Recurring concern

Failure to provide sufficient GP involvement in patient care

First to latest report 17 Jan 2014 — 26 Mar 2026

Reports that mention this concern
17
Times this concern has been raised
17
Stated actions linked to this concern
17

What this concern includes

Includes failures to provide, maintain or act on sufficiently active GP involvement in a patient's care, including minimal involvement, failure to conduct requested GP reviews and failure to provide necessary GP oversight of changing or abnormal clinical circumstances.

What is not included
  • Excludes generic communication, referral, staffing or documentation deficiencies unless they directly result in insufficient GP involvement in the patient's care.
  • Excludes failures of specialist, hospital, mental-health or nursing involvement where GP involvement is not the shared unsafe condition.
  • Excludes isolated failures to act on a specific test, prescription or referral when sufficient GP involvement was otherwise provided and the issue belongs to a narrower clinical process.
  • Excludes routine care in which GP involvement was not clinically indicated or requested.

Reports and published responses 17 reports

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

  1. Manchester South

    AI-generated summary

    Irene Anne Pearson · 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

    Irene Anne Pearson had terminal colon cancer that had spread to other organs and was receiving palliative Matrifen patches. On 19 July 2015, she was found dead in a hot bath at home, apparently still wearing the patch; the stated medical cause of death included opiate toxicity. Concerns included warnings about hot baths and patch removal, advice and communication about opiate medication, unclear prescribing records, and the adequacy of information supplied by the GP practice to the Coroner.

    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 liaison with the GP Practice over regulation of additional opiate pain-control

    Wider context from the report

    “4. I was told that the Macmillan Nurses will prescribe additional opiate pain-control, but there seemed little or no liaison with the GP Practice as to the regulation of this.(Macmillan Cancer Care) ”

    Source location

    Irene Anne Pearson · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

    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 faxing practice within 24 hours and GP record scanning are considered sufficient liaison for medication changes.

    Verbatim wording from the response

    “I was told that the Macmillan Nurses will prescribe additional opiate pain control, but there seemed little or no liaison with the GP Practice as to the regulation of this.”

    Source location

    I-Pearson-Response2
    Page 1 · response
    Published 19 January 2016

    Open published response

  2. Manchester South

    AI-generated summary

    Nathaniel Luke Phillips · 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

    Nathaniel Luke Phillips died at Tameside General Hospital after an acute asthma attack; the inquest recorded hypoxic brain injury due to the attack. Concerns included the cost of regular asthma prescriptions, his apparent loss to adult asthma services, and delays in ambulance availability during his final emergency.

    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 GP escalation or reassessment when regular prescriptions are not collected

    Wider context from the report

    “One of the concerns raised by the family and the GP was that a diagnosis of brittle asthma is not one of the illnesses covered by the medical exemption certificate, despite the fact that it is a life-threatening condition requiring medication. It was confirmed that illnesses such as diabetes and epilepsy which require continuous medication are covered. As indicated earlier due to the cost of his constant medication Nathaniel did not always collect regular prescriptions and relied on family members asthma medication. This meant his GP did not escalate his case or reassess his requirements and asthma control. ”

    Source location

    Nathaniel Luke Phillips · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Viola Burke · 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

    Viola Burke, aged 80, died on 5 January 2015 after developing a productive cough and shortness of breath, receiving a diagnosis of chest infection, and later collapsing at home. Concerns included reliance on an asthma pump despite no recorded asthma diagnosis, the absence of a care plan that would have provided Out of Hours clinicians with fuller medical records, and questions about the implementation and accessibility of the care plan system.

    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 raise care-plan provision during subsequent patient contacts

    Wider context from the report

    “(3) Evidence was given at the inquest that Viola had been sent an invitation letter on 1 October 2014 to attend the surgery for the care plan. When Viola did not respond the GP receptionist is reported to have made three unanswered telephone calls to Viola’s landline number. The GP consultation record produced at inquest stated ‘Admission avoidance care ended’. The records also showed that Viola attended the surgery with her son on 5 October, and on two further occasions during October on the 11th and 21st. Her daughter is also seen to have telephoned on the 30th. Viola then has eight monitoring entries in November and four in December 2014. At no point was the matter of the Care Plan raised with her. ”

    Source location

    Viola Burke · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Brighton and Hove

    AI-generated summary

    Paul Leslie HYDE · 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

    Paul Leslie Hyde died after taking an overdose of medication that had been stopped, with the sedatory effect contributing to his death. The report raised concerns that his referral for a psychiatric medication review was not appropriately addressed, that he was not seen within the required period or followed up, and that the re-referral system was not fit for purpose.

    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 contact the GP about the referral

    Wider context from the report

    “(1) On the 14th April 2014, GP Dr. Peter Devlin having anxieties expressed to him by one of the Community Mental Health Workers concerning Paul Hyde’s deteriorating condition, sought advice from the Assessment and Treatment Team of the Community Mental Health Services. He spoke to Graham Walton who advised him that he should refer Mr. Hyde back to ATS (Assessment and Treatment Service). He therefore wrote a letter on the 15th July, 2014 and this was sent so that it arrived on the same day, expressing his anxiety. (2) The request was for Mr. Hyde to see a Psychiatrist to carry out a medication review. It is clear that this Medication Review needs to be carried out by the Psychiatrist in a face-to-face review with the patient. (3) The referral was not appropriately addressed until some 14 days in to the 28-day period within which the patient is required either to have been seen by ATS or the Psychiatrist or the GP. It was decided, though very poorly documented that the Psychiatrist should phone the GP to see whether, after discussion, it was possible for the GP to prescribe a new medication for Mr. Hyde. It should have been obvious from the start that this was not a direction for this referral to take. There seems to be no facility for the Psychiatrist to be involved in the assessment procedure and indicate a course him or herself. There should be. In any event, no contact was made with the GP and there is apparently no follow up system so no one seems to have picked up that not only was Mr. Hyde not seen within the 28-days of referral, but in fact that he was not seen at all i.e. he was lost to follow up. (4) From the point of view of Mr. Hyde, the re-referral system was not fit for purpose. In the event, Mr. Hyde took an overdose of the medication which had been stopped, although he still had some tablets, and the very sedatory effect that he had complained about kicked in, resulting in his death. ”

    Source location

    Paul Leslie HYDE · Prevention of Future Deaths report
    Page 1 · 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

    Allocate named Consultant Psychiatrists to GPs and arrange meetings to clarify referral roles and expectations.

    Verbatim wording from the response

    “We are always striving to improve the interface between primary care and secondary mental health services. In order to improve relationships between GPs and Consultant Psychiatrists, GPs have been allocated named Consultant Psychiatrists. Meetings between the psychiatrists and GPs have been arranged. ████████ is leading on this to ensure both GPs and psychiatrists are clear on their roles and the expectations of referrals. Work is on-going to ensure there is a joined-up approach for our service users and their families and there is continual learning and improvement. Mr Hyde’s experience has been shared (anonymously) with staff to drive home the lessons to be learned. In addition, to ensure widespread learning, feedback from the case has been given to ████████ Director of Nursing Standards and Safety.”

    Source location

    2014-0527-Response-by-Sussex-Partnership-NHS
    Page 2 · response
    Published 5 December 2014

    Open published response

  5. Manchester (North)

    AI-generated summary

    Lucasz Lewandowski · 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

    Lucasz Lewandowski suffered catastrophic head injuries after jumping from the roof of his employer’s building on 16 July, and died two days later. The principal concerns included delays and communication failures in emergency and mental-health responses, failures in psychiatric information-sharing and continuity of care, and issues concerning clinical decision-making and responsibility for his safety.

    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 and reluctance to correspond with patients’ GPs and other healthcare professionals after consultation

    Wider context from the report

    “4. The psychiatric practice’s failure and reluctance to correspond with a patient’s GPs and/or other healthcare professionals following consultation, jeopardising continuity of care. ”

    Source location

    Lucasz Lewandowski · Prevention of Future Deaths report
    Page 3 · 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

    Implement a psychiatric protocol requiring documented risk assessments, action on identified risks, communication with relevant healthcare professionals, and periodic review.

    Verbatim wording from the response

    “Bearing in mind the particular circumstances and lessons from this case, a protocol is now being implemented specifically in relation to psychiatric practice so that a clear risk assessment must be recorded on the patient’s notes and such risk assessment to be acted upon and communicated to other relevant healthcare professionals.”

    Source location

    2014-0445-Response-by-Green-Surgery-Medical-Dental-Care
    Page 1 · response
    Published 15 October 2014

    Open published response

  6. Portsmouth and South East Hampshire

    AI-generated summary

    George Robert Vickery · 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

    George Vickery fell after getting out of an ambulance outside Oak Park Community Clinic while attending for leg treatment, sustaining a broken hip and dying the next day in hospital. The concern was that the decision to treat him at the clinic rather than at home did not take account of his GP’s request that he be treated at home.

    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 have proper regard to the patient's GP's views on treatment arrangements

    Wider context from the report

    “That the decision to treat Mr Vickery at the clinic rather than in his own home (as had been the case previously) was taken without regard to a request from his GP that he should be treated at home, not at a clinic. In my opinion, when assessing how and where a patient should be treated, or when assessing whether any changes should be made as to how and where a patient is treated, Southern Health's Integrated Community Services should formally consult with the Patient's GP and have proper regard to the GP's views on these matters. ”

    Source location

    George Robert Vickery · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Cornwall

    AI-generated summary

    JULIA SHEEREN DELL · 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

    Julia Sheeren Dell, aged 45, took her own life after jumping from cliffs at Duckpool Beach and died of multiple injuries. The report identified concerns about limited primary-care contact after 4 April 2012, no formal handover between doctors, and no apparent action on a care plan received from the Community Mental Health Team.

    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 primary care to maintain involvement and awareness of fluctuating mood

    Wider context from the report

    “I was told that on 4 April 2012 Mrs Dell decided to change GP within the practice and her care then passed to ███████ and ███████ who job share. In the period from 4 April until Mrs Dell’s death on 22 August there was only one further contact with primary care. At inquest, ███████ conceded that: “it would have been nice for there to have been more involvement from primary care after 4 April 2012”. He indicated also that the surgery was unaware of Mrs Dell’s fluctuating mood from April until her death. (1) There appears to have been no formal hand over between ████████ to ████████ in early April 2012. (2) On 19 April 2012 a care plan was received from the Community Mental Health Team following Mrs Dell’s discharge from their care back to primary care. No action seems to have been taken upon its receipt. It appears as though the doctors have accepted the reassurance of the CPN that Mrs Dell’s moods had stabilised on the medication prescribed to her notwithstanding the fact that only three weeks previously on 22 March 2012 ████████ had contacted ████████ to express his concerns over Mrs Dell’s wellbeing ”

    Source location

    JULIA SHEEREN DELL · 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