Recurring concern

Unreliable tracking and routing of electronic patient contacts in GP practices

First to latest report 23 Aug 2024 — 15 Oct 2024

Reports that mention this concern: 2
Times this concern has been raised: 5
Stated actions linked to this concern: 4

What this concern includes

Includes failures in GP practices' dedicated electronic patient-contact and referral process, including receipt, tracking, audit trails, triage routing, transfer to the patient record and availability to medically qualified staff when these controls affect safe review or follow-up.

What is not included

Excludes failures in general electronic patient records where the electronic contact-intake or routing process is not deficient.
Excludes clinical triage or follow-up failures occurring after an electronic patient contact has been reliably captured and routed to the responsible clinician.
Excludes generic IT, staffing, communication or documentation deficiencies unless they directly impair tracking or routing of electronic patient contacts in GP practices.
Excludes non-GP electronic enquiries and referrals unless the assertion explicitly concerns the same GP electronic patient-contact process.

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

Reports about this concern sent to each recipient.

Department of Health and Social Care2

NHS Derby and Derbyshire Integrated Care Board1

SSP Health1

Reports and published responses 2 reports

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

15 Oct2024
Manchester South
Concerns raised2
1. Failure to provide clear electronic patient enquiry routing information
2. Failure to transfer administrative patient enquiries to the patient record and make them available to doctors
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses

Department of Health and Social Care
NHS Derby and Derbyshire Integrated Care Board
Stated actions 2
1. NHS Derby and Derbyshire Integrated Care Board
  Discuss adding record-keeping resources to the Hub Plus online information and support suite.
2. NHS Derby and Derbyshire Integrated Care Board
  Discuss high-quality patient-record and medical-record guidance at a Clinical Governance Leads patient-safety agenda item.
Respondent positions 3
1. NHS Derby and Derbyshire Integrated Care Board
  Online consultation tools are delivered nationally at scale, leaving little or no local capability to vary their layout or contents.
  Unable to act
1. Department of Health and Social Care
  Individual general practices, rather than the department, are responsible for maintaining reliable patient-interaction and care-navigation systems.
  Redirects responsibility
2. NHS Derby and Derbyshire Integrated Care Board
  GP practices choose which online consultation tool to use and may opt out of automated integration with electronic patient records.
  Redirects responsibility
AI-generated summary

Stephen Charles Stringer · 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 Charles Stringer developed a hoarse voice from January 2023, but its persistence and deterioration were not recognised as a potential cancer warning sign until October 2023. He was diagnosed in January 2024 with stage 4 squamous cell carcinoma of the glottis and treated palliatively. The report identified concerns about delayed referral, gaps in electronic patient enquiry systems, fragmented oversight of his care, and limited awareness of persistent hoarseness as a possible cancer symptom.

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 provide clear electronic patient enquiry routing information
Wider context from the report
“1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally. ”
Source location
Stephen Charles Stringer · 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
Failure to transfer administrative patient enquiries to the patient record and make them available to doctors
Wider context from the report
“1. The inquest heard evidence that the GP practice had in accordance with the local requirements introduced an electronic patient enquiry service alongside a telephone service. Patients contacting the surgery had to select which stream within the practice their enquiry went to. It was not always clear from the headings whether the query would be seen by a GP or the admin team. Information that went into the admin work stream from a patient did not go onto the patient record and was not seen by a doctor. The GPs at the practice were unaware of this and patients had no way of knowing that the information they had sent in was not in the patient record. The practice involved in this inquest had taken steps since identifying the issue to mitigate the risks. However the evidence before the inquest was that the software in question was widely used by GP practices within Derbyshire and nationally. ”
Source location
Stephen Charles Stringer · 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
Discuss adding record-keeping resources to the Hub Plus online information and support suite.

Verbatim wording from the response
“The DDICB will also liaise with HUB+ to discuss the possibility of Record Keeping being added to their suite of online information and support for general practice.”

Source location
Response from Derby and Derbyshire Integrated Care Board
Page 5 · response
Published 16 October 2024
Open published response
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
Discuss high-quality patient-record and medical-record guidance at a Clinical Governance Leads patient-safety agenda item.

Verbatim wording from the response
“At the Clinical Governance Leads meeting with general practice the below documents will be discussed as part of the Patient safety standard agenda item.”

Source location
Response from Derby and Derbyshire Integrated Care Board
Page 4 · response
Published 16 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Online consultation tools are delivered nationally at scale, leaving little or no local capability to vary their layout or contents.

Verbatim wording from the response
“The online consultation tools are delivered nationally and at scale with the support of the National Procurement Hub and frameworks, with little or no capability to vary the layout, contents, etc on a local basis. There is a wide range of functionality available across the online consultation solutions we have within our system ranging from simple forms, through to more complex systems which aim to direct the patient to self-care.”

Source location
Response from Derby and Derbyshire Integrated Care Board
Page 3 · response
Published 16 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Individual general practices, rather than the department, are responsible for maintaining reliable patient-interaction and care-navigation systems.

Verbatim wording from the response
“General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. It is essential that clinical issues mistakenly categorized as administrative are identified and appropriately”

Source location
Response from DHSC
Page 1 · response
Published 16 October 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
GP practices choose which online consultation tool to use and may opt out of automated integration with electronic patient records.

Verbatim wording from the response
“While the ICB is currently the contract holder for online consultation tools in use within Primary Care, the choice of which online consultation to utilise resides with the GP Practice.”

Source location
Response from Derby and Derbyshire Integrated Care Board
Page 2 · response
Published 16 October 2024
Open published response
23 Aug2024
Manchester South
Concerns raised3
1. Failure to provide effective triage of electronic patient contacts by medically qualified staff
2. Failure to track and regularly check electronic patient contacts
3. Lack of a clear audit trail for electronic patient contacts
Linked responses

Department of Health and Social Care
The Pike Practice
Stated actions 2
1. The Pike Practice
  Establish or update standard operating procedures for managing practice emails.
2. The Pike Practice
  Implement monthly compliance audits of email response times and maintain email auditing as a standing SSP Health process.
Respondent positions 2
1. The Pike Practice
  Existing email controls and established electronic triage systems are considered appropriate for managing non-urgent communications and urgent-care routing.
  Existing arrangements considered sufficient
1. Department of Health and Social Care
  Individual practices are responsible for establishing reliable systems and managing email correspondence according to their local requirements.
  Redirects responsibility
AI-generated summary

Allan Robin Hamilton · 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

Allan Robin Hamilton emailed his GP practice on 14 November 2023 about breathing difficulties, but the email was not responded to until 17 November. He was found unresponsive at home on 19 November and died from lobar pneumonia. The principal concerns were the absence of systems for tracking and triaging email queries and the lack of clear, robust audit and follow-up processes.

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 provide effective triage of electronic patient contacts by medically qualified staff
Wider context from the report
“The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team. In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ”
Source location
Allan Robin Hamilton · Prevention of Future Deaths report
Page 1 · 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
Failure to track and regularly check electronic patient contacts
Wider context from the report
“The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team. In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ”
Source location
Allan Robin Hamilton · Prevention of Future Deaths report
Page 1 · 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 a clear audit trail for electronic patient contacts
Wider context from the report
“The inquest heard evidence that the GP practice in question is owned by SSP Health. The company owns a number of GP practices and that operate on a similar model. Like many GP practices the surgery in question had moved to a system where contact was encouraged electronically. The surgery had no system for tracking email queries such as the one sent by Mr Hamilton and there was no clear system for triage of emails such as the one he sent. The inquest heard evidence that an electronic system of patient referrals is only effective if there is a clear and robust process for checking regularly for patient contacts, a clear audit trial and effective triage by medically qualified members of the team. In Mr Hamilton’s case effective scrutiny of his query and follow up contact from his GP on 14/11 and medical advice would probably have meant he would not have died when he did. The inquest heard evidence that there was a risk of a similar situation arising if GP practices do not have clear and robust triage and audit processes in place. ”
Source location
Allan Robin Hamilton · 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
Establish or update standard operating procedures for managing practice emails.

Verbatim wording from the response
“- Response to family members (Appendix A) - Timeline of events (Appendix B) - Action Log (Appendix C) - Update of Automated Email response across all SSP practices (Outlook item attached) - Audits of the Email response times over a six-month period, showing compliance of response times (Appendix E) - Governance Meeting Minutes (Appendix F) - SOPs (Appendix G) - The response to be added to all SSP practice websites. - Educational communications via social media practice accounts - Audit to highlight the automated email and audit of email responses to be a standing process across SSP Health - HR discussions with staff - Staff competency and updated by the practice manager. - Meetings with senior management to discuss.”

Source location
Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024
Open published response
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
Implement monthly compliance audits of email response times and maintain email auditing as a standing SSP Health process.

Verbatim wording from the response
“In addition to the steps already mentioned, a monthly compliance audit has been implemented as a preventative measure. This audit reviews email response times to ensure the process remains efficient, with the automated patient response system fully operational.”

Source location
Response from SSP - The Pike Practice
Page 2 · response
Published 30 August 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Existing email controls and established electronic triage systems are considered appropriate for managing non-urgent communications and urgent-care routing.

Verbatim wording from the response
“In the context of it being widely recognised that emails are not for medical use, The Pike Practice, along with all SSP practices, has a structured system for managing emails. Each email is read, reviewed, and directed to the appropriate staff member. While this process was in place and adhered to at the time of the incident, the email in question was not read within the usual 48-hour window, resulting in a delay of 24 hours beyond our usual internal standard timeframe.”

Source location
Response from SSP - The Pike Practice
Page 1 · response
Published 30 August 2024
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Individual practices are responsible for establishing reliable systems and managing email correspondence according to their local requirements.

Verbatim wording from the response
“General practices are independent businesses who are contracted by NHS commissioners to perform medical services, and as a result it is the responsibility of the individual practice (provider) to have reliable systems in place to manage interactions with patients. If a”

Source location
Response from DHSC
Page 1 · response
Published 30 August 2024
Open published response

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

Data last updated 7 September 2026

What this concern includes

Trends

Reports mentioning this concern, over time

Concerns raised2

Failure to provide clear electronic patient enquiry routing information

Failure to transfer administrative patient enquiries to the patient record and make them available to doctors

Linked responses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.3

Concerns raised3

Failure to provide effective triage of electronic patient contacts by medically qualified staff

Failure to track and regularly check electronic patient contacts

Lack of a clear audit trail for electronic patient contacts

Linked responses

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

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2

Stated actions 2

Respondent positions 3

Stated actions 2

Respondent positions 2