Recurring concern

Inadequate GP consultation provision for safe patient assessment

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First reported 26 Feb 2016•Latest report 18 Dec 2025

Definition

What this concern includes

Includes deficiencies in the GP consultation system or its dedicated controls that materially limit timely, sufficiently thorough or effective assessment and communication, including appointment capacity or duration and consultation arrangements that impede understanding of deterioration.

Not included

  • Excludes generic workforce, administrative or communication failures not specifically tied to the safety of GP consultation provision.
  • Excludes failures in hospital, ambulance, prescribing, discharge, or other care pathways unless the assertion specifically concerns GP consultation provision.
  • Excludes isolated documentation, follow-up, referral, or clinical-management failures that do not make GP consultation provision itself unsafe.
Reports
17

Distinct published reports

Individual concerns
19

A report can raise multiple concerns

Date range
2016–2025

First to latest report issue date

Stated actions
27

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.

Department of Health and Social Care7
NHS England5
NHS Greater Manchester Integrated Care Board5
NHS Birmingham and Solihull Integrated Care Board2
Ashfield Surgery1
Beech Cliffe Grange1
Beech Cliffe Limited1
Black Country Family Practice1
Egton Medical Information Systems Limited1
Family of Richard Parkes1
Greater Manchester Health and Social Care Partnership1
Midlands Partnership University NHS Foundation Trust1
Nottinghamshire Healthcare NHS Foundation Trust1
Partnering Health Limited1
Queen Mary University of London1

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.

  1. Manchester South

    AI-generated summary

    Amy Hogan · 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

    Amy Hogan reported feeling unwell from around September 2019 and attended an out-of-hours doctor on 20 January 2020 with light-headedness, weakness and exhaustion. She became acutely unwell and collapsed at home the following day, dying at hospital aged 23. The principal concerns were that her previous GP records had not transferred and that the out-of-hours GP could not electronically access her regular records, including information that she was prescribed the oral contraceptive pill.

    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

    Unavailability of electronic access to regular GP records in out-of-hours care

    Wider context from the report

    “2) Notwithstanding numerous previous initiatives as to information-sharing and digitisation of patient data, it is a matter of concern that the out of hours GP receiving Miss Hogan had no electronic access to her regular GP records. Access to such records would have revealed, amongst other things, Miss Hogan was prescribed the oral contraceptive pill, which is likely to have led the doctor to ask additional questions about her symptoms. Again, it is a matter of particular concern that an inability to access regular GP records in the out of hours setting raises additional risks for vulnerable patients. ”

    Source location

    Amy Hogan · 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

    Enable authorised professionals to access GP records through GP-Connect across primary care settings.

    Verbatim wording from the response

    “Over recent months significant progress has been made around the access to GP records out of hours. As a response to the pandemic, we have enabled the use of GP-Connect across the whole primary care estate. This eases facilitation for authorised professionals in multiple care settings to directly access in a safe and secure manner GP records which are held at GP out of hours services, CCAS, Extended Access Hubs and NHS 111.”

    Source location

    2020-0147-Response-from-NHS-England.pdf
    Page 1 · response
    Published 7 October 2020

    Open published response
  2. Manchester South

    AI-generated summary

    George Townsend · 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 Townsend, who was receiving long-term antibiotic therapy, developed worsening diarrhoea and was later diagnosed in hospital with Clostridium difficile infection and pneumonia. He died at Trafford General Hospital on 30 August 2019 from multi-organ failure due to bronchopneumonia. The concerns included delayed GP assessment and testing, inadequate escalation from the nurse to a doctor, failure to recognise the risks associated with his health conditions, poor medical record-keeping, and longstanding concerns about GP practice capacity and oversight.

    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

    Insufficient GP capacity to see patients

    Wider context from the report

    “1. The inquest heard that Mr Townsend should have seen a GP and had further tests prior to his admission to Salford Royal Hospital. The inquest heard that at the GP practice in question there were insufficient GPs to see patients. In addition there was no evidence of a clear escalation process from the Nurse to a Doctor within the practice. ”

    Source location

    George Townsend · 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

    Gather workforce data and identify Trafford primary-care areas needing workforce-model support through the Primary Care Workforce Delivery Group.

    Verbatim wording from the response

    “To offer further assurance around GP availability generally, the CCG has a Primary Care Workforce Delivery Group which has a remit to review current primary care workforce supply and demand in Trafford, and to make recommendations for improvement and sustainability, aligned to integrated commissioning principles. Some of its key actions include:”

    Source location

    2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
    Page 3 · response
    Published 22 October 2020

    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

    Lead the Greater Manchester GP Retention Scheme to promote flexible working and support retention of general-practice clinicians.

    Verbatim wording from the response

    “An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford’s allocated funding for 2020/21 has been used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.”

    Source location

    2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
    Page 3 · response
    Published 22 October 2020

    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

    Use 2020/21 Trafford funding to secure Basic Trainer Course placements for five GPs, increasing local training capacity.

    Verbatim wording from the response

    “An example of an area of work undertaken by this group includes leading on the GM GP Retention Scheme which aims to facilitate initiatives to enable clinicians to stay in the workforce, through promoting new ways of working and providing a more flexible offer that will create a sustainable model within general practice. The CCG is keen to attract, train and retain clinical roles and so part of Trafford’s allocated funding for 2020/21 has been used to secure placements on the Basic Trainer Course for 5 Trafford GPs, increasing the number of training environments within the borough. This initiative not only provides placements for training clinicians but also supports the professional development of our existing workforce.”

    Source location

    2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
    Page 3 · response
    Published 22 October 2020

    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

    Undertake a practice diagnostic and progress its resulting organisational action plan with the CCG’s primary-care leadership.

    Verbatim wording from the response

    “September 2018 Following meetings between Dr ████████ and the CCG’s Medical Director, Dr ████████ (MJ), Dr ████████ agreed for the CCG to undertake a “practice diagnostic”. The diagnostic took place on the 25th & 26th September 2018. The report made 14 recommendations, which were mainly organisational issues. The report concluded that the clinical care was generally safe and this was based on triangulating a number of nationally available data sources. The report also noted that the practices were offering more appointments per 1000 population than the evidence suggested, however the report advised Dr ████████ to appoint two additional full time GPs.”

    Source location

    2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
    Page 5 · response
    Published 22 October 2020

    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

    The practice had slightly more GP appointments available than average, disputing that insufficient GP cover caused the concern.

    Verbatim wording from the response

    “Whilst there are general guiding principles and different methodologies for calculating the number of GPs to cover the number of patients a practice has, GP cover varies from practice to practice. The earlier diagnostic workup that the practice had slightly more GP appointments available to patients than average.”

    Source location

    2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
    Page 2 · response
    Published 22 October 2020

    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

    The CCG could not recruit additional GPs, appoint a caretaker or formally intervene because operational responsibility remained with the practice contract holder.

    Verbatim wording from the response

    “inspections, Dr ████████ CQC registration was suspended from his Old Trafford contract meaning he would be unable to practice. In the case of GH his registration was not suspended meaning, whilst he could not practice he was still responsible for the day to day operational running of that practice, including the adequate clinical cover for patients registered at GH. The CCG were unable to intervene with recruiting with more GP’s and other support generally as this was the responsibility of Dr ████████ at that time.”

    Source location

    2020-0157-Response-from-NHS-Trafford-Clinical-Commissioning-Group_Redacted-1.pdf
    Page 6 · response
    Published 22 October 2020

    Open published response
  3. South Yorkshire (Eastern)

    AI-generated summary

    Steven Jones · 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

    Steven Jones, aged 27, was a non-verbal resident of a care home who became ill with sickness, diarrhoea, loss of appetite and sleep disturbance before dying on 10 December 2013. He was diagnosed with a perforated colon, leading to multi-organ failure and hypoxic brain injury. Concerns included failures to escalate carers’ concerns, insufficient incident reporting, delayed medical referral, and delays in calling emergency services and transferring him 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

    Failure to ensure the resident and one-to-one carer attend general-practitioner consultations

    Wider context from the report

    “(5) In the case of a non-verbal resident with serious problems very early referral to a general practitioner was not made and when made the resident was not present at the consultation nor was his one to one carer in attendance. ”

    Source location

    Steven Jones · 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

    Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.

    Verbatim wording from the response

    “In June 2014 the Anticipatory HealthCare Calendar (AHCC) was introduced. ████████ raised the introduction of this system in her evidence to the Inquest on 9 November 2017. This is a NHS proforma that acts as a criteria-referenced monitoring system for health-related issues in those with learning disabilities. Specific symptoms are listed and given a risk level of Green, Amber or Red; amber and red directly link to required specific staff actions and responses, which are described within the tool and recorded on a Significant Communication Sheet, part of the tool. These range from continued monitoring, through administering pain relief or attending a GP surgery when possible, to contacting emergency services immediately. AHCC is a career-level tool that is directive in terms of response to specific symptoms.”

    Source location

    2017-0357-Response-by-Beech-Cliffe-Limited
    Page 3 · response
    Published 11 February 2018

    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

    The resident’s absence from the GP consultation was treated as a justified one-off decision based on infection and behavioural concerns.

    Verbatim wording from the response

    “As set out at paragraph 17 of her witness statement dated 4 October 2017, paragraph 20 of her witness statement dated 4 April 2016 and in evidence to the Inquest on 9 November 2017 Sarah did not take Steven to the appointment on 28 November 2013 because she was concerned that due to his diarrhoea and the unknown result of the stool sample he could be infectious. Also Steven had previously exhibited anxious and challenging behaviour at appointments. She explained her reasoning to the GP, ███████ who was happy to proceed with the appointment. When asked by the Coroner on 8 November 2016 ███████ confirmed that he could have insisted on seeing Steven either at the GP surgery or at the Home.”

    Source location

    2017-0357-Response-by-Beech-Cliffe-Limited
    Page 6 · response
    Published 11 February 2018

    Open published response
  4. Manchester North

    AI-generated summary

    Christopher Ian Fairhurst · 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

    Christopher Ian Fairhurst, aged 26, was found deceased on a footpath near Spotland Bridge, Rochdale, on 5 December 2016, with empty alcohol bottles and paracetamol packets nearby. The report identified concerns about shortages of GPs, lack of continuity and accessibility of care, inadequate appointment times and GP training, and increasing demand and referral thresholds for adult and children’s Autism and ADHD/ADD services.

    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 duration of GP appointments

    Wider context from the report

    “3. In order to meet ever increasing demand and to reduce delays in accessibility, GPs are being forced to adopt alternative systems such as telephone consultations (upwards of 50 per day; this is over and above all other aspects of their job) rather than face to face appointments, offering patients appointments with other health care professionals rather than a doctor etc. Further, the average appointment with a doctor – where an appointment is secured – has decreased as a direct consequence of demand and is currently an average of 7.5 minutes per patient. This is insufficient in most cases and wholly inadequate in others e.g. where the patient has a complex medical history or mental health problems. Offering double or treble appointments does not solve this problem as it reduces the number of appointments available for others. ”

    Source location

    Christopher Ian Fairhurst · 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 of general practice access systems to provide appropriate doctor consultations

    Wider context from the report

    “3. In order to meet ever increasing demand and to reduce delays in accessibility, GPs are being forced to adopt alternative systems such as telephone consultations (upwards of 50 per day; this is over and above all other aspects of their job) rather than face to face appointments, offering patients appointments with other health care professionals rather than a doctor etc. Further, the average appointment with a doctor – where an appointment is secured – has decreased as a direct consequence of demand and is currently an average of 7.5 minutes per patient. This is insufficient in most cases and wholly inadequate in others e.g. where the patient has a complex medical history or mental health problems. Offering double or treble appointments does not solve this problem as it reduces the number of appointments available for others. ”

    Source location

    Christopher Ian Fairhurst · 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

    Delays and unavailability in access to GP appointments

    Wider context from the report

    “4. Patients frequently find themselves held in long telephone queues when trying to get appointments. When they eventually get through (often after half an hour or so of waiting), they are told that all appointments for that day have already gone. When they ring the following day, the situation is repeated. Patients often give up or spend days trying before they eventually get a GP appointment. At peak times (Monday/Friday mornings) surgeries can have as many as 300 incoming calls first thing. ”

    Source location

    Christopher Ian Fairhurst · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
  5. Staffordshire South

    AI-generated summary

    Dean Mark Rowland · 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

    Dean Mark Rowland, who had a history of two recent self-harm attempts and depression, was found hanging from a bannister on 21 March 2017, and the inquest concluded that his death was suicide. Concerns included his inability to obtain a GP appointment or telephone consultation for nine days when he wished to discuss increasing his antidepressant medication, and his discharge from the community mental health team after one consultation without a follow-up plan beyond returning to primary care.

    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

    Delays in access to a GP for medication discussions

    Wider context from the report

    “(1) The deceased wished to discuss an increase in his antidepressant medication with a doctor. He was unable to get an appointment or speak to a GP on the telephone for nine days. ”

    Source location

    Dean Mark Rowland · 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

    Implement a duty-doctor and telephone-triage system providing prompt callbacks and same-day clinical assessment when routine appointments are unsuitable.

    Verbatim wording from the response

    “We have instituted a duty doctor and telephone triage system in the practice. If the patient attends or phones the practice requesting an appointment they are told when the next routine appointment is available for the doctor of their choice and for any doctor. If they feel they need to be seen that day or that their condition will not wait until the next available routine appointment they are offered a “callback”. They will be called as soon as possible by one of the duty team who will either deal with the problem over the telephone or make them an appointment that day to see a doctor or a nurse practitioner - whichever is the most appropriate for the problem. This means that everyone who needs to be seen will be seen on the same day.”

    Source location

    2017-0208-Response-by-Peel-Medical-Practice
    Page 1 · response
    Published 12 September 2017

    Open published response
  6. Birmingham and Solihull

    AI-generated summary

    Timothy Simon Jones · 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

    Timothy Simon Jones, who had Down syndrome, epilepsy and dementia and required PEG feeding, was admitted to hospital with breathing difficulties and aspiration pneumonia, was discharged and readmitted the same day, and died on 17 July 2016. Concerns included incomplete GP record keeping, unclear communication and documentation of requests for home visits, lack of GP clinical assessment despite deteriorating health and complex needs, a home-visit policy that did not address residents with complex chronic conditions, and antibiotic prescribing for aspiration pneumonia.

    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 GP clinical assessment for patients with deteriorating conditions and complex needs

    Wider context from the report

    “3. There was no clinical assessment of the deceased by a GP after the 25 May 2016 despite his deteriorating condition and complex needs. ”

    Source location

    Timothy Simon Jones · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report
  7. Black Country

    AI-generated summary

    Mr Richard Parkes · 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

    Mr Richard Parkes collapsed and died on 28 December 2015 after developing deep vein thrombosis with associated pulmonary thromboembolism. Concerns included poor record keeping, unavailable records from an August appointment, and the practice policy of not seeing patients more than ten minutes late, including on an occasion when Mr Parkes was not seen because he was late.

    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 assess the risks of excluding patients who are late for appointments on a case-by-case basis

    Wider context from the report

    “1. There was evidence of poor record keeping at The Black Country Family Practice. Specifically records of the August appointment were not available and there was a policy of not seeing patients who were more than ten minutes outside their appointment time. Evidence emerged during the inquest that the GP who had seen Mr Parkes initially on the 12 October 2015 and arranged a further appointment on the 23 October 2015 and crucially, was aware of his medical history had decided not to see him on the latter date when he was late for his appointment. 2. Continuity of care and knowledge of medical history is extremely important in the management of patient care and this GP Practice may wish to consider reviewing their policy and management of record keeping. 3. In addition they may wish to consider reviewing the systems in place for excluding patients who are more than ten minutes or more late for appointments. There are inherent risks in adopting this policy and each case should be considered on a case by basis based on risk assessment. ”

    Source location

    Mr Richard Parkes · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026