Recurring concern

Unreliable arrangements for requesting and responding to GP home visits

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First reported 24 Nov 2016•Latest report 16 Dec 2020

Definition

What this concern includes

Includes failures in the GP home-visit process from receiving and clinically recognising a request through recording, prioritising, assigning and arranging the visit, and communicating or documenting the response, including requests made through out-of-hours or ordinary GP services.

Not included

  • Excludes generic GP access, appointment, referral or clinical-assessment failures where a home visit is not the material process.
  • Excludes failures in conducting or documenting the clinical care during a home visit after the visit has been arranged and attended.
  • Excludes general telephone, administrative-task or record-keeping deficiencies unless they directly impair requesting, prioritising, arranging or responding to a GP home visit.
  • Excludes failures to seek medical advice or escalation in care homes where no GP home-visit request or arrangement is identified.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2016–2020

First to latest report issue date

Stated actions
1

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.

Covid-19 Pandemic Response Service1
NHS Birmingham and Solihull Integrated Care Board1
NHS Pathways1
Richmond Medical Centre (Solihull)1

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. Cumbria

    AI-generated summary

    Patricia Ann Douglas · 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

    Patricia Ann Douglas contacted NHS 111 with severe breathlessness and a history of anaemia requiring a blood transfusion. Her referral to a Covid assessment service contained an incomplete telephone number, so the doctor could not contact her and the call was closed; she later deteriorated, collapsed at A&E and could not be resuscitated. Concerns included the initial triage pathway, the failure to follow up the referral, and a potentially missed opportunity to investigate and treat her.

    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 act on requests for a doctor visit from people feeling very unwell

    Wider context from the report

    “(3) This lady rang for help feeling very unwell, I am told she wanted a doctor to visit, unfortunately nothing happened and it seems very likely that an opportunity to investigate and treat her was missed. I note that two GPs would have been working for the OOH provider at Penrith Hospital –just a mile from Patricia’s home, that Sunday afternoon, one based in the hospital and the other doing home visits. ”

    Source location

    Patricia Ann Douglas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. 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 clearly request and document home visits

    Wider context from the report

    “2. I heard evidence at the inquest that the residential home had requested several home visits from the GP, on 5 July 2016, 12 July 2016 and 13 July 2016, but the GP disputed this. The mechanism of communication within the GP practice caused concern in that several aspects of care were classified as “admin tasks” when they required further clinical assessment. The process of requesting and documenting requests for home visits needs to be clearer. The role of “admin tasks” needs to be clarified so that these are only used for true administration tasks. ”

    Source location

    Timothy Simon Jones · 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

    Issue a learning alert to all Solihull member practices covering home-visit requests, policies, care-home requests and administrative-task classifications.

    Verbatim wording from the response

    “• In addition a ‘learning alert’ will be issued to all Solihull member practices to highlight concerns and learning in relation to: ○ Recording of requests for home visits ○ GP home visit policies ○ Nursing/residential home requests for GP home visits ○ Classifications of administrative tasks”

    Source location

    2016-0421-Response-by-Solihull-Clinical-Commissioning-Group
    Page 1 · response
    Published 19 February 2017

    Open published response
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Data last updated 7 September 2026