First reported 5 Dec 2014•Latest report 4 Nov 2024
Definition
What this concern includes
Includes failures by care, community, mental-health, supported-accommodation or other services to identify when a patient's safety concern requires primary-care involvement and to contact, refer to or obtain a response from the patient's GP or appropriate primary-care service, including unclear escalation guidance, failure to arrange GP attendance and failure to follow up intended GP support.
Not included
Excludes routine communication or notifications to primary care that do not concern a patient-safety issue requiring GP involvement.
Excludes failures in specialist, emergency, hospital or social-care referral pathways where primary-care escalation is not the shared unsafe condition.
Excludes failures occurring after primary care has been reliably contacted and has accepted responsibility, unless the asserted concern is a separate failure of GP clinical care.
Excludes generic communication, staffing, documentation or care-coordination deficiencies unless they directly impair escalation of a patient-safety concern to primary care.
Excludes the existing broader concern about notifying primary care of changes in patient care when the assertion concerns notification of a status change rather than escalation of an active safety concern requiring GP involvement.
Reports
9
Distinct published reports
Individual concerns
9
A report can raise multiple concerns
Date range
2014–2024
First to latest report issue date
Stated actions
15
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.
Care Quality Commission2
NHS England2
A & B Healthcare Limited1
Brighton and Hove City Council1
Department of Health and Social Care1
Dorset Council1
Dorset Police1
East London NHS Foundation Trust1
East Riding of Yorkshire Council1
HM Prison and Probation Service1
Homerton Healthcare NHS Foundation Trust1
H & R Healthcare Limited1
Jigsaw Homes Group Limited1
Ministry of Justice1
Sussex Partnership NHS Foundation Trust1
English unitary authority3
NHS trust3
Executive non-departmental public body2
Health and social care service regulator2
Ministerial department2
Private limited company2
Executive agency1
Police force1
Registered provider of social housing1
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.
East Riding and Hull
Concerns raised1
Failure to follow up on intended GP support
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each 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
Action
Undertake an unannounced assessment covering visit duration, nutrition and hydration, health monitoring, escalation, record keeping, governance, safeguarding and decision-making.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 5 November 2024.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Neither inspection raised concerns about staff failing to escalate health concerns, and the earlier inspection found appropriate healthcare referrals.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Position
The January 2020 inspection found no concerns about staff supporting people to access healthcare services and support.
Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
Dorset
Concerns raised1
Failure to ensure PPNs reach GPs for Dorset Council residents
Responses linked to these concerns
Each 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.8
Action
Review PPN-sharing processes with Dorset and BCP Adult Social Care partners to identify safeguarding risks and consistency improvements.
Stated by Dorset PoliceStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
Action
Conduct a further review with Health and Social Care partners of PPN-sharing processes, using national best practice to identify improvements.
Stated by Dorset PoliceStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Review current PPN-sharing processes with Dorset Police and BCP Council to identify improvements.
Stated by Dorset CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
Action
Amend Dorset Police and Dorset Council PPN-sharing processes to align with BCP processes.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Fund and recruit additional MASH staff to support sharing PPNs with GPs, with recruitment planned by the end of May 2022.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Meet with Dorset Police, BCP and health partners, including GP safeguarding leads, to discuss PPN-sharing processes and improvements.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Seek approval to align a partnership review of Adult MASH PPN sharing with the Children’s MASH review.
Stated by Dorset CouncilStated plannedThe respondent said that this action was planned when they made their response on 4 February 2022.
Action
Amend the Adult Access Team process to forward PPNs to relevant agencies regardless of Adult Social Care involvement.
Stated by Dorset CouncilStated completedThe respondent said that this action was complete when they made their response on 4 February 2022.
Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.2
Position
Police cannot share PPNs with GPs directly because it lacks access to the Dorset Care Record.
Stated by Dorset PoliceUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Position
Dorset Council Adult Social Care staff will be responsible for sharing PPNs with GPs using the Dorset Care Record.
Stated by Dorset PoliceRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.
Cornwall and Isles of Scilly
Concerns raised1
Failure of doctors considering opiate prescriptions to contact the registered GP
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 concerns
Each 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.5
Action
Inspect each registered online provider identified from the inquest and review their medication-prescribing management processes.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
Action
Submit proposals to DHSC for legislative changes addressing regulatory safety gaps in independent online primary care services.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
Action
Share key learning and practice points from the inquest with relevant providers and stakeholders.
Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 22 February 2021.
Action
Continue using enforcement powers to require improvements when online providers fail to meet regulatory requirements.
Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 22 February 2021.
Action
Publish guidance setting expectations for providers to inform patients’ GPs about prescribed medicines and assess safety when information sharing is declined.
Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 22 February 2021.
Black Country
Concerns raised1
Failure to contact the GP or a family member when a patient living alone requires follow-up
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Manchester North
Concerns raised1
Failure to redirect concerns or contact the person's GP
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Exeter and Greater Devon
Concerns raised1
Failure to ensure that the GP is informed
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 concerns
Each 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
Position
The provider could not share consultation details with the patient’s GP because there was no legal justification to breach confidentiality.
Stated by NHS EnglandUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
Inner North London
Concerns raised1
Lack of clear guidance for Community District Nursing team nurses on when to involve a community patient’s GP
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 concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Failure to contact the patient’s GP to verify medication application answers
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
Brighton and Hove
Concerns raised1
Failure to contact the GP about the referral
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 concerns
Each 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
Action
Allocate named Consultant Psychiatrists to GPs and arrange meetings to clarify referral roles and expectations.
Stated by Sussex Partnership NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 December 2014.
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Includes failures by care, community, mental-health, supported-accommodation or other services to identify when a patient's safety concern requires primary-care involvement and to contact, refer to or obtain a response from the patient's GP or appropriate primary-care service, including unclear escalation guidance, failure to arrange GP attendance and failure to follow up intended GP support.
