Recurring concern

Failure to maintain accurate patient addresses and primary-care details

First to latest report 6 Feb 2014 — 12 Jul 2024

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

What this concern includes

Includes failures to record, verify, update or make available a patient's current address, GP practice, GP registration or GP contact details where those details are needed to route clinical information, arrange follow-up or contact primary care.

What is not included
  • Excludes inaccurate contact details for family members, next of kin, keyholders or other non-primary-care recipients unless the assertion also concerns the patient's own address or GP details.
  • Excludes generic clinical-record or administrative-data deficiencies where patient address or primary-care details are not the unsafe object.
  • Excludes failures to communicate with or follow up a patient after accurate address and GP details were available.
  • Excludes broader referral, discharge or continuity-of-care failures where inaccurate or unavailable patient address or primary-care details are not the material cause.

Reports and published responses 4 reports

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

  1. Inner West London

    AI-generated summary

    Judith Maike OBHOLZER · 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

    Mrs Obholzer died by suicide on 12 July 2023 after jumping in front of a moving train, following a significant period of worsening depression and anxiety. Concerns included delays in NHS mental-health assessment and waiting-list placement, unclear routes for private practitioners to obtain NHS crisis support, difficulties contacting her GP, and the absence of shared medical notes between private and NHS 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

    Unavailability of GP registration and contact details to medical practitioners

    Wider context from the report

    “3. In the course of the evidence it was confirmed that the private consultant psychiatrist was unable to send the urgent letter to Mrs Obholzer’s GP in part because their details had not been provided. Consideration should be given to ensuring that all medical practitioners (private and NHS) can access GP registration details for patients and GP contact details to avoid delays where there is an urgent need to contact a person’s GP. ”

    Source location

    Judith Maike OBHOLZER · 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

    Continue trialling Summary Care Record access with private hospitals and privately funded healthcare services.

    Verbatim wording from the response

    “The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 July 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

    Work with an Expert Advisory Committee to seek approval for independent-sector rollout and consider its scope, exclusions, constraints, and caveats.

    Verbatim wording from the response

    “The SCR Team at NHS England have undertaken significant work with a number of private sector organisations, including a range of private hospitals and privately funded healthcare services trialling the use of SCRs within settings where they have previously been unavailable, and this work continues. The Team will work with an Expert Advisory Committee to seek full rollout approval within the independent/private sector and consider the scope of this approval and any specific exclusions, constraints, or caveats.”

    Source location

    Response from NHS England
    Page 2 · response
    Published 31 July 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

    Review the interface between NHS and non-NHS-funded independent health providers.

    Verbatim wording from the response

    “Work is also in progress to review the interface between the NHS and non-NHS funded independent health providers. This work is in its infancy, but NHS England can provide an update to the Coroner in due course if this would assist. We understand that the Care Quality Commission (CQC) are also undertaking work regarding standards for online care and are exploring opportunities for better sharing of information both into private sector providers and receiving information back to the patient’s registered GP practice from private providers.”

    Source location

    Response from NHS England
    Page 3 · response
    Published 31 July 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

    Access to GP registration and contact details is considered a national issue for the Department of Health or NHS England.

    Verbatim wording from the response

    “The Trust does not feel able to provide a response to this aspect of the PFDR as access to GP registration details is a national issue. We understand that the response to this concern will come from the DH or NHSE response.”

    Source location

    Response from SW London Mental Health Trust
    Page 6 · response
    Published 31 July 2024

    Open published response

  2. West Yorkshire Eastern

    AI-generated summary

    Scott Patrick Carton · 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

    Scott Patrick Carton was released from prison on 5 January 2017 to the Westgate Project Hostel in Wakefield and was found dead there on 10 January 2017. His death involved the synergistic combination of prescribed methadone, pregabalin and tramadol. Concerns included the suitability of his hostel placement, the lack of anticipated psychological support and a clear management plan, and wider gaps in support for prisoners with mental health and drug dependence issues before and after release.

    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 arrange immediate GP registration after release

    Wider context from the report

    “6. To maximise the prospect of a successful reintegration into society, prisoners with mental health issues and/or drug dependence need appropriate support services to be in place prior to their release and arrangements made to have them registered with a GP immediately (so as to provide a conduit to community mental health services) ”

    Source location

    Scott Patrick Carton · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. London Inner (North)

    AI-generated summary

    John DACK · 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

    John Dack sustained fractures to both ankles, underwent procedures and was discharged home unable to weight bear without the planned follow-up. He later developed an infected left ankle with osteomyelitis and died on 24 September 2014 after hospital treatment. The report’s principal concern was that an incorrect address in his medical notes prevented follow-up despite notifications from his daughter; it also raised concern about early discharge home after the MDT meeting.

    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 maintain accurate patient addresses in medical notes

    Wider context from the report

    “Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff of this on two separate occasions. What seems at first blush to be a relatively unimportant administrative matter can therefore have serious consequences. I heard from the surgeon treating Mr Dack that this has happened before with other patients. It seems that this part of the system of administration would benefit from review. ”

    Source location

    John DACK · 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

    Emphasize to relevant staff the importance of accurately recording and changing patient details.

    Verbatim wording from the response

    “Our investigation has concluded that the ward clerk was told to change Mr Dack’s address by the patient’s nurse. A mistake was made however as she recorded him as being of ‘no fixed abode’. We have asked the ward matron to speak to her staff to remind them of the importance of accurately changing patient details and the consequences of not doing so.”

    Source location

    2015-0151-Response-by-Barts-Health-NHS
    Page 1 · response
    Published 19 February 2015

    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 clerical address error did not cause Mr Dack to be lost to follow-up because he knew about and rearranged his appointment.

    Verbatim wording from the response

    “Your concern was that Mr Dack was not called for follow up because his medical notes recorded the wrong address for him, despite the fact that one of his daughters had notified staff.”

    Source location

    2015-0151-Response-by-Barts-Health-NHS
    Page 1 · response
    Published 19 February 2015

    Open published response

  4. Staffordshire South

    AI-generated summary

    Ethel Smith Leese · 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

    Ethel Smith Leese, aged 94, was admitted to hospital after a fall at her care home on 1 January 2013 and died on 4 January 2013. The inquest concluded that her death was accidental, involving intracerebral and subdural haemorrhage, a fall, warfarin-induced coagulopathy, and other listed conditions. The principal concern was chaotic monitoring arrangements for her warfarin levels, including uncertainty and errors concerning her address and GP practice after she moved to the care 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 maintain accurate patient address and GP practice details

    Wider context from the report

    “(1) There was one matter of concern which relates to the monitoring of Mrs Leese’s warfarin levels. The move to the care home required Mrs Leese to be changed to a different GP practice. The checking by the hospital of Mrs Leese’s address (including the address for posting for the yellow booklet) appears to have been fairly chaotic. Her address on the paperwork seems to have remained unchanged, there appears to have been doubt as to whether Cumberland House Medical Practice in Stone or the Penkridge Medical Practice (covering Dunston) were her GPs practice and indeed on one occasion information was sent to the wrong GP practice in Stone (Mansion House). It may be that Mrs Leese was initially considered to be a temporary resident at the care home in Dunston but I wonder if there is a possibility to record addresses better. Possibly this may not just apply in the Haematology Department but in the hospital as a whole. Whilst this may not have been directly relevant in this case it could be significant in other deaths. ”

    Source location

    Ethel Smith Leese · 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