Source location

    Charles Ray Woodward · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  5. Gateshead and South Tyneside

    AI-generated summary

    Tamara Mills · 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

    Tamara Mills, who had longstanding asthma and repeated acute exacerbations, developed breathing difficulties during the night of 10th/11th April 2015 and died after paramedics were called. The principal concerns were fragmented care, inadequate coordination and communication, insufficient recognition of her deteriorating chronic respiratory condition, and the absence of a long-term management plan.

    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

    Lack of effective communication between primary and secondary care services

    Wider context from the report

    “8. Two further areas of concern presented, inter related but independently significant and critical in this matter : A) Tamara’s mother readily presented her child for care in an out of hours to primary care and secondary care, but there was a lack of effective communication between these services, either at the time of referral or after consultation and treatment. B) Evidence was also received of the development of a Tertiary service designed to improve medical care in the area of paediatrics. i) There was a singular lack of understanding by practitioners of how referrals to the service were to be made and once made an anxiety that the receiving trust not be seen to be acquiring a patient at the expense of the referring trust. The net result of this inhibition a further fragmentation in the care and management of the patient. ii) Within this service there were and indeed are specialist Respiratory Physicians who because of their level of expertise could and did demonstrate their ability to make a difference if they had been permitted in one instance to assume long term management of the child’s care and iii) More tragically in another because she was referred to the hospital but not to the service and therefore not to the Tertiary Specialists, managed only as an acute presentation 9. Tamara was never formally referred to this level of service. ”

    Source location

    Tamara Mills · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  6. Cardiff & the Vale of Glamorgan

    AI-generated summary

    Thomas George Smith · 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

    Thomas George Smith, aged 13, developed symptoms including headache, neck pain and vomiting before being admitted to hospital, where he later became unresponsive and died after suspected meningitis and raised intracranial pressure. The report identified concerns about delays in recognising and treating meningitis and raised intracranial pressure, communication and handover, responding to nursing concerns, monitoring physiological trends, and the transfer of the patient to hospital.

    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

    Incomplete handovers between primary and secondary care providers

    Wider context from the report

    “(1) No criticism is made of the actions of the Out of Hours Doctor ████████. The inquest however revealed the importance of full and accurate handover between primary and secondary care providers. Such handovers should record full observations and details of any medication already given (for instance painkillers may mask fever). Can the clinical director confirm OOH doctors observe this practice. ”

    Source location

    Thomas George Smith · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  7. South Yorkshire (Western)

    AI-generated summary

    Denise Sharon Parramore · 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

    Denise Sharon Parramore, who had a lengthy history of mental ill health and previous self-harm, died from respiratory depression after taking Tramadol in excess of the prescribed level in combination with other medication. The concerns were that psychiatric services were unaware of the Tramadol prescription and that primary and secondary care should have open two-way communication and access to each other's documentation.

    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 of two-way communication about prescribing between primary and secondary care

    Wider context from the report

    “(1) The Psychiatric Services, and in particular her Consultant Psychiatrist, was not aware, prior to Denise Parramore's death, of her being prescribed Tramadol by her General Practitioner. Concerns would have been raised, and action likely taken, if she had been aware. The Consultant Psychiatrist was not informed either by Mrs Parramore herself, nor the General Practitioner of the prescribing of the Tramadol. My concern is that there should be open, and constant two-way communication between those in primary care and secondary care such as in these circumstances. ”

    Source location

    Denise Sharon Parramore · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Lack of access to each other's clinical documentation between primary and secondary care

    Wider context from the report

    “(2) For the same reasons as given above, will it be possible for those in primary and secondary care access each other's documentation, which would likely have revealed the prescribing. ”

    Source location

    Denise Sharon Parramore · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. East London

    AI-generated summary

    Joanne Manning · 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

    Joanne Manning had a history of poly-substance abuse and methadone treatment, developed asthma and increasing breathlessness, and died from respiratory failure. The inquest conclusion attributed the respiratory failure to the combination of her respiratory disease, methadone, mirtazapine, cocaine and morphine. Concerns included a failure to provide the methadone-prescribing psychiatrist with information about her diagnosis and treatment, and the absence of a procedure ensuring clear communication between general practice and secondary care methadone providers.

    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

    Lack of a procedure or policy ensuring clear communication between general practitioners and secondary care methadone providers

    Wider context from the report

    “(1) Methadone is to be used with caution in a patient suffering from asthma. In order for the prescriber of methadone to exercise all due caution, they would have to be fully informed of the patient’s diagnosis and treatment by other healthcare professionals involved in the patient’s care. (2) Evidence was heard that methadone should be used with caution in a patient who is also receiving mirtazapine. (3) The psychiatrist prescribing the methadone requested further information about the patient’s medication and treatment from The Practice, Loxford. The letter from the psychiatrist was in general practice file. It was not however responded to. (4) The general practitioner who gave evidence at the Inquest agreed that the psychiatrist should have been fully informed, but she felt that the patient could tell the psychiatrist about her diagnosis and treatment. (4) The general practitioner was unable to comment on whether it would be appropriate for a patient who often attended appointments intoxicated, to inform the psychiatrist of key clinical information. It is my view that this would not be appropriate. (5) Evidence was given at the Inquest that there was no procedure or policy in place to ensure clear lines of communication between general practitioners to secondary care providers of methadone. It was agreed by the general practitioner and psychiatrist that such a policy/procedure would be desirable to protect patients in the future. ”

    Source location

    Joanne Manning · Prevention of Future Deaths report
    Page 2 · 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